chronic kidney disease ekha: world kidney day …ekha: world kidney day chronic kidney disease can...
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EKH
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orld
Kid
ney
Day
Chronic Kidney Disease
Can dialysis be prevented?
Ron Gansevoort, nephrologist University Medical Center Groningen
The Netherlands
Brussels, March 5, 2013
Nr. of patients on Renal Replacement Therapy
284,000
1995 2000 2005 2010 2015
360,000 435,000
503,000 ~565,000
ERA-EDTA Registry
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Direct medical costs: ~21 billion Euro/yr
Calculated for the EU-27 countries
2. Dialysis is nowadays also started in elderly and frail patients, who were previously not accepted for dialysis
✚ Europe has an aging population
The number of patients on RRT increases EK
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3. Death rates due to cardiovascular disease have decreased. Consequently these patients now face the chronic complications of atherosclerosis: a.o. kidney failure
Why?
1. Changes in lifestyle have led to more diabetes and hypertension, the main causes for chronic kidney disease
How to prevent progression of CKD?
Kidney function
0%
10%
Follow-up (years)
0 1 2 3 4 5 6 7 8 9 10
Late intervention
Early intervention
Start dialysis
60%
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Kid
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Day
Can we detect CKD in an early phase?
Duration of diabetic kidney disease (years)
10
30
100
1.000
10.000
3.000
0
30
60
90
120
Urin
ary
prot
ein
loss
(mg/
d)
Kid
ney
func
tion
(%)
Normal
Moderately increased
Severely increased
Normal
Impaired
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Kid
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Kidney function
Urinary protein loss
Dialysis
Incidence of Renal Replacement Therapy EK
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Urinary protein loss positive Urinary protein loss negative
0.01
0.1
1.0
10
100
1000
Kidney function (%) 0 30 60 90 120
Number of subjects starting RRT per 1000 screenees
Iseki et al, Am J Kidney Dis 2004
Screening the general population, n=95.252, follow-up: 7 years
Simple dipstick test:
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Matsushita et al, Lancet 2010, Gansevoort et al, Kidney Int 2011
Meta-analysis of 41 cohort studie including more than 1.5 million people
Incidence of (cardiovascular) mortality
Kidney function (%) Kidney function (%)
The new International Classification of CKD
Urinary protein loss
Kid
ney
func
tion
<30 mg/d
30-300 mg/d
>300 mg/d
>90%
60-90%
45-60%
30-45%
15-30%
<15%
No CKD (89%)
Mild risk (8%)
Moderate risk (2%)
High risk (~1%)
KDIGO Guidelines for Definition and Classification of CKD
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Kidney International 2013 Lever, Coresh, Matsushita and Gansevoort et al
CKD amplifies cardiovascular risk EK
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Atherosclerosis Coronary artery disease
Valvular disease Left ventricular hypertrophy
Decreased coronary perfusion Arrhytmias
Early CKD Kidney function >60% Urinary protein loss +
Mild to moderate CKD Kidney function 60 – 30%
Severe CKD Kidney function <30%
Gansevoort et al, Lancet (in press)
Acute kidney injury
27,5 32,9 41,1 48,858,0
34,6 28,125,9
24,4 7,5
37,9 39,0 33,0 26,8 34,5
0%10%20%30%40%50%60%70%80%90%
100%
Normal 60 - 45% 45 - 30% 30 - 15% <15% or RRT
Kidney function
OthersCancerCardiovascular
Causes of death in CKD EK
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Gansevoort et al, Lancet (in press)
Alberta Kidney Disease Network data Adjusted for age and gender N=949,119. Courtesy: Brenda Hemmelgarn
Kidney function
40,9
19,9
36,9
18,8
23,9
12,4
15,3
7,212,1
5,6
0
5
10
15
20
25
30
35
40
45
30 35 40 45 50 55 60 65 70 75 80
Age (years)
Normal kidney function
60 - 45%
45 - 30%
30 - 15%
<15% or RRT
Life
exp
ecta
ncy
(in
year
s)
Chronic Kidney Disease and life expectancy
Gansevoort et al, Lancet (in press)
Alberta Kidney Disease Network data N=949,119. Courtesy: Brenda Hemmelgarn
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Kid
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Costs attributable to CKD
2012 Reports of the US MediCare and Renal Database System
Population Costs
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RRT 0.1% RRT 6.8%
Interventions to improve prognosis? EK
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Strict blood pressure control Lowering of urinary protein loss (RAASi)
Strict diabetes regulation Stop smoking Fight obesity
Use healthy food
Can cardiovascular disease in CKD be prevented?
medication diet
Strict blood pressure control Strict diabetes regulation
Lowering cholesterol Stop smoking Fight obesity
Use healthy food
diet medication
Food and CKD EK
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Medication and food interact EK
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Kidney Events
Cardiovascular events
Normal blood pressure lowering agents
Normal blood pressure lowering agents
RAAS inhibitors
RAAS inhibitors
Lambers Heerspink et al, J Am Soc Nephrol 2012
RENAAL / IDNT studies, N=1177 patients Diabetic kidney disease, protein loss > 300 mg/d
Prevention works !!! EK
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2012 Report of the US Renal Database System Adjusted for age and gender
Patient awareness of early CKD is low EK
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than 30% function Less
than 30% function
Less than 10% function
no symptoms
life threatening
symptoms
Fatigue
Itching
Nausea
Loss of appetite
Weight loss
Screening for early CKD is inadequate EK
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2012 Report of the US Renal Database System
Kidney function Urinary protein loss
Both tests
50
55
60
65
70
75
80
85
90
95
100
Normal 60-45 45-30 30-15 <15 orRRT
Kidney function (%)
AspirinNovel platelet blockersBeta-blockerStatin
Therapeutic nihilism in CKD EK
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50
55
60
65
70
75
80
85
90
95
100
Normal 60-45 45-30 30-15 <15 orRRT
Kidney function (%)
Smoking cessation Cardiac rehabilatationDietExercise
Fox et al, Circulation 2010
N=30.462 Registry of patients admitted to a coronary care unit
Drug treatment at discharge
Life style advice at discharge
Percentage Percentage
TAKE CARE
BETTER START WORKING!
DOCTORS
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We need guidelines
Key Messages EK
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- Late stage CKD, with need for renal replacement therapy - Early stage CKD, with a high risk for cardiovascular events
High burden of disease for subjects involved (QoL and morbidity) and for the society at large (costs).
Prevention is possible, but we need to increase awareness among doctors and patients to improve early identification of high risk patients, in whom treatment should be started.
MEPs can help: - Implement guidelines, especially for general practice - Implement screening programs - Regulation of food industry, and influencing healthy behavior - Stimulate research (Horizon 2020)