APPROACH TO CHRONIC KIDNEY DISEASE

1.How many adults worldwide have some form of kidney damage?

  • A-About 1 out of 10
  • B-About 1 out of 1000
  • C-About 1 out of 10,000

CKD as a Public Health Issue

  • 26 million American affected
  • Prevalence is 11-13% of adult population in the US
  • 28% of Medicare budget in 2013, up from 6.9% in 1993
  • $42 billion in 2013
  • Increases risk for all-cause mortality, CV mortality, kidney failure (ESRD), and other adverse outcomes.
  • 6 fold increase in mortality rate with DM + CKD
  • Disproportionately affects African Americans, Asians and Hispanics

Pakistan

-15 to 20 percent of persons 40 years of age or older had a reduced estimated GFR in a survey from Karachi
hypertension is even higher  affecting about one third of Pakistanis over 45 years according to the 1990–1994 National Health Survey of Pakistan and verified in 2017

Gaps in CKD Diagnosis

 Improved Diagnosis…

Studies demonstrate that clinician behavior changes when CKD diagnosis improves. Significant improvements realized in:

  • Increased urinary albumin testing
    • Increased appropriate use of ACEi or ARB
    • Avoidance of NSAIDs prescribing among patients with low eGFR
    • Appropriate nephrology consultation

Impact of primary care CKD detection with a patient safety approach

 —  Screen patients with the  following for CKD


Diabetes,  
  Cardiovascular disease, Hypertension/PIH, —  Hyperlipidemia —  Obesity —  Metabolic syndrome —  Smoking —  Hepatitis B/C —  Malignancy —  F/H of CKD —  >60 years —  History of potentially nephrotoxic —  drugs

  —  Recovery from AKI —  Stones—  UTI —  Autoimmune disease —  Systemic infections —  Hakim medications

Criteria for CKD

—  Abnormalities of kidney structure or
function, present for >3 months, with implications for health

—  Either of the following must be
present for >3 months:

—  ACR >30 mg/g ( albumin
mg:creatinine g ratio)

—  Markers of kidney damage (one or
more*)

—  GFR <60 mL/min/1.73 m2

—  *Markers of kidney damage can
include nephrotic syndrome, (biopsy) nephritic syndrome, tubular syndromes, urinary tract symptoms, asymptomatic urinalysis abnormalities, asymptomatic radiologic abnormalities (polycystic), hypertension due to kidney disease.

Proteinuria


Screening Tools: EGFR

—  Considered the best overall index of kidney function.

—  Normal GFR varies according to age, sex, and body size, and
declines with age.

—  The NKF recommends using the CKD-EPI Creatinine Equation
(2009) to estimate GFR

—  GFR calculators are available online at www.kidney.org/GFR.

Calculation of Glomerular Filtration Rate

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Calculation of GFR



Chronic Kidney Disease and CV Risk

Traditional risk factors

Non-traditional risk factors

Age

Sex

Hypertension

HDL and LDL cholesterol

Diabetes

Smoking

Physical activity

Family history of CVD

LVH

Albuminuria

Homocysteine

LP(a) and apolipoproteins

Anaemia

Ca/phosphate metabolism

Salt and water overload

Oxidative stress

Inflammation

Malnutrition

Thrombogenic factors

Sleep disturbance

NO/endothelin balance…

Cardio-Metabolic Protection

—  Valsartan Significantly Reduces Risk of New-onset Atrial Fibrillation vs. Amlodipine

—  Valsartan Reduces The Rate of New-onset AF in Patients on Standard CHF Therapy

—  Valsartan Reduces incidence of Stroke in Post-MI Patients Similar to Captopril

—  Valsartan Significantly Reduces The Risk of New-onset Diabetes Compared to Amlodipine

—  Valsartan Reduces The Risk of Diabetes in Patients with High CV Risk on Monotherapy

Summary: Valsartan Provides Proven Cardio/Reno/Metabolic protective Benefits

—  Protects the vasculature and improves vascular structure/function

—  Positively impacts hypertension, oxidative stress and effects of angiotensin II

—  Blocks the negative effects of angiotensin II at the AT1 receptor

—  Acts at the source of vascular damage

—  Improves vasodilation and arterial compliance, and reduces oxidative stress

—  Improves left ventricular ejection fraction and left ventricular internal dimension at end diastole in patients with heart failure

—  Improves endothelial function

—  Proven benefits in HF and post-myocardial infarction patients

—  Significantly reduces UAER in patients with Type 2 diabetes mellitus

Conclusions

—  Microalbuminuria is frequent in hypertension and is associated with target organ damage and the incidence of CV complications

—  The pathophysiological link between microalbuminuria and CV risk is not completely understood but it may be due to endothelial dysfunction with an impaired NO balance, activation of local mediators and increased activity of the RAAS system

—  Blockade of the RAAS with ACE inhibitors or AT1 receptor blockers is an important therapeutic approach to reduce microalbuminuria and to prevent the development of CV and renal complications in hypertension

What can primary care providers do?
First Line of Defense!

—  Identify CKD. Recognize and test at-risk patients

—  Monitor eGFR and ACR (encourage labs to report these tests)

—  Manage blood pressure and diabetes

—  Evaluate and manage anemia, malnutrition, CKD-MBD, hyperkalemia, metabolic acidosis and other complications in at-risk patients

—  Refer to dietitian for nutritional guidance

—  Consider patient safety issues in CKD

—  Educate patients about CKD and treatment

—  Address other CVD risk factors  to improve patient outcomes.

 

Additional Online Resources for CKD Learning

National Kidney Foundation: www.kidney.org

United States Renal Data Service: www.usrds.org

CDC’s CKD Surveillance Project: http://nccd.cdc.gov/ckd

National Kidney Disease Education Program (NKDEP): http://nkdep.nih.gov

Facebook pages: HealthNet Echo Pakistan and Kidney Diseases in Pakistan

Summary

—  High CKD prevalence

—  Underdiagnosed

—  Use equations to calculate creatinine clearance

—  Asymptomatic