Stadien der Progression bei CKD

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2 Stadien der Progression bei CKD Complications Normal Increased risk Damage GFR Kidney failure CKD death Screening for CKD risk factors CKD risk reduction; Screening for CKD Diagnosis & treatment; Treat comorbid conditions; Slow progression Estimate progression; Treat complications; Prepare for replacement Replacement by dialysis & transplant

3 Randomisierte kontrollierte Studien in der Nephrologie Palmer et al., Am J Kidney Dis 2011;58:335-7

4 Liu et al., BMC Nephrology 16:31, 2015

6 CKD und ESRD sind mit überproportionaler Mortalität assoziiert ESRD vs general population Stage 3-4 CKD vs general population (GP) Expected remaining life-years Europe US Whites General population Mortality rate per 1000 pt-yr GP males Stage 3 males Stage 4 males GP females Stage 3 females Stage 4 females Dialysis Age (years) Age groups Jager, ERA-EDTA and USRDS data

7 CKD und ESRD sind mit überproportionaler Mortalität assoziiert Daten adjustiert für Alter, Geschlecht, Rasse, CVD, sytol. BP, Alter, Rauchen, Gesamtcholesterin Matsushita et al., Lancet 375: , 2010

8 Mortalität im ersten Jahr an Dialyse Collins et al., CJASN 4:S5-11, 2009

Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and stage, 2016 Data source: Special analyses, Medicare 5%

9 Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and stage, 2016 Data source: Special analyses, Medicare 5% sample. January 1 of each reported year, point prevalent Medicare patients aged 66 and older. Adjusted for age/sex/race. Standard population: Medicare 2016 patients. Abbreviations: CKD, chronic kidney disease; unk/unspc, CKD stage unidentified. USRDS Annual Data Report Annual Data Report Volume 2, Chapter 5

10 Proteinurie verschlechtert das Outcome bei CKD weiter N=920,985 Adverse clinical outcomes (per 1000 patients-years) Proteinuria Normal Mild Heavy All cause mortality Adverse clinical outcomes (per 1000 patients-years) Proteinuria Normal Mild Heavy Acute myocardial infarction Adverse clinical outcomes (per 1000 patient-years) egfr (ml/min/1.73m 2 ) Proteinuria Normal Mild Heavy End stage renal disease Adverse clinical outcomes (per 1000 patient-years) egfr (ml/min/1.73m 2 ) Proteinuria Normal Mild Heavy Doubling of serum creatinine egfr (ml/min/1.73m 2 ) Hemmelgarn et al., JAMA 303:423-9, egfr (ml/min/1.73m 2 ) mild: trace or 1+; heavy: 2+

11 Proteinurie verschlechtert das Outcome bei CKD weiter Matsushita et al., Lancet 375: , 2010

12 ACR und kardiovaskuläre Ereignisse bei älteren Patienten PO783 CKD: Sonaliet al. Reduced Kidney Function and the Risk of ST and Non-ST Elevation Myocardial Infarction

13 ACR und kardiovaskuläre Ereignisse bei alteren Patienten PO783 CKD: Sonaliet al. Reduced Kidney Function and the Risk of ST and Non-ST Elevation Myocardial Infarction

14 Adjusted mortality (deaths per 1,000 patient-years) by calendar year, treatment modality, and comorbidity among ESRD patients and comorbidity-specific Medicare populations aged 65 & older, Data Source: Special analyses, USRDS ESRD Database and Medicare 5% sample. Unadjusted and adjusted (sex and race) mortality rates starting with the January 1 point prevalent sample in the ESRD and general populations, aged 65 and older (per 1,000 patientyears at risk). Reference population: period prevalent ESRD patients, Abbreviations: AMI, acute myocardial infarction; CHF, congestive heart failure; CVA/TIA, cerebrovascular accident/transient ischemic attack; ESRD, end-stage renal disease Annual Data Report Volume 2, Chapter 5 USRDS Annual Data Report

15 Mortalität nach Region in DOPPS McCullogh et al., Kidney Int 58:158-65, 2014

23 Residual Kidney Function and Mortaliy in First Year of Dialysis TH-OR094 Association of Ultrafiltration Rate and Decline in Residual Kidney Function among Thrice-Weekly Hemodialysis Patients

24 Modifizierbare Risikofaktoren für Frühmortalität an HD

25 Late Breaking Clinical Trials Palmer et al., N Engl J Med, doi: /NEJMoa , Oct 26, 2018

26 Late Breaking Clinical Trials

27 Late Breaking Clinical Trials

28 Late Breaking Clinical Trials

31 ESA-Dosis um Ziel-Hb von g/dl zu erreichen

32 Primärer Endpunkt Signifikant für Noninferiority, nicht für Superiority

33 CV Endpunkt signifikant für Hospitalization for HF Auch signifikant weniger: Recurrent primary events, blood transfusions

36 Behandlungsoptionen für Patienten mit Typ 2 DM und CKD

41 RAS-Inhibition und kardiovaskuläre Mortalität/Outcome FR-OR116: Qin et al. Towards Better Medication Usage in Patients with CKD Real World Dosing Practices of Renin- Angiotensin-Aldosterone System Inhibitors Is Associated with Risk of Adverse Clinical Events in CKD Patients.

42 RAS-Inhibition und kardiovaskuläre Mortalität/Outcome FR-OR116: Qin et al. Towards Better Medication Usage in Patients with CKD Real World Dosing Practices of Renin- Angiotensin-Aldosterone System Inhibitors Is Associated with Risk of Adverse Clinical Events in CKD Patients.

48 Chronic kidney disease is recognised as a major global public health problem.1,2 The disease aff ects 10 16% of the adult population in Asia, Australia, Europe, and the USA,3 6 and increases the risk of all-cause mortality, cardiovascular disease, and progression to kidney failure, even after accounting for traditional risk factors such as hypertension and diabetes mellitus n_us.pdf

51 Das Risiko für kardiovaskuläre Ereignisse steigt ab einer GFR < ml/min überproportional an. current guidelines that identify individuals with CKD as being at high risk for cardiovascular mortality

52 Kunihiro Matsushita u. a.: Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascularmortalityin generalpopulationcohorts: a collaborativemeta-analysis. In: The Lancet. Band 375, Nr. 9731, 12. Juni 2010

53 Kunihiro Matsushita u. a.: Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascularmortalityin generalpopulationcohorts: a collaborativemeta-analysis. In: The Lancet. Band 375, Nr. 9731, 12. Juni 2010

54 Baseline egfr threshold below which risk for ESRD exceeded risk for death for each age group. Ann M. O'Hare et al. JASN 2007;18: by American Society of Nephrology

55 Distribution of egfr among cohort patients in each age group. Ann M. O'Hare et al. JASN 2007;18: by American Society of Nephrology

56 MNC GmbH: Jahresbericht für den G-BA für das Berichtsjahr 2017

57 vol 1 Figure 3.1 Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and year, (b) Adjusted 2018 ANNUAL DATA REPORT VOLUME 1: CHRONIC KIDNEY DISEASE Chapter 3: Morbidity and Mortality Data source: Special analyses, Medicare 5% sample. January 1 of each reported year, point prevalent Medicare patients aged 66 and older. 1.b adjusted for age/sex/race and 1.c adjusted for age/sex/race/comorbidities. 1.e adjusted for age/sex and 1.f adjusted for age/sex/comorbidities. Standard population: Medicare 2011 patients. Abbreviation: CKD, chronic kidney disease Annual Data Report Volume 2, Chapter 5 57

58 vol 1 Figure 3.1 Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and year, (c) Adjusted for comorbidities Data source: Special analyses, Medicare 5% sample. January 1 of each reported year, point prevalent Medicare patients aged 66 and older. 1.b adjusted for age/sex/race and 1.c adjusted for age/sex/race/comorbidities. 1.e adjusted for age/sex and 1.f adjusted for age/sex/comorbidities. Standard population: Medicare 2011 patients. Abbreviation: CKD, chronic kidney disease Annual Data Report Volume 2, Chapter 5 58

59 vol 1 Figure 3.1 Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and year, (d) Unadjusted Data source: Special analyses, Medicare 5% sample. January 1 of each reported year, point prevalent Medicare patients aged 66 and older. 1.b adjusted for age/sex/race and 1.c adjusted for age/sex/race/comorbidities. 1.e adjusted for age/sex and 1.f adjusted for age/sex/comorbidities. Standard population: Medicare 2011 patients. Abbreviation: CKD, chronic kidney disease Annual Data Report Volume 2, Chapter 5 59

60 vol 1 Figure 3.1 Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and year, (e) Adjusted Data source: Special analyses, Medicare 5% sample. January 1 of each reported year, point prevalent Medicare patients aged 66 and older. 1.b adjusted for age/sex/race and 1.c adjusted for age/sex/race/comorbidities. 1.e adjusted for age/sex and 1.f adjusted for age/sex/comorbidities. Standard population: Medicare 2011 patients. Abbreviation: CKD, chronic kidney disease Annual Data Report Volume 2, Chapter 5 60

61 vol 1 Figure 3.1 Unadjusted and adjusted all-cause mortality rates per 1,000 patient-years at risk for Medicare patients aged 66 and older, by CKD status and year, (f) Adjusted for comorbidities Data source: Special analyses, Medicare 5% sample. January 1 of each reported year, point prevalent Medicare patients aged 66 and older. 1.b adjusted for age/sex/race and 1.c adjusted for age/sex/race/comorbidities. 1.e adjusted for age/sex and 1.f adjusted for age/sex/comorbidities. Standard population: Medicare 2011 patients. Abbreviation: CKD, chronic kidney disease Annual Data Report Volume 2, Chapter 5 61

62 Vielen Dank für die Aufmerksamkeit!

Chapter 2: Identification and Care of Patients With Chronic Kidney Disease

Chapter 2: Identification and Care of Patients With Chronic Kidney Disease Introduction The examination of care in patients with chronic kidney disease (CKD) is a significant challenge, as most large datasets