Sheffield Kidney Institute

Global Kidney Academy

CKD Micro-LectureEpidemiology, Screening and Guidelines

Professor Meguid El Nahas, PhD, FRCPSheffield Kidney Institute

UK

Sheffield Kidney Institute

Lysaght, J Am Soc Nephrol, 2002

Global ESRD

1990 2003 2010

426,000

1,000,000

2,000,000

Sheffield Kidney Institute

USRDSIncident counts & adjusted

rates, by age

Sheffield Kidney Institute

USRDSIncident counts & adjusted rates,

by primary diagnosis

Incident ESRD patients; rates adjusted for age, gender, & race.

Sheffield Kidney Institute

ESRD0.1%

Undetected CKD: 10-15%?!

Sheffield Kidney Institute

eGFR

MDRD 4 variables formula:

eGFRml/min/1.73m2 =

175 x{[sCr / 88.4] -1.154}x age (years)-.203 x 0.742 if F x1.21 B

Sheffield Kidney Institute

K/DOQI

CKD ClassificationStage Description GFR

1 Kidney damage/normal GFR* >90ml/min

2 Mild renal insufficiency 89-60

3 Moderate renal insufficiency 59-30

4 Severe renal insufficiency 29-15

5 Kidney Failure <15

Sheffield Kidney Institute

NICE Stages of CKD

CKD Stage Description (eGFR ml/min/1.73m2)

Stage 1 Normal eGFR (>90)With other evidence of kidney damage*

Stage 2 eGFR 60 – 90With other evidence of kidney damage*

Stage 3aStage 3b

eGFR 45-59eGFR 30-44

Stage 4 eGFR 15 – 29

Stage 5 eGFR < 15

* Evidence of chronic kidney damage includes: persistent microalbuminuria or proteinuria, haematuria, structural abnormalities, biopsy proven glomerulonephritis.

Sheffield Kidney Institute

Growth in recognition of Chronic kidney disease

UK CKD KDOQI

Sheffield Kidney Institute

Albuminuria & Age

MONICANHANESIII

14,622

19% 32.7%15%

Garg et al, 2002

Sheffield Kidney Institute

eGFR

MDRD 4 variables formula:

eGFRml/min/1.73m2 =

175 x{[sCr / 88.4] -1.154}x age (years)-.203 x 0.742 if F x1.21 B

Sheffield Kidney Institute

MDRD & GC

Poggio et al, 2005

Sheffield Kidney Institute

CKD and the ageing Population

Sheffield Kidney Institute

CKDCVD

Sheffield Kidney InstituteHillege et al, 2002 Arnlov et al, 2005

Microalbuminuria and Survival

Sheffield Kidney Institute

CKD and CVD Risk

HOORN Study, Henry et al, 2002 Pooled Analysis, Weiner et al, 2004

eGFR<60

eGFR>60

Sheffield Kidney Institute

Screening At-risk Population

• Diabetics• Hypertensives• CVD • Relatives of CKD5• Systemic vasculitis• Recurrent UTIs, and urological problems• Chronic NSAIDs

Sheffield Kidney Institute

CKD management guidelinesParameter Target Agent used

BP 130/80 mmHg or125/75 in DM and those with proteinuria.

Start with ACEI or ARBs if proteinuria or DM microalbuminuria - caution in the elderly and those with atherosclerosis. Monitor eGFR within 1-2 weeks of initiation, review if eGFR decreases by ≥15%, stop at ≥25%.

Proteinuria Lowest achievable ACEi/ ARBs

sCholesterol Refer to national guidelines

Lifestyle Standard CV risk reduction measures, including salt restriction

Avoid NSAIDs, COX2s and radiocontrast agents

Sheffield Kidney Institute

Evolution

Sheffield Kidney Institute

CKD management guidelinesParameter Target Agent used

BP 130/80 mmHg or

125/75 in DM and those with proteinuria

Start with ACEI or ARBs if proteinuria >1g/24hor DM

Proteinuria Lowest achievable<1g/24h

ACEi/ ARBs

sCholesterol Refer to national guidelines

Lifestyle Standard CV risk reduction measures, including salt restriction

Avoid NSAIDs, COX2s and radiocontrast agents

Sheffield Kidney InstituteLocatelli et al 1996

Sheffield Kidney Institute

Sheffield Kidney Institute

Sheffield Kidney Institute

Sheffield Kidney Institute

CKD (Stages 3-5) management of complicationsComplication Target Management

Anaemia Hb 10.5-12.5 g/dl Replace deficienciesErythropoietin in CKD stage 4-5

Renal osteodystrophy

(Stages 4& 5 only)

Ca: 2.2-2.35 mmol/lPO4 <1.7 mmol/l

Calcium carbonate / alfacalcidolPhosphate binders

Acidosis Venous Bicarbonate > 22 mmol/l Sodium bicarbonate

Undernutrition Adequate calorie & normal protein intake

Infections Chest infectionsHepatitis B

Immunize: influenza & pneumococcusvaccination (CKD stages 4-5)

Sheffield Kidney Institute

CKDCVD

MINIMIZE