1. Chronic Kidney Disease (CKD) Dr. Sham Sunder

2. Now we know why the titanic sank !! < 0.5 % 5- 10%

3. CKD – A scary Challenge for Us all !! CKD – Chronic kidney disease

4. We have intricate things to learn !!

5. Practice Guidelines of CKD The National Kidney Foundation (NKF) National Kidney Diseases Education Program The NKDEP KIDNEY / DISEASE OUTCOMES QUALITY INITIATIVE The K/DOQI

6. Physicians Must be Engaged Indian scenario 1. 80 lak pts with eGFR 30-60 ml/min/1.73 m 2 2. Pts with albuminuria are double this number 3. About 2,000 full-time nephrologists 4. Nearly 4,000 new patients per nephrologist 5. Means 11 new pts per day per nephrologist 6. Obviously not possible. Physicians must treat CKD

7. CKD – A Silent Killer CKD – Increased Death CKD at a glance CKD – A Global Pandemic CKD – A Global Pandemic CKD 1-2 are asymptomatic CKD 1-2 are asymptomatic Third after CVD, Cancer Third after CVD, Cancer 1 in 10 Indians have CKD 1 in 10 Indians have CKD 10 million people of CKD 10 million people of CKD Term ‘CRF’ no longer used Term ‘CRF’ no longer used Dialysis ↑ death rate 100 x Dialysis ↑ death rate 100 x Small ↑ in Creat - ↑ ↑ in CV Small ↑ in Creat - ↑ ↑ in CV

8. The Nephron

9. Filtration, Reabsorption and Secretion Normal GFR 120 ml/min/1.73m 2 Only 20% nephrons work at a time In a day 210 L of water is filtered 2 L /day of urine is excreted

10. Definition of CKD 1. Either GFR < 60 ml/min/1.73m 2 for  3 mon or 2. Kidney damage for  3 mon as manifested by a. Persistent microalbuminuria / macroproteinuria b. Biochemical abnormalities in RFT c. Persistent non-urological hematuria d. Structural renal abnormalities by USG e. Biopsy proven Glomerulonephritis (rarely needed) (Any one of the above evidences)

11. CKD Clinical Stages StageDescription GFR (ml/min/1.73 m 2 ) 1 Kidney damage with normal or ↑ GFR  90 2 Kidney damage with mild  GFR 60-89 3 Kidney damage with moderate  GFR 30-59 4 Severe  GFR 15-29 5 Kidney Failure (ESRD) < 15 (or dialysis)

12. ESRD versus Total CKD

13. K/DOQI CKD Staging

14. Natural History of Nephropathy

15. Definition of ESRD vs Kidney Failure ESRD is a federal government defined term that indicates chronic treatment by dialysis or transplantation ESRD is a federal government defined term that indicates chronic treatment by dialysis or transplantation Kidney Failure: GFR < 15 ml/min/1.73 m 2 or on dialysis Kidney Failure: GFR < 15 ml/min/1.73 m 2 or on dialysis

16. Global profile of ESRD

17. Prevalence of Abnormalities at each level of GFR *>140/90 or antihypertensive medicationp-trend < 0.001 for each abnormality

18. CKD Features – Stage wise CKDeGFRB.PACRUrineEdemaAnemia Ca x P SHPT Stage 1 >90NMAUNNoNoNNo Stage 2 60+↑MAU↑NoNNo Stage 3 30 + ↑ALB↑NoN Stage 4 15+↑ALB↑↓↑↑ Stage 5 <15↑↑ALB↓↑↑

19. Death rates from all causes (panel A) and cardiovascular events (panel B), as per eGFR Go, A, et al. NEJM 351: 1296

20. Physicians and Nephrologist in CKD

21. How to handle CKD ? A A1c < 6.5, ACEi, ARBs A A1c < 6.5, ACEi, ARBs BBlood pressure < 125/75 BBlood pressure < 125/75 CCholesterol LDL < 100 CCholesterol LDL < 100 DDrugs – avoid nephrotoxicity DDrugs – avoid nephrotoxicity Diet – Moderate in protein Na, K, Ph, Fluids, Cal Na, K, Ph, Fluids, Cal

22. CKD – Management Strategy 1. Decrease Cardiovascular Risk 2. Arrest or slow progression to ESRD 3. Manage complications – 1. Anemia (Normocytic normochromic) 2. Bone loss (Renal osteodystrophy)

23. CKD – Management Goals 1. Blood pressure < 125/75 HT is both a cause and consequence HT is both a cause and consequence 2. Glycemic control – Hb A1c < 6.5 3. Hemoglobin level > 11 g% 4. Calcium x Phosphorous product < 50 Normal values : GFR 120 to 150 ml/min/1.73m2 Ca 9 to10.5mg%, Ph 3 to 4.5mg%, Ca x Ph < 50 iPTH 150 to 300 pg/ml

24. Early treatment makes a difference in CKD Brenner, et al., 2001

25. CKD death Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies Complications Screening for CKD risk factors CKD risk reduction; Screening for CKD Diagnosis & treatment; Rx. comorbid conditions; ↓ progression Estimate progression; Rx. complications; Prepare for replacement Replacement by dialysis & transplant Normal Increased risk Kidney failure Damage  GFR

26. Stage-wise management of CKD Stage 0 Test for CKD, Management of Risk Factors Stage 1 Manage co-morbidity, Rx. of CVD and RF Stage 2 Slow rate of loss of Kidney function - ACEi Stage 3 Prevent Anemia, Bone effects, Ca x Ph Stage 4 Preparation for RRT; refer to nephrology Stage 5 RRT – PD, HD or RT – Donor / Cadavre

28. Preparation for RRT Choice of Renal Replacement Choice of Renal Replacement Timely Access Surgery Timely Access Surgery Timely Dialysis initiation Timely Dialysis initiation When GFR < 25ml/min When GFR < 25ml/min Renal transplant is the first choice Renal transplant is the first choice Workup living donors Workup living donors If no donors available If no donors available List patient on cadavre transplant list List patient on cadavre transplant list Place A-V fistula if HD preferred Place A-V fistula if HD preferred

29. Conclusions CKD – ESRD patient population is increasing in our country CKD – ESRD patient population is increasing in our country Early detection and proper management has many advantages Early detection and proper management has many advantages Later stages, i.e. ESRD – RRT is required Later stages, i.e. ESRD – RRT is required Various modalities of RRT – Dialysis (Hemo/ Peritoneal) as well as renal transplantation available Various modalities of RRT – Dialysis (Hemo/ Peritoneal) as well as renal transplantation available

30. Let this not happen please! Normal ESRD