TREAT THE KIDNEY TO SAVE THE HEART. Leanna Tyshler, MD Chronic Kidney Disease Medical Advisor Northwest Kidney Centers February 2 nd, 2009

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1 TREAT THE KIDNEY TO SAVE THE HEART Leanna Tyshler, MD Chronic Kidney Disease Medical Advisor Northwest Kidney Centers February 2 nd,

2 ESRD Prevalent Rates in 1996 per million population December 31 point prevalent ESRD patients. By HSA; rates adjusted for age, gender, & race. Excludes patients residing in Puerto Rico & the Territories. USRDS

3 ESRD Prevalent Rates in 2006 per million population December 31 point prevalent ESRD patients. By HSA; rates adjusted for age, gender, & race. Excludes patients residing in Puerto Rico & the Territories. 3 USRDS 2008

4 Projected Counts of Incident & Prevalent ESRD Patients through 2020 USRDS 2008 Counts projected using a Markov model. Original projections used data through 2000; new projections use data through

5 Diabetes is the Most Common Primary Diagnosis in Patients with Kidney Failure Number of Patients (thousands) Diabetes 45% 45% Other 20% 8% Glomerulonephritis 27% Hypertension Year Prevalent ESRD (2002: 431,284) Prevalent Dialysis (2002: 308,910) Prevalent Transplant (2002: 122,374) Incident ESRD (2002: 100,359) ESRD = End Stage Renal Disease. USRDS 2004 Annual Data Report. 5

6 Prevalent Counts & Rates December 31 point prevalent ESRD patients; rates adjusted for age, gender, & race. 6 USRDS 2008

7 In the United States There are 506,256 patients with endstage renal failure BUT THERE ARE 30 MILLION PEOPLE WITH CKD - AND THEY HAVE A SIGNIFICANTLY INCREASED RISK OF CARDIOVASCULAR DISEASE 7

8 Diabetes, HTN, CKD Medicare population, USRDS ADR, 2006

CKD, Kidney Failure, Heart Failure, Diabetes; Number of Patients and Costs; USA 2002 Populations estimated from the 5 percent Medicare sample, & include patients surviving the entire cohort year of

9 CKD, Kidney Failure, Heart Failure, Diabetes; Number of Patients and Costs; USA 2002 Populations estimated from the 5 percent Medicare sample, & include patients surviving the entire cohort year of 2002 with Medicare as primary payor, plus period prevalent ESRD patients for Diagnoses determined from claims in Patients with ESRD in the 5 percent sample are excluded, as they are counted in the ESRD 9 population. Costs are for the second year of the two-year period. USRDS, 2005

10 Increased Morbidity During the Transition from CKD to ESRD is Associated with High Costs Incident ESRD patients, Medicare: incident patients with Medicare as primary payor (not enrolled in an HMO). Medstat: patients enrolled for full year in both 2001 &

11 Medicare-entitled patients diagnosed with CKD in the year prior to death; data from the 5 percent Medicare sample. CKD Patients Who Die: Costs in the Year Prior to Death, by Dx 11

12 Economic Burdens of Kidney Disease $27.3 billion for ESRD alone $17 billion or 6.7% for ESRD alone from Medicare $35 billion for CKD from Medicare $901 million for EGHP patients with CKD $65,000-$85,000 per ESRD patient per year $28,000 estimated costs per CKD patient per year The majority of the costs for CKD patients comes from hospitalizations 12

13 National Kidney Foundation (NKF). Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266 Definition of CKD Kidney damage for 3 months Defined by structural or functional abnormalities of the kidney, with or without decreased kidney function GFR less than 60ml/min/1.73m 2 for 3 months Reduced kidney function estimated by glomerular filtration rate (egfr) New staging for CKD is primarily based on kidney function (egfr) 13

14 1 in 7 Adult Americans Have Chronic Kidney Disease (CKD) CKD Stage 1 2 GFR (ml/min/1.73 m 2 ) Albuminuria with nl or increased kidney function ( 90) Albuminuria with mildly reduced kidney function ( 60-89) Number of Individuals 5.6 million 5.7 million million ,000 5 <15 or dialysis 431,284 GFR = glomerular filtration rate. Coresh et al, J Am Soc Nephrol. 2005;16:

15 K/DOQI CKD Staging Requires 2 or more GFR, 3 or more months apart GFR If other markers kidney disease: proteinuria, hematuria, anatomic Complications Possible Complications Evident Renal Replacement CKD Stages 15

16 Chronic Kidney Disease Premature Death from Cardiovascular Disease Kidney Failure 16

17 CKD is Associated with CVD Rate of CVD Events < 15 Go, et al., 2004 egfr Age-Standardized Rate of CVD events per 100 person-year. 17

18 Foley, RN, et al, Am J Kidney Dis 1998;32(suppl 3):S112-S119 18

19 GFR = ml/min/1.73m 2, RRT = renal replacement therapy 19 Keith DS, et al, Arch Intern Med 2004:

20 Increased Mortality in Patients with DM and CKD: 2-Year Clinical Outcomes Patients (%) No Events ESRD, CKD Stage 5 Death DM, - CKD - DM, +CKD Medical Cohort + DM, + CKD CKD identified as ICD-9-CM diagnosis code, includes CKD from diabetes, hypertension, obstructive uropathy, and other diagnosis codes reported on USRDS ESRD registration forms. Collins et al, Kidney Int. 2003;64(suppl 87):S24-S31. 20

21 Annual Transition Rate KDOQI Clinical Practice Guidelines, AJKD, 49 (2), Suppl 2, Feb

22 CKD is Prevalent in CVD 60 Patients With CKD (%) % 33% 46% 0 CAD CrCl 60 ml/min AMI GFR <60 ml/min CHF GFR 60 ml/min 22 Ix, et al., 2003; Anavekar, et al., 2004; Shlipak, et al., 2004.

23 CKD and CVD CKD patients = highest CVD risk category CKD uniquely exacerbates CVD CVD risk factors accelerate CKD Majority of new patients with Kidney Failure have CVD Most CKD patients die of CVD before Kidney Failure Patients with CKD should be treated for CVD risk reduction 23

24 Advanced CKD Involves Multiple Complex Issues 1. Hypertension and other CVD elements 2. Bone disease 3. Anemia 4. Dyslipidemia 5. Nutrition 6. Counseling and rehabilitation 7. Preparation for renal replacement Renal Physicians Association Clinical Practice Guideline, October

25 Early Detection and Appropriate Treatment May be Effective in Delaying the onset of CKD in those at increased risk Slowing CKD progression Decreasing the development of cardiovascular disease in people with CKD 25

26 Intervention Makes a Difference BP less than 130/80 Use of ACEI or ARB agent Treatment of proteinuria Treatment of diabetes Attention to nutrition Treatment of anemia Treatment of hyperphosphatemia Treatment of hyperlipidemia and other CV risk factors Referring patients to a nephrologist for an early evaluation Proactive permanent AV fistula placement 26

27 Early Treatment Makes a Difference 27 Brenner, et al, 2001

28 CKD is NOT Being Recognized Only 38% of labs routinely report egfr with creatinine Less than 40% of patients with egfr <30 were coded with CKD Stevens, et al., 2005; NKDEP,

29 McClellan et al, 2003; Kinchen, et al, 2002; McClellan et al,1997 CKD is Not Being Recognized or Treated Most practices screen fewer than 20% of their Medicare patients with diabetes* Patients are referred late to a nephrologist, especially African-American men Less than 1/3 of people with identified CKD get an ACE Inhibitor *Data provided by the USRDS based on 5 percent Medicare enrollment and claims data 29

30 Diabetic CKD Patients on ACE-Is/ARBs has been Slow to Improve Percent of patients USRDS ADR, 2007

Awareness of Early-Stage CKD is Low in the US Population Patients Who Are Aware of Weak or Failing Kidneys* (%) 20 15 10 5 0 Albuminuria: 5.5 1.1 1.6 3.9 18.6 2.4 2.9 17.

31 Awareness of Early-Stage CKD is Low in the US Population Patients Who Are Aware of Weak or Failing Kidneys* (%) Albuminuria: < < < Sex: F M egfr: Proportion of patients who were told they had weak or failing kidneys, egfr (ml/min/1.73 m 2 ) Coresh et al, J Am Soc Nephrol. 2005:16:

32 Facing CKD Epidemic in 2009 CKD is a public health problem Public awareness of CKD is low Patients with CKD are often under-diagnosed despite the fact that economical, effective testing and treatment exist 32

33 Identifying Kidney Disease Protects the Heart Assess all patients for presence of CKD risk factors Screen all patients with CKD risk factors for CKD Evaluate all CKD patients for CKD complications Treat CKD-associated abnormalities both to optimize cardiovascular status and to slow CKD progression and Kidney Failure Consult with a nephrologist as needed 33

34 Who Should be Tested for Chronic Kidney Disease All individuals should be assessed for CKD risk factors upon their initial medical encounter Individuals with one or more CKD risk factors should be tested for CKD regularly 34

35 Assess All Patients for Presence of CKD Risk Factors Diabetes Hypertension Relative with kidney failure Cardiovascular disease Metabolic Syndrome Age>60 Nephrotoxic drug exposure including NSAIDS Ethnic minority 35

36 Metabolic Syndrome Significantly Increases the Risk of CKD Independent of Hypertension/Diabetes 50% of US adults, 30% of US children/adolescents are obese 20% of US adults have metabolic syndrome Metabolic syndrome traits Odds ratio for CKD Significance < < < <.05 Abdominal obesity, dyslipidemia, hypertension, hyperglycemia; ARIC study, 9 years36 Chertow et al, JASN, July 2005

37 The Risk of Kidney Failure is Not Uniform Relative risks compared to Whites: African Americans Native Americans 3.8 X 2.0 X Asians/Pacific Islander 1.3 X USRDS, 2004 The relative risk of Hispanics compared to non-hispanics is about 1.5 X 37

8 times as likely to have diabetes mellitus than ageadjusted White Americans 1 >30% of Black

38 Prevalent Counts & Rates by Race December 31 point prevalent ESRD patients; rates adjusted for age & gender. 1 Black Americans are 1.8 times as likely to have diabetes mellitus than ageadjusted White Americans 1 >30% of Black Americans over age 18 have hypertension 2 USRDS

39 How to Test for CKD Blood Pressure Measurement Estimated GFR from serum creatinine using the MDRD prediction equation Urine microalbumin with a microalbumin dipstick or Spot urine albumin to creatinine ratio or standard dipstick *24 hour urine collections are NOT needed. Bouleware, et al.,

40 At What Level of Creatinine Does a 65-Year-Old Diabetic, Hypertensive White Woman Weighing 50 Kilograms Have CKD? 77% said: Creatinine > 1.5 mg / dl GFR = 37 ml/min/ 1.73 m 2 Ccreat = 30 ml/min Creatinine = 1.0 for GFR = 59 ml/min/1.73 m 2 Nat Kid Ed Prog,

Estimated Glomerular Filtration Rate egfr The best method available for most people to assess total kidney function Can be calculated using the MDRD prediction equation which factors in the

41 Estimated Glomerular Filtration Rate egfr The best method available for most people to assess total kidney function Can be calculated using the MDRD prediction equation which factors in the following: Serum creatinine, age, gender, race, normalized to average adult surface area of 1.73m 2 calculator.cfm The MDRD equation has been validated in diabetic and nondiabetic kidney disease, kidney transplant recipients, African Americans and Caucasians with CKD 41

42 Cardiovascular Outcomes Worsen With CKD Progression: 3-Y Follow-Up by egfr Levels Estimated Event Rate (%) egfr (ml/min/1.73 m 2 ) P< <45 0 Composite End Point Death From CV Causes Reinfarction CHF Stroke Resuscitation CHF = congestive heart failure. Anavekar et al, N Engl J Med. 2004;351:

43 Albuminuria: a New Risk Factor/Marker High Prevalence: 7% of the general population 20% hypertensive population 40% diabetic population Easy and Cheap to measure Mild decrease in GFR and Microalbuminuria are signs of mild CKD Predicts later development of heart disease, stroke and diabetes 43

44 Microalbuminuria is not Just a Renal, but also a CV Risk Factor in Patients with Diabetes, HTN, General Population A two-fold increase in UAC is associated with RR of 1.29 for CV mortality Independent risk factor for CV disease with RR of 1.59, which is numerically higher than RR of 1.4, associated with elevated creatinine concentration Hillege et al, Circulation 106:1777, 2002 Mann et al, Ann Int Med 134:629,

45 Treat the Kidney to Save the Heart We need to identify CKD early and then assess and optimize cardiovascular status of CKD patients by aggressive treatment of cardiovascular risk factors 45

46 We Can Make a Difference! Educate patients and providers about CKD Recognize who is at risk for CKD Test patients at risk for CKD Encourage labs to report egfr Treat CKD to slow down disease and prevent complications Control BP Goal is less than 130/80 Use ACEI/ ARBs Control blood sugar in diabetics Treatment of proteinuria Optimize CV status Treat other CKD complications Anemia, metabolic bone disease, malnutrition, preparation for RRT Monitor egfr, urine ACR 46

Chronic Kidney Disease

Chronic Kidney Disease Chronic Kidney Disease (CKD) Educational Objectives Outline Demographics Propose Strategies to slow progression and improve outcomes Plan for treatment of CKD Chronic Kidney Disease