Acknowledgements. National Kidney Foundation of Connecticut Mark Perazella. Co-PI Slowing the progression of chronic kidney disease to ESRD

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1 A Practical Approach to Chronic Kidney Disease Management for the Primary Care Practioner: A web-site sponsored by the National Kidney Foundation of Connecticut Robert Reilly, M.D.

2 Acknowledgements National Kidney Foundation of Connecticut Mark Perazella Co-PI Slowing the progression of chronic kidney disease to ESRD Ali Abu-Alfa Web master Anemia Susan Crowley Preparation of the patient mentally and physically for RRT Rex Mahnensmith Identification and treatment of comorbid conditions (cardiovascular disease)

3 Why a web-site directed at primary care providers? National Kidney Foundation Web-site Nephrologists Nurses Social workers Dieticians Patients Primary care practitioners take care of the majority of patients with chronic kidney disease and they always will

4 Chronic kidney disease prevalence Definition of CKD NHANES III HMO 1 Cr > sex specific normal 9.1 million (3.7%) Men- 1.2 mg/dl, women- 1.4 mg/dl 1 Cr million (2.5%) 1 Cr million (1.0%) 1 Cr million (0.5%) 3.4 million (1.4%) 2 Cr elevated separated by 90 days 2 Cr 2.0 mg/dl separated by 90 days 4.2 million (1.7%) 2.1 million (0.8%) Nissenson AR et al Am J Kid Dis 37: , 2001.

5 Relationship of CKD to ESRD ESRD CKD

6 There aren t enough nephrologists to take care of patients with ESRD At the present rate of growth (5%) in ESRD incidence, there will be in excess of 700,000 ESRD patients by the year This would represent a doubling of the current ESRD population. To care for these patients, in excess of 5,000 full-time equivalent (FTE) nephrologists will be needed. Today, there are about 300,000 patients with ESRD who are being managed by 5,000 nephrologists, each spending an average of 35% of their time on ESRD patients (i.e., 1,750 FTEs). To produce the needed number of nephrologists to meet future needs, we need 480 new nephrology trainees annually, a lot more than the 160 we have now.

7 Web-site approach to the patient Establish the presence of chronic kidney disease Estimate the glomerular filtration rate Enact an action plan based on the severity of disease

8 Why call it chronic kidney disease? Why call it CKD as opposed to pre-esrd, pre-dialysis or chronic renal failure. Pre-ESRD gives the impression that dialysis is the inevitable outcome of all kidney diseases and that there are no effective therapies to retard its progression. It is the equivalent of referring to life as pre-death. The term renal failure also has a negative connotation and includes the term renal, which is not easily understood by patients and their families.

9 Definition of CKD CKD results when a disease process damages the structural or functional integrity of the kidney. This is clinically detected using either physical exam (hypertension), laboratory (hematuria, proteinuria, microalbuminuria) or imaging studies (CT, MRI, IVP or renal ultrasound). Almost all patients with a GFR 60 ml/min/1.73m 2 have CKD. However, since GFR declines normally with age (approximately 1 ml/min/1.73 m 2 /year after age 20), a GFR between 60 and 90 ml/min/1.73m 2 in the elderly may not be indicative of the presence of CKD. In order for patients to be classified as having CKD there must be some objective evidence on either physical exam, laboratory or imaging studies of kidney damage.enact an action plan based on the severity of disease

10 Estimate the glomerular filtration rate Estimates of the glomerular filtration rate (GFR) based on the serum creatinine have a high degree of correlation with determinations of GFR based on inulin (gold standard) or iothalamate clearances. The later are more accurate but are cumbersome and costly. These estimations also perform well when compared to collections of 24 hour urine which are difficult for patients to carry out and are often performed incorrectly. Cockcroft-Gault equation- [[140 - age(yr)]*weight(kg)]/[72*serum Cr(mg/dL)] (multiply by 0.85 for women) MDRD equation * [serum creatinine (mg/dl)] * [age (years)] * [0.762 if pt is female] * [1.180 if pt is black] * [BUN (mg/dl)] * [albumin (g/dl)]

11 Correlation between calculated and measured GFR Cockcroft-Gault MDRD equation 7 Levey AS et al Ann Intern Med 130: , 1999.

12 Why can t I just use the serum creatinine? The serum creatinine alone is not an accurate measure of glomerular filtration rate. Creatinine unlike inulin is secreted by renal tubules and as renal function worsens the amount secreted increases. Normal ranges for serum creatinine are misleading because they do not take into account the age, sex, or weight of the patient. Levey AS et al Ann Intern Med 130: , 1999.

13 Clinical example Consider the following two patients with identical serum creatinines of 1.2 mg/dl. Patient 1- a 60 year old 50 kg woman Patient 2- a 30 year old 90 kg man The first patient has a GFR of 39 ml/min/1.73 m 2, which is markedly abnormal, while the second has a GFR of 115 ml/min/1.73 m 2,well within the normal range.

14 Stepped-care action plan Action depends on the degree of impairment of GFR. Step 1- slow the progression of chronic kidney disease to end-stage renal disease (ESRD) Step 2- identify and treat co-morbid conditions (cardiovascular) Step 3- identify and prevent complications of CKD (anemia, divalent ions, malnutrition) Step 4- prepare the patient mentally and physically for renal replacement therapy

15 Stepped-care parallels impairment of GFR Degree of CKD GFR Action Mild ml/min/1.73 m 2 Steps 1,2 Moderate ml/min/1.73 m 2 Steps 1,2,3 Severe ml/min/1.73 m 2 Steps 1,2,3,4 Step 1- slow the progression of chronic kidney disease to end-stage renal disease (ESRD) Step 2- identify and treat co-morbid conditions (cardiovascular) Step 3- identify and prevent complications of CKD (anemia, divalent ions, malnutrition) Step 4- prepare the patient mentally and physically for renal replacement therapy

16 Rationale for a stepped-care action plan PTH and 1,25 D 3 parallel decline in GFR

17 Rationale for a stepped-care action plan Degree of anemia parallels decline in GFR GFR (ref group GFR > 80) Decrease in Hct (men) Women ml/min - 0.1% % ml/min ml/min ml/min ml/min ml/min < 20 ml/min Hsu C-Y et al Kidney Int 59: , % - 0.4% - 0.3% - 1.6% - 2.6% - 6.5% % % % % % %

Characteristics of factor x so that its clearance = GFR. Such factors that meet these criteria. Renal Tests. Renal Tests

Characteristics of factor x so that its clearance = GFR. Such factors that meet these criteria. Renal Tests. Renal Tests Renal Tests Holly Kramer MD MPH Associate Professor of Public Health Sciences and Medicine Division of Nephrology and Hypertension Loyola University of Chicago Stritch School of Medicine Renal Tests 1.