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

High blood pressure develops

during the course of chronic

kidney disease.

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