TREAT THE KIDNEY TO SAVE THE HEART Leanna Tyshler, MD Chronic Kidney Disease Medical Advisor Northwest Kidney Centers February 2 nd, 2009 1
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 2008 2
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
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 2006. 4
Diabetes is the Most Common Primary Diagnosis in Patients with Kidney Failure Number of Patients (thousands) 500 400 300 200 100 0 Diabetes 45% 45% Other 20% 8% Glomerulonephritis 27% Hypertension 78 80 82 84 86 88 90 92 94 96 98 00 02 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
Prevalent Counts & Rates December 31 point prevalent ESRD patients; rates adjusted for age, gender, & race. 6 USRDS 2008
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
Diabetes, HTN, CKD Medicare population, 2004 8 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 2002 with Medicare as primary payor, plus period prevalent ESRD patients for 2003. Diagnoses determined from claims in 2002. 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
Increased Morbidity During the Transition from CKD to ESRD is Associated with High Costs Incident ESRD patients, 2002. Medicare: incident patients with Medicare as primary payor (not enrolled in an HMO). Medstat: patients enrolled for full year in both 2001 & 2002. 10
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
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
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
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 3 30-59 7.4 million 4 15-29 300,000 5 <15 or dialysis 431,284 GFR = glomerular filtration rate. Coresh et al, J Am Soc Nephrol. 2005;16:180-188 14
K/DOQI CKD Staging Requires 2 or more GFR, 3 or more months apart GFR 90 60 30 15 If other markers kidney disease: proteinuria, hematuria, anatomic Complications Possible Complications Evident Renal Replacement 1 2 3 4 5 CKD Stages 15
Chronic Kidney Disease Premature Death from Cardiovascular Disease Kidney Failure 16
CKD is Associated with CVD 40.0 36.6 35.0 30.0 25.0 20.0 15.0 10.0 5.0 Rate of CVD Events 2.1 3.7 11.3 21.8 0.0 60 45-59 30-44 15-29 < 15 Go, et al., 2004 egfr Age-Standardized Rate of CVD events per 100 person-year. 17
Foley, RN, et al, Am J Kidney Dis 1998;32(suppl 3):S112-S119 18
GFR = ml/min/1.73m 2, RRT = renal replacement therapy 19 Keith DS, et al, Arch Intern Med 2004:164 659-663
Increased Mortality in Patients with DM and CKD: 2-Year Clinical Outcomes Patients (%) 100 80 60 40 84.0 67.6 2.9 61.6 No Events ESRD, CKD Stage 5 Death 6.1 20 15.7 0.3 29.5 32.3 0 + 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
Annual Transition Rate KDOQI Clinical Practice Guidelines, AJKD, 49 (2), Suppl 2, Feb 2007 21
CKD is Prevalent in CVD 60 Patients With CKD (%) 40 20 23% 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.
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
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 2002 24
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
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
Early Treatment Makes a Difference 27 Brenner, et al, 2001
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, 2008 28
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
Diabetic CKD Patients on ACE-Is/ARBs has been Slow to Improve 80 70 60 50 40 30 20 Percent of patients 10 0 95 96 97 98 99 00 01 02 03 30 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 17.9 <30 30+ <30 30+ <30 30+ Sex: F M egfr: 90+ 60-89 30-59 30-59 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. 2005:16:180-188 31
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
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
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
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
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 1 1.13 <.05 2 1.53 <.05 3 1. 75 <.05 4 2.45 <.05 Abdominal obesity, dyslipidemia, hypertension, hyperglycemia; ARIC study, 9 years36 Chertow et al, JASN, July 2005
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
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 2008 www.diabetes.org/uedocuments/nationaldiabetesfactsheetrev.pdf. www.americanheart.org/presenter.jhtml?identifier=3000927 38
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., 2003 39
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, 2005 40
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 http://www.kidney.org/prifessionals/kdoqi/gfr calculator.cfm The MDRD equation has been validated in diabetic and nondiabetic kidney disease, kidney transplant recipients, African Americans and Caucasians with CKD 41
Cardiovascular Outcomes Worsen With CKD Progression: 3-Y Follow-Up by egfr Levels Estimated Event Rate (%) 60 50 40 30 20 10 egfr (ml/min/1.73 m 2 ) P<0.001 75 60-74 45-59 <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;351:1285-1295 42
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
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, 2001 44
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
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