disclosures
play

Disclosures CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST - PowerPoint PPT Presentation

8/9/2019 Disclosures CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW I am on the Scientific Advisory Boards with stock option compensation for the following companies: MICHAEL G. SHLIPAK, MD, MPH TAI Diagnostics


  1. 8/9/2019 Disclosures CHRONIC KIDNEY DISEASE UPDATE: WHAT THE GENERALIST NEEDS TO KNOW  I am on the Scientific Advisory Boards with stock option compensation for the following companies: MICHAEL G. SHLIPAK, MD, MPH  TAI Diagnostics SCIENTIFIC DIRECTOR , KIDNEY HEALTH RESEARCH COLLABORATIVE  Cricket Health, Inc. PROFESSOR OF MEDICINE, EPIDEMIOLOGY & BIOSTATISTICS UNIVERSITY OF CALIFORNIA, SAN FRANCISCO ASSOCIATE CHIEF OF MEDICINE FOR RESEARCH DEVELOPMENT SAN FRANCISCO VA MEDICAL CENTER August 8, 2019 Outline Outline  Definition and Complications  Definition and Complications  New CKD Staging 2013  New CKD Staging 2013  Screening for CKD  Screening for CKD  Introduction to Cystatin C  Introduction to Cystatin C  Treatment of CKD  Treatment of CKD  Hyperkalemia  Hyperkalemia 1

  2. 8/9/2019 Question 1: Which of these patients has CKD? Heart failure patient in ED with creatinine A. DEFINITION & CLASSIFICATION of 2.0 OF CHRONIC KIDNEY DISEASE 44% Diabetes patient with albumin/creatinine B. 35% of 100 mg/g, creatinine= 1.0 mg/dL KDIGO 2012 Clinical Practice Guideline (CPG) for the Evaluation and Management of Chronic Kidney Disease 35 year old African American man with 15% C. Kidney inter., Suppl. 2013; 3: 1–150 creatinine of 1.5 6% All of the above D. e . v . . . . . . . o n r b h e i t m a t i n w A e e h i t n t t n a a f p e c o i i e t r l a f A l r A u p d i l s a e o l f t t e r r b a a e a e i y H D 5 3 Introduction Definition and Complications  Overall CKD definition unchanged  Chronic Kidney Disease (CKD):  Defined in 2002 with original CKD staging  Chronic kidney disease: >3 month duration of either:  Decreased kidney function (GFR<60)  Replaced earlier terms “chronic renal insufficiency”,  Injury/damage to the kidney (e.g. albuminuria, cysts, stones) “chronic renal failure”, or “high creatinine”  Etiology of CKD:  Previous 5 CKD stages were developed by an expert Common diseases treated by generalists: diabetes, hypertension, a) panel cardiovascular disease, heart failure Other systemic diseases typically treated by specialists : systemic  Most CKD epidemiology research has been conducted b) lupus erythematosus, HIV, urological diseases since the 5 stages were defined Primary kidney disease: polycystic kidney disease, glomerular c) disease 2

  3. 8/9/2019 Prognosis by eGFR and Albuminuria Complications of CKD  Kidney failure (end-stage renal disease)  Key meta-analysis published in 2010 in Lancet  Death  Evaluated prognosis by eGFR and albuminuria  Other chronic disease:  21 studies, 1.2 million patients  Atherosclerotic Cardiovascular Disease  Heart failure  Predictor:  Osteoporosis/fracture  eGFR categories  Cognitive impairment/dementia  Albuminuria (ACR categories)  Frailty  Outcome: mortality risk  Treatment Complications:  Medications  Procedures Albuminuria and eGFR grid ESRD Risk Chronic Kidney Disease Prognosis Consortium . Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality : a collaborative meta-analysis. Lancet 2010 Kidney Failure Equation: kidneyfailurerisk.com AGE, SEX, RACE and CARDIOVASCULAR RISK FACTOR ADJUSTED HAZARD RATIO for All-cause Mortality Albuminuria Classes (mg/g) <10 10-29 30-300 >300 All Albuminuria Classes (mg/g) <10 10-29 30-300 >300 All >105 1.0 1.4 0.1 4.4 1.2 >105 1.0 1.4 2.0 4.4 1.2 90-104 1.0 1.3 0.1 3.1 1.0 eGFR 75-89 0.9 1.2 0.1 2.5 1.0 90-104 1.0 1.3 1.5 3.1 1.0 (mL/min/ 60-74 0.9 1.2 0.3 3.0 1.3 eGFR 75-89 0.9 1.2 1.7 2.5 1.0 1.73m 2 ) 45-59 0.1 0.8 1.4 5.3 0.3 (mL/min/ 60-74 0.9 1.2 1.8 3.0 1.3 30-44 1.7 2.1 9.2 4.4 4.0 1.73m 2 ) 45-59 1.2 1.5 1.9 3.4 2.0 15-29 4.0 3.0 37.7 6.0 3.6 30-44 1.7 2.1 3.0 4.4 4.0 All 1.0 1.3 1.6 3.6 15-29 4.0 3.0 4.2 6.0 3.6 *P<0.05 All 1.0 1.3 2.0 3.6 *P<0.05 CKD Prognosis Consortium. Lancet: 2073-81. 2010 CKD Prognosis Consortium. Kidney Int. 2011; 80(1): 93-104 3

  4. 8/9/2019 Outline CKD Stages and Prevalence  Definition and Complications U.S. Prevalence Estimated GFR CKD Stage N (1000’s) (mL/min per 1.73 m 2 )  New CKD Staging 2013 (%) CKD Stage 1 90+* 3,200 (1.6)  Screening for CKD CKD Stage 2 60-89* 6,500 (3.2)  Introduction to Cystatin C CKD Stage 3 30–59 15,500 (7.7)  Treatment of CKD CKD Stage 4 15–29 700 (0.4)  Hyperkalemia CKD Stage 5 <15 (or dialysis) 400 (0.2) * With evidence of kidney damage, e.g. albuminuria KDOQI Guidelines, AJKD, Feb. 2002 Problems with Old Staging From Old to New Staging  Stages 1 and 2 were the same CGA Staging (like TMN) replaces the prior 5 stages of CKD U.S. Prevalence Estimated GFR • “CKD” is an inadequate GFR CKD Stage N (1000’s)  Stage 3 (30-60) was too broad; eGFR of 30-45 is Cause Albuminuria (mL/min per 1.73 m 2 ) (mL/min per 1.73 m 2 ) descriptor (like diabetes) (%) very different from 45-60 • Hypertensive with eGFR= 50, CKD Stage 1 90+* 3,200 (1.6) Diabetes G1 (>90) A1 (ACR< 30) ACR= 10  Did not address levels of albuminuria; and only Hypertension G2 (60-89) A2 (ACR 30-300) • Diabetic CKD with eGFR= 75, CKD Stage 2 60-89* 6,500 (3.2) used albuminuria for Stages 1 and 2 ACR= 500 Polycystic Disease G3a (45 -59) A3 (ACR > 300) CKD Stage 3 30–59 15,500 (7.7) GN G3b (30 -44) Unknown CKD Stage 4 G4 (15 15–29 -29) 700 (0.4) G5 (< 15) CKD Stage 5 <15 (or dialysis) 400 (0.2) 4

  5. 8/9/2019 CGA Staging for CKD Outline  Definition and Complications  It is recommended that CKD be classified by:  New CKD Staging 2013  Cause  Screening for CKD  GFR category  Introduction to Cystatin C  Albuminuria category  Treatment of CKD Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic  Hyperkalemia Kidney Disease. Kidney inter., Suppl. 2013; 3: 1–150. Screening for CKD Who to Screen with Urine Albumin?  International CKD guidelines do not address when  Primary prevention screens: or how to screen  Diabetes- annual  No RCT evidence for or against  Hypertension  Relative costs of screening vary by region  Elderly  Hypertension, Diabetes, and CVD guidelines all  CKD Staging: recommend some form of CKD screening.  Urine albumin is now important part of CKD staging  The following are my suggestions for primary care:  Should be measured and documented in all CKD patients  Repeat annually in diabetics  every 2-3 years in non-diabetics 5

  6. 8/9/2019 How to Measure Urine Albumin Who and When to Check Creatinine?  Begin screening:  Often listed as “microalbumin panel”  Age >40 lower-risk populations  Focus on albumin/creatinine ratio (ACR):  Age >30 Blacks, Native Americans ACR (mg/g) OLD NEW  Diagnosis of hypertension, diabetes, cardiovascular < 30 Normal Normal or mildly disease, heart failure elevated 30-300 Microalbuminuria Moderately elevated  Frequency of creatinine monitoring (no evidence)  No risk factors: 3-5 years >300 Macroalbuminuria Severely elevated  Risk factors: 1-2 years  Dipstick: “trace” is abnormal  Creatinine cost: $0.20  If dipstick is abnormal, quantify ACR Question 3: Which of the following is GFR Estimation from Creatinine true about creatinine GFR estimates?  Estimated GFR: More accurate in older populations than A. middle-aged because prevalence of  Automatic reporting by most labs kidney disease is higher  Equations are rough 75%  <60 concerning for kidney disease, but not specific They have been validated in most ethnic B.  >60- so imprecise, its considered just “>60” groups  3 equations in current use: They are more likely to be accurate in C.  Cockroft-Gault (Nephron, 1976)- used by FDA and healthy persons than in persons with 17% pharmacies 6% chronic illness 3%  MDRD (Annals, 1999)- used for most automated reporting  CKD-EPI (Annals, 2009)- favored by researchers All of the above e D. . . . v . . . o . e b . . t b a r o a e d t d e l i y h o l a e l t v n k f n o i e l i e l e e l t r A a b o r u e m v c c a e h a r a e y r e y o h e M T h T 6

Recommend


More recommend