1、Chronic Kidney Disease in the United States,Reasons for a National Kidney Disease Education Program,Kidney failure is a public health problem Economical, effective testing and therapy exist Testing and therapy are inadequately applied,ESRD Rates Continue to Rise,USRDS, 2004,Kidney Failure Compared t
2、o Cancer Deaths in the U.S. in 2000 (in Thousands),Seer, 2004,Prevalence of Renal Insufficiency in U.S.,Thus, about 8 million Americans have a GFR less than 60 mL/min/1.73 m2. Plus 11 million more have a GFR over 60 but have persistent microalbuminuria.,Coresh, et al., 2005,Incident Counts & Adjuste
3、d Rates, By Primary Diagnosis,USRDS, 2004,USRDS, 2000,Incidence of Kidney Failure (per million population, 2000, by HSA, unadjusted),USRDS, 2000,The Risk of Kidney Failure is Not Uniform,Relative risks compared to Whites:African Americans 3.8 XNative Americans 2.0 XAsians/Pacific Islander 1.3 XThe r
4、elative risk of Hispanics compared to non-Hispanics is about 1.5 X,USRDS, 2004,Costs of Kidney Failure are High (in $billions for 2002),USRDS, 2004,CKD Predicts CVD,Go, et al., 2004,Age-Standardized Rate of Cardiovascular Events (per 100 person-yr),Estimated GFR (mL/min/1.73 m2),Treatment to Prevent
5、 Progression of CKD to Kidney Failure,Intensive glycemic control lessens progression from microalbuminuria in type 1 diabetes - DCCT, 1993 Antihypertensive therapy with ACE Inhibitors lessens proteinuria and progression- Giatras, et al., 1997- Psait, et al., 2000- Jafar, et al., 2001 Low protein die
6、ts lessen progression- Fouque, et al., 1992- Pedrini, et al., 1996- Kasiske, et al., 1998,Meta-Analyses,Meta-Analyses,CKD is Not Being Recognized or Treated,Most practices screen fewer than 20% of their Medicare patients with diabetes* Patients are referred late to a nephrologist, especially African
7、-American men Less than 1/3 of people with identified CKD get an ACE Inhibitor,Kinchen, et al., 2002; McClellan et al.,1997 *Data provided by the USRDS based on 5 percent Medicare enrollment and claims data,Is “System Level” Action Necessary?,Universal medical coverage? Disease management teams? Imp
8、roved reimbursement for prevention? Other?,Age-Adjusted Cardiovascular Death is Declining,Parallels Between Hypertension in 1972 and Kidney Disease in 2005,Recent documentation of effective therapy Treatment of a silent disease to reduce risk for a disastrous outcome Simple screening Advantages for
9、patients, physicians, industry,Who to Test for Chronic Kidney Disease,Regular testing of people at risk Diabetes Hypertension Relative with kidney failure Cardiovascular disease,How to Test for Chronic Kidney Disease*,In individuals with diabetes: “Spot” urine albumin to creatinine ratioIn others at
10、 risk: “Spot” urine albumin to creatinine ratio OR standard dipstick (Bouleware, et al., 2003) Estimate GFR from serum creatinine using the MDRD prediction equation*24 hour urine collections are NOT needed. Diabetics should be tested once a year. Others at risk testing less frequently as long as nor
11、mal.,At What Level of Creatinine Does a 65-Year-Old Diabetic, Hypertensive White Woman Weighing 50 Kilograms Have CKD?,77% said: Creatinine 1.5 mg / dlCreatinine = 1.0 for GFR = 59 mL/min/1.73 m2,GFR = 37 mL/min/ 1.73 m2 Ccreat = 30 mL/min,Who Should be Treated for Chronic Kidney Disease,With diabet
12、es: With urine albumin/creatinine ratios more than 30mg albumin/1 gram creatinine Without diabetes: With urine albumin/creatinine ratios more than 300mg albumin/1 gram creatinine corresponding to about 1+ on standard dipstick Or Any patient: With estimated GFR less than 60 mL/min/1.73 m2,How to Trea
13、t for Chronic Kidney Disease,Maintain blood pressure less than 130/80 mmHg Use an ACE Inhibitor or ARB More than one drug is usually required and a diuretic should be part of the regimen Continue best possible glycemic control in individuals with diabetes,How to Treat for Chronic Kidney Disease (con
14、tinued),Refer to dietician for a reduced protein diet Consult a nephrologist early Team with the nephrologist for care if GFR is less than 30 mL/min/1.73 m2 Monitor hemoglobin and phosphorous with treatment as needed Treat cardiovascular risk, especially smoking and hypercholesterolemia,Early Treatm
15、ent Makes a Difference,Brenner, et al., 2001,Target Audiences,African Americans with- Diabetes- Hypertension - Family history of kidney failure Primary Care Providers,NKDEP Activities,“You Have The Power To Prevent Kidney Disease” awareness campaign Improved laboratory measurements and routine repor
16、ting of kidney function CKD quality indicators among Medicare beneficiaries hospitalized for cardiovascular disease Consult letter template for nephrologists Working with other non-profit, industry, and government groups,PCP Must be Engaged,7.7 million people with GFR 30-60 mL/min/1.73 m2 About 5,00
17、0 full-time nephrologists Nearly 1,500 new patients per nephrologistTherefore, 7 new patients per day per nephrologist. Obviously not possible.,What can Primary Care Providers do?,Recognize who is at risk Provide testing and treatment Encourage labs to provide and report estimated GFR and spot urine
18、 albumin/creatinine ratios,You Have The Power To Prevent Kidney Disease,www.nkdep.nih.gov,References,Bouleware LE, Jaar BG, Tarver-Carr ME, Brancati FL, Powe NR. Screening for Proteinuria in US Adults: A cost-effectiveness analysis. Journal of the American Medical Association. 2003 Dec; 290(23):3101
19、-3114. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S, the RENAAL Study Investigators. Effects of Losartan on Renal and Cardiovascular Outcomes in Patients with Type 2 Diabetes and Nephropathy. New England Journal of Medicine. 2001 Sep
20、20;345(12):861-9. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of Renal Insufficiency in the U.S. American Journal of Kidney Disease. 2003 Jan;41(1):1-12. Coresh J, Byrd-Holt D, Astor BC, Briggs JP, Eggers, PW, Lacher DA, Hostetter TH. Chronic Kidney Disease Awareness. Prevalence, a
21、nd Trends among U.S. Adults, 1999 to 2000. Journal of the American Society of Nephrology. 2005 Jan;16(1):180-8. Go AS, Chertow GM, Fan D, McCulloch CE, Chi-Yuan H. Chronic Kidney Disease and the Risks of Death, Cardiovascular Events, and Hospitalization. New England Journal of Medicine. 2004 Sep 23;
22、351(13):1296-1305.,References (continued),Kinchen KS, Sadler J, Fink N, Brookmeyer R, Klag MJ, Levey AS, Powe NR. The Timing of Specialist Evaluation in Chronic Kidney Disease and Mortality. Annals of Internal Medicine. 2002 Sep 17;137(6):479-86. McClellan WM, Ramirez SP, Jurkovitz C. Screening for
23、Chronic Kidney Disease: Unresolved Issues. Journal of the American Society of Nephrology. 2003 Jul;14 (7 Suppl 2):S81-7. Review. McClellan WM, Knight DF, Karp H, Brown WW. Early Detection and Treatment of Renal Disease in Hospitalized Diabetic and Hypertensive Patients: Important Differences Between
24、 Practice and Published Guidelines. 1997 Mar;29(3):368-75. National Diabetes Information Clearing House. Diabetes Control and Complications Trial (DCCT). Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, US Department of Health and Human
25、Services; 1993 (NIH Publication No. 02-3874). Available from: http:/diabetes.niddk.nih.gov/dm/pubs/control/,References (continued),Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Fay MP, Feuer EJ, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2000, National Cancer
26、Institute. Bethesda, MD, http:/seer.cancer.gov/csr/1975_2000/,2003. U.S. Renal Data System, USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2004. U.S.
27、Renal Data System, USRDS 2003 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2003. U.S. Renal Data System, USRDS 2000 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2000.,
