Circulation 2005
Circulation 2005
US Prevelance of CKD
Coresh J et al, Am J Kidney Dis 2003, 41:1-12
%
o
fP
o
p
u
la
c
ja
U
S
A
5.9
Mill
5.3
Mill
7.6
Mill
0.4
Mill
0.3
Mill
Ogółem
11% (19.2 Mill)
0.001
0.01
0.1
1
10
100
25-34 35-44 45-54 55-64 65-74 75-84
> 85
Age (years)
A
n
n
u
a
l
M
o
rt
a
li
ty
(
%
)
GP Male
GP Female
GP Black
GP White
Dialysis Male
Dialysis Female
Dialysis Black
Dialysis White
Sarnak . Am J Kidney Dis.
2000;35(suppl1):S117
Cardiovascular Mortality in the General Population
and in ESRD Treated by Dialysis
Patients with CKD are more
likely to die than go on to
dialysis
Adapted from Collins, Adv Studies in Med, (3C) 2003, Medicare Cohort 1998-99
25
%
30 %
40%
15 %
9%
Time to ESRD related to GFR decrease
of 2, 4, 8 ml/min/1.73 m
2
b.w. /year
ESRD
-2 ml/min/1.73 m2 body
weight/year
Hemodialysis treatment
Arteriovenous fistula.
One important step before starting
hemodialysis
Anemia Evaluation
• Hemoglobin (Hgb) and/or Hematocrit (Hct)
• Red blood cell (RBC) indices
• Reticulocyte count
• Iron parameters:
–Serum iron
–Total Iron Binding Capacity (TIBC)
–Percent transferrin saturation (serum iron
× 100 divided by TIBC) [TSAT]
–Serum ferritin
• A test for occult blood in stool
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
Bone Disease in Chronic Kidney Disease
• The pathophysiology of bone disease due to
secondary hyperparathyroidism is related to
abnormal mineral metabolism:
• (1) decreased kidney function leads to reduced
phosphorus excretion and consequent phosphorus
retention;
• (2) elevated serum phosphorus can directly
suppress calcitriol (dihydroxyvitamin D3)
production;
• (3) reduced kidney mass leads to decreased
calcitriol production;
• (4) decreased calcitriol production with
consequent reduced calcium absorption from the
gastrointestinal tract contributes to hypocalcemia,
as does abnormal calcium-phosphorus balance
leading to an elevated calcium-phosphorus product
Complications That May Prompt
Initiation of Kidney Replacement
Therapy
• Intractable ECV overload
Hyperkalemia
Metabolic acidosis
Hyperphosphatemia
Hypercalcemia or hypocalcemia
Anemia
Neurologic dysfunction (e.g., neuropathy,
encephalopathy)
Pleuritis or pericarditis
Otherwise unexplained decline in functioning
or well-being
Gastrointestinal dysfunction (e.g., nausea,
vomiting, diarrhea, gastroduodentitis)
Weight loss or other evidence of malnutrition
Hypertension uncontrolled
GUIDELINE 9. ASSOCIATION OF LEVEL OF GFR
WITH NUTRITIONAL STATUS
• Panels of Nutritional Measures for Nondialyzed
Patients: "For individuals with CRF (GFR <20
mL/min) protein-energy nutritional status
should be evaluated by serial measurements of
a panel of markers including at least one value
from each of the following clusters:
• (1)
Serum albumin;
• (2) Edema-free actual body weight, percent
standard (NHANES II) body weight, or
subjective global assessment (SGA); and
• (3) Normalized protein nitrogen appearance
(nPNA) or dietary interviews and diaries.
(Evidence and Opinion)"
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
PTFE graft
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
Structure of a typical hollow fiber dialyzer
The dialyzer is a large canister containing thousands of
small fibers through which your blood is passed. Dialysis
solution, the cleansing fluid, is pumped around these
fibers. The fibers allow wastes and extra fluids to pass
from your blood into the solution, which carries them
away. The dialyzer is sometimes called an artificial
kidney.
Arterial and venous needles.
Most dialysis centers use two needles—one to carry
blood to the dialyzer and one to return the cleaned
blood to your body.
• One important step before starting
hemodialysis is preparing a vascular
access, a site on your body from which
your blood is removed and returned.
• A vascular access should be prepared
at least 6 weeks or 3 months before
you start dialysis.
• It will allow easier and more efficient
removal and replacement of your
blood with fewer complications.
Getting Your Vascular Access Ready
Peritioneal dialysis (APD, CAPD)
Hemodialysis (high flux, low flux)
Hemofiltration
Hemodiafiltration
Kidney transplant
What are the treatment choices?
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
GUIDELINE 1. DEFINITION AND STAGES OF
CHRONIC KIDNEY DISEASE
Adverse outcomes of chronic kidney disease can often be
prevented or delayed through early detection and
treatment.
Earlier stages of chronic kidney disease can be detected
through routine laboratory measurements.
The presence of chronic kidney disease should be
established, based on presence of kidney damage and
level of kidney function (glomerular filtration rate [GFR]),
irrespective of diagnosis.
Among patients with chronic kidney disease, the stage of
disease should be assigned based on the level of kidney
function, irrespective of diagnosis, according to the
KDOQI CKD classification
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
Suspected prevalance of ESRD treated
on dialysis
Year (Dec. 31)
N
u
m
b
e
r
o
f
Pa
ti
e
n
ts
(
in
t
h
o
u
sa
n
d
s)
1978 1984 1990 1996 2002 2008 2014 2020 2026
0
1
0
0
0
2
0
0
0
3
0
0
0
384,458
790,028
1,620,951
3,126,268
Year (Dec. 31)
N
u
m
b
e
r
o
f
Pa
ti
e
n
ts
(
in
t
h
o
u
sa
n
d
s)
1978 1984 1990 1996 2002 2008 2014 2020 2026
0
1
0
0
0
2
0
0
0
3
0
0
0
384,458
645,689
1,005,237
1,502,040
Year (Dec. 31)
N
u
m
b
e
r
o
f
Pa
ti
e
n
ts
(
in
t
h
o
u
sa
n
d
s)
1978 1984 1990 1996 2002 2008 2014 2020 2026
0
1
0
0
0
2
0
0
0
3
0
0
0
384,458
724,567
1,315,198
2,228,682
Year (Dec. 31)
N
u
m
b
e
r
o
f
Pa
ti
e
n
ts
(
in
t
h
o
u
sa
n
d
s)
1978 1984 1990 1996 2002 2008 2014 2020 2026
0
1
0
0
0
2
0
0
0
3
0
0
0
384,458
790,028
1,620,951
3,126,268
Year (Dec. 31)
N
u
m
b
e
r
o
f
Pa
ti
e
n
ts
(
in
t
h
o
u
sa
n
d
s)
1978 1984 1990 1996 2002 2008 2014 2020 2026
0
1
0
0
0
2
0
0
0
3
0
0
0
384,458
645,689
1,005,237
1,502,040
Year (Dec. 31)
N
u
m
b
e
r
o
f
Pa
ti
e
n
ts
(
in
t
h
o
u
sa
n
d
s)
1978 1984 1990 1996 2002 2008 2014 2020 2026
0
1
0
0
0
2
0
0
0
3
0
0
0
384,458
724,567
1,315,198
2,228,682
Hemodialysis - costs of
treatment
Lysaght MJ.
Lysaght MJ.
J Am Soc Nephrol
J Am Soc Nephrol
2002;
2002;
13
13
: S37-S40.
: S37-S40.
1990
1990
2000
2000
2010
2010
2.5
2.5
0.5
0.5
1.0
1.0
1.5
1.5
2.0
2.0
0
0
Global HD
population
P
o
p
u
la
ti
o
n
(
m
il
li
o
n
s
)
P
o
p
u
la
ti
o
n
(
m
il
li
o
n
s
)
1200
1200
600
600
0
0
U
S
$
(
b
il
li
o
n
s
)
U
S
$
(
b
il
li
o
n
s
)
1981-1990
1981-1990
1991-2000
1991-2000
2001-2010
2001-2010
800
800
1000
1000
400
400
200
200
10-years
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
Estimating and Slowing Progression
of Chronic Kidney Disease in Adults
• GFR <60 mL/min/1.73 m2
• Fast GFR decline in the past ( 4 mL/min per year)
• Risk factors for faster progression
• Ongoing treatment to slow progression
• Exposure to risk factors for acute GFR decline.
KDOQI Clinical Practice Guidelines for Chronic
Kidney Disease: Evaluation, Classification, and
Stratification
$601 billion
$231 billion
$283
billion
