Sheffield Kidney Institute

Global Kidney Academy

CKD Micro-LectureCKD and CVD

Professor Meguid El Nahas, PhD, FRCPSheffield Kidney Institute

UK

Sheffield Kidney InstituteYach et al, 2004

20021990 2020Predicted

0

40

50

30

N°o

f dea

ths

(mill

ions

)

10

20

CHRONIC DISEASES DEATHS WORLDWIDE

Chronic diseases (NCD)

20021990 2020Predicted

0

40

50

30

N°o

f dea

ths

(mill

ions

)10

20

Communicable diseases

CKD as a Global Public Health ProblemCKD as a Global Public Health Problem

Sheffield Kidney Institute

Global deaths (58 million) by major cause 2005

CVD

30% CVD = 17,528,000 deaths

Yach et al, 2004

CKD as a Global Public Health ProblemCKD as a Global Public Health Problem

Sheffield Kidney InstituteThe oedematous woman - Gerard Dou 1662 (Louvre Museum)

Look at Urine and Diagnose Heart Disease

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

Microalbuminuria and Survival

Sheffield Kidney Institute

Proteinuria and Survival in Diabetes

1.0

0.9

0.8

0.7

0.6

0.50 1 2 3 4 5 6

Years

Surv

ival

(all-

caus

e m

orta

lity)

Normoalbuminuria(n=191)

Microalbuminuria(n=86)

Macroalbuminuria(n=51)

Gall, MA et al. , 1995

CKD as a Global Public Health Problem

Sheffield Kidney Institute

Albuminuria

Inflammation EndothelialDysfunction

Cardio Kidney DamageCKD

CKD as a Global Public Health Problem

Sheffield Kidney Institute

CKD and CVD Risk

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

eGFR<60

eGFR>60

CKD as a Global Public Health Problem

Sheffield Kidney Institute

CKD & CVD death39 studies, 1,371,990

Tonelli et al, 2006

CKD as a Global Public Health Problem

Sheffield Kidney Institute

Common factors associated with adverse outcomes in CVD and CKD

• Traditional– Age– Hypertension– Diabetes– Dyslipidemia– Family history– Smoking– Obesity

‘Non traditional’• Kidney function• Albuminuria/ Proteinuria

• Anemia• iPTH excess• Calcium phosphate

abnormalities

• Vitamin D deficiency

CKD as a Global Public Health Problem

Sheffield Kidney Institute

CKD + Anemia

Vlagopoulos et al, 2005

IHD

Stroke Death

CVD

CKD+anemia

CKD+anemia

CKD as a Global Public Health Problem

Sheffield Kidney Institute

Common factors associated with adverse outcomes in CVD and CKD

• Traditional– Age– Hypertension– Diabetes– Dyslipidemia– Family history– Smoking– Obesity

‘Non traditional’• Kidney function

• Albuminuria/ ProteinuriaAnemia

• iPTH excess• Calcium phosphate

abnormalities• Vitamin D

CKD as a Global Public Health Problem

Sheffield Kidney Institute

CKDMineral and Bone Disorder

CKD as a Global Public Health Problem

Sheffield Kidney Institute

Mineral and Bone DisorderCKD as a Global Public Health Problem

Sheffield Kidney Institute

Types of Vascular Calcification in CKD

Uremic arteriopathy Atherosclerosis

CKD as a Global Public Health Problem

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Vascular Calcifications

CKD as a Global Public Health Problem

Sheffield Kidney Institute

Control of vascular calcifications

SMC Osteoblast

InhibitorsFetuinMGlaPOsteoprotegerinOsteopontin

ActivatorsPhosphorusUremic toxinsPTHVitaminDOxLDL

- +

CKD as a Global Public Health Problem

Sheffield Kidney Institute

Heart Disease Fall

-70%/last 3 decades

CKD as a Global Public Health Problem

Sheffield Kidney Institute

CKD management guidelinesParameter Target Agent usedBP 130/80 mmHg or

125/75 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

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Evolution

CKD as a Global Public Health Problem

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 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)

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CKDCVD

MINIMIZE

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CKD

=

Cardio-Kidney Damage

CKD as a Global Public Health Problem