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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
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USRDSIncident counts & adjusted
rates, by age
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USRDSIncident counts & adjusted rates,
by primary diagnosis
Incident ESRD patients; rates adjusted for age, gender, & race.
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ESRD0.1%
Undetected CKD: 10-15%?!
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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
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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
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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.
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Growth in recognition of Chronic kidney disease
UK CKD KDOQI
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Albuminuria & Age
MONICANHANESIII
14,622
19% 32.7%15%
Garg et al, 2002
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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
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MDRD & GC
Poggio et al, 2005
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CKD and the ageing Population
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CKDCVD
Sheffield Kidney InstituteHillege et al, 2002 Arnlov et al, 2005
Microalbuminuria and Survival
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CKD and CVD Risk
HOORN Study, Henry et al, 2002 Pooled Analysis, Weiner et al, 2004
eGFR<60
eGFR>60
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Screening At-risk Population
• Diabetics• Hypertensives• CVD • Relatives of CKD5• Systemic vasculitis• Recurrent UTIs, and urological problems• Chronic NSAIDs
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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
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Evolution
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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
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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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