1. Sheffield Kidney Institute Global Kidney Academy CKD Micro-Lecture Epidemiology, Screening and Guidelines Professor Meguid El Nahas, PhD, FRCP Sheffield Kidney Institute UK

2. Sheffield Kidney Institute Lysaght, J Am Soc Nephrol, 2002 Global ESRD 1990 2003 2010 426,000 1,000,000 2,000,000

3. Sheffield Kidney Institute USRDS Incident counts & adjusted rates, by age

4. Sheffield Kidney Institute USRDS Incident counts & adjusted rates, by primary diagnosis Incident ESRD patients; rates adjusted for age, gender, & race.

5. Sheffield Kidney Institute ESRD 0.1% Undetected CKD: 10-15%?!

6. Sheffield Kidney Institute eGFR MDRD 4 variables formula: eGFRml/min/1.73m 2 = 175 x{[sCr / 88.4] -1.154 }x age (years) -.203 x 0.742 if F x1.21 B

7. Sheffield Kidney Institute K/DOQI CKD Classification StageDescriptionGFR 1Kidney damage/normal GFR*>90ml/min 2Mild renal insufficiency89-60 3Moderate renal insufficiency59-30 4Severe renal insufficiency29-15 5Kidney Failure<15

8. Sheffield Kidney Institute NICE Stages of CKD CKD StageDescription (eGFR ml/min/1.73m 2 ) Stage 1Normal eGFR (>90) With other evidence of kidney damage* Stage 2eGFR 60 – 90 With other evidence of kidney damage* Stage 3a Stage 3b eGFR 45-59 eGFR 30-44 Stage 4eGFR 15 – 29 Stage 5eGFR < 15 * Evidence of chronic kidney damage includes: persistent microalbuminuria or proteinuria, haematuria, structural abnormalities, biopsy proven glomerulonephritis.

9. Sheffield Kidney Institute Growth in recognition of Chronic kidney disease UK CKD KDOQI

10. Sheffield Kidney Institute Albuminuria & Age MONICA NHANESIII 14,622 19% 32.7% 15% Garg et al, 2002

11. Sheffield Kidney Institute eGFR MDRD 4 variables formula: eGFRml/min/1.73m 2 = 175 x{[sCr / 88.4] -1.154 }x age (years) -.203 x 0.742 if F x1.21 B

12. Sheffield Kidney Institute MDRD & GC Poggio et al, 2005

13. Sheffield Kidney Institute CKD and the ageing Population

14. Sheffield Kidney Institute CKD CVD

15. Sheffield Kidney Institute Hillege et al, 2002 Arnlov et al, 2005 Microalbuminuria and Survival

16. Sheffield Kidney Institute CKD and CVD Risk HOORN Study, Henry et al, 2002 Pooled Analysis, Weiner et al, 2004 eGFR<60 eGFR>60

17. Sheffield Kidney Institute Screening At-risk Population Diabetics Hypertensives CVD Relatives of CKD5 Systemic vasculitis Recurrent UTIs, and urological problems Chronic NSAIDs

18. Sheffield Kidney Institute CKD management guidelines ParameterTargetAgent used BP 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 achievableACEi/ ARBs sCholesterol Refer to national guidelines Lifestyle Standard CV risk reduction measures, including salt restriction Avoid NSAIDs, COX2s and radiocontrast agents

19. Sheffield Kidney Institute Evolution

20. Sheffield Kidney Institute CKD management guidelines ParameterTargetAgent used BP130/80 mmHg or 125/75 in DM and those with proteinuria Start with ACEI or ARBs if proteinuria >1g/24h or DM ProteinuriaLowest 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

21. Sheffield Kidney Institute Locatelli et al 1996

22. Sheffield Kidney Institute

25. CKD (Stages 3-5) management of complications ComplicationTargetManagement Anaemia Hb 10.5-12.5 g/dlReplace deficiencies Erythropoietin in CKD stage 4-5 Renal osteodystrophy (Stages 4& 5 only) Ca: 2.2-2.35 mmol/l PO4 <1.7 mmol/l Calcium carbonate / alfacalcidol Phosphate binders Acidosis Venous Bicarbonate > 22 mmol/lSodium bicarbonate Undernutrition Adequate calorie & normal protein intake Infections Chest infections Hepatitis B Immunize: influenza & pneumococcus vaccination (CKD stages 4-5)

26. Sheffield Kidney Institute CKD CVD MINIMIZE