Chronic Kidney Chronic Kidney DiseaseDisease

What You Need to KnowWhat You Need to Know

Phil Ramos, MD, MSCIPhil Ramos, MD, MSCI

Denver Nephrologists, P.C.Denver Nephrologists, P.C.

ObjectivesObjectives

• What are the kidneys and how do What are the kidneys and how do they work?they work?

• What is Chronic Kidney Disease?What is Chronic Kidney Disease?• What are the causes?What are the causes?• How do I know if I have chronic How do I know if I have chronic

kidney disease?kidney disease?• How do I prevent this from How do I prevent this from

happening to me?happening to me?

The KidneyThe Kidney

• 2 bean-shaped 2 bean-shaped organsorgans

• the human body’s the human body’s internal filtersinternal filters

• Main Job: Main Job: Helps Helps Make Urine!Make Urine!

• Other important Other important functionsfunctions

The NephronThe Nephron• 1 million nephrons 1 million nephrons

per kidneyper kidney• Filters the blood Filters the blood

keeping the good keeping the good (proteins) and (proteins) and excreting the waste excreting the waste (toxins, drugs)(toxins, drugs)

• Regulation of Regulation of electrolytes (sodium, electrolytes (sodium, potassium, calcium potassium, calcium and phosphorus)and phosphorus)

• Regulation of WaterRegulation of Water

Other Important Other Important FunctionsFunctions

• Produces HormonesProduces Hormones• Helps Red Blood Cells Develop Helps Red Blood Cells Develop

((ErythropoietinErythropoietin))• Regulates Bone Health (calcium and Regulates Bone Health (calcium and

phosphorus) by producing a special phosphorus) by producing a special Vitamin DVitamin D

• Produces enzyme (Produces enzyme (ReninRenin) which helps ) which helps regulate salt balance and blood regulate salt balance and blood pressurepressure

Estimating Kidney Estimating Kidney FunctionFunction

• Measure blood (serum) creatinineMeasure blood (serum) creatinine• Estimated Glomerular Filtration RateEstimated Glomerular Filtration Rate

• eGFReGFR• Sum of all the filtration rate of the “working” Sum of all the filtration rate of the “working”

nephronsnephrons• The kidneys filter about 180 liters of blood per day The kidneys filter about 180 liters of blood per day

(125 milliliters per minute)(125 milliliters per minute)• Normal eGFR is 130 and 120 mL/min for men and Normal eGFR is 130 and 120 mL/min for men and

women, respectivelywomen, respectively• used clinically to assess the degree of kidney used clinically to assess the degree of kidney

impairment and to follow the course of the diseaseimpairment and to follow the course of the disease

What is Chronic Kidney What is Chronic Kidney DiseaseDisease

• Kidney damage for Kidney damage for 3 months3 months• Defined by structural or functional Defined by structural or functional

abnormalities of the kidney, with or without abnormalities of the kidney, with or without decreased eGFR (protein and/or blood in the decreased eGFR (protein and/or blood in the urine, multiple kidney cysts, small kidneys)urine, multiple kidney cysts, small kidneys)

• Reduced eGFR <60 mL/min for Reduced eGFR <60 mL/min for 3 months, with 3 months, with or without other evidence of kidney damageor without other evidence of kidney damage

• Staging for chronic kidney disease (CKD) Staging for chronic kidney disease (CKD) is primarily based on kidney function but also is primarily based on kidney function but also evidence of damage to the filtering units evidence of damage to the filtering units (glomeruli)(glomeruli)

National Kidney Foundation (NKF). Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.

CKD Progresses in CKD Progresses in Stages (Defined by Stages (Defined by

eGFR)eGFR)CKD

Stage DescriptionGFR

(mL/min/1.73 m2)

1 Kidney damage with normal or GFR

90

2 Kidney damage with mild GFR

60-89

3 Moderate GFR 30-59

4 Severe GFR 15-29

5 Kidney failure <15 or dialysis

NKF. Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.

The Epidemic of CKDThe Epidemic of CKD• Approximately 26 million Americans Approximately 26 million Americans

suffer from chronic kidney disease, suffer from chronic kidney disease, many of whom are undiagnosed since many of whom are undiagnosed since symptoms of kidney disease are not symptoms of kidney disease are not obvious until the kidneys totally failobvious until the kidneys totally fail

• Many more at risk…Many more at risk…• Over 500,000 Americans suffer from Over 500,000 Americans suffer from

end stage renal disease (ESRD) and end stage renal disease (ESRD) and this number continues to increase this number continues to increase yearly.yearly.

CKD Is a Growing CKD Is a Growing EpidemicEpidemic

CKD Stage Number of Individuals*

1 90 3.6 million

2 60-89 6.5 million

3 30-59 15.5 million

4 15-29 700,000

5 <15 or dialysis 500,000

GFR(mL/min/1.73 m2)

*Coresh et al. JAMA; 298 (17): 2038 (2007)United States Renal Data System, 2008

Risk Factors for CKDRisk Factors for CKD• DiabetesDiabetes• HypertensionHypertension• Vascular diseaseVascular disease• Kidney stonesKidney stones• Chronic urinary tract infectionsChronic urinary tract infections• Exposure to certain drugs and Chinese Exposure to certain drugs and Chinese

herbsherbs• High cholesterolHigh cholesterol• Obesity Obesity • SmokingSmoking

Diabetic Kidney Diabetic Kidney DiseaseDisease

Hypertension Kidney Hypertension Kidney DiseaseDisease

Medication Risk Factors: Medication Risk Factors: NSAID’sNSAID’s

• Non-Steroidal Anti-inflammatory Drugs Non-Steroidal Anti-inflammatory Drugs (NSAID’s)(NSAID’s)• Almost 60% of community-dwelling adults use Almost 60% of community-dwelling adults use

NSAID’sNSAID’s• Higher doses and longer exposure to NSAID’s Higher doses and longer exposure to NSAID’s

are associated with an increased risk of kidney are associated with an increased risk of kidney disease progression disease progression

• For those with CKD due to another cause, For those with CKD due to another cause, NSAIDs can worsen kidney function NSAIDs can worsen kidney function quickly. Consult your doctor about this.quickly. Consult your doctor about this.

Gooch, K. et. al. Am J Med 2007;120.

NSAID’sNSAID’s

• MotrinMotrin• NaprosynNaprosyn• IbuprofenIbuprofen• AleveAleve• BC PowderBC Powder• Daypro, Celebrex, Feldene, Lodine, Daypro, Celebrex, Feldene, Lodine,

Anaprox, Dolobid, VoltarenAnaprox, Dolobid, Voltaren

Signs/Symptoms of CKDSigns/Symptoms of CKD

• You cannot “feel” CKD at the early You cannot “feel” CKD at the early stagesstages

• The amount of urination can be The amount of urination can be “normal”, decreased, or even “normal”, decreased, or even increased with CKDincreased with CKD• Worsening high blood pressureWorsening high blood pressure• increased swelling in the legs, hands increased swelling in the legs, hands

or faceor face• foamy or bloody urinefoamy or bloody urine

Signs/Symptoms of End Signs/Symptoms of End Stage Renal Disease Stage Renal Disease

(ESRD)(ESRD)• decreased appetite and malnutritiondecreased appetite and malnutrition• metallic taste to foodmetallic taste to food• nausea, vomiting, stomach pain nausea, vomiting, stomach pain • chest pain and shortness of breathchest pain and shortness of breath• generalized itchinggeneralized itching• decreased concentration and memorydecreased concentration and memory• sleep disturbancessleep disturbances• numbness in the hands and feet numbness in the hands and feet • worsening anemia worsening anemia • bone fracturesbone fractures

Signs/Symptoms of End Signs/Symptoms of End Stage Renal Disease Stage Renal Disease

(ESRD)(ESRD)• Most Common Cause of Sickness Most Common Cause of Sickness

and Death in CKD and ESRD and Death in CKD and ESRD Cardiovascular Disease (heart Cardiovascular Disease (heart

attack, heart failure, stroke)attack, heart failure, stroke)

• CKD/ESRD highly associated with CKD/ESRD highly associated with cardiovascular disease compared to cardiovascular disease compared to the non-kidney disease populationthe non-kidney disease population

Blood and Urine Results Blood and Urine Results in CKD/ESRDin CKD/ESRD

• High blood urea nitrogen (BUN) and High blood urea nitrogen (BUN) and creatininecreatinine

• Worsening anemia (decreased red blood Worsening anemia (decreased red blood cells)cells)

• High blood phosphorus and low calcium. High blood phosphorus and low calcium. High parathyroid hormoneHigh parathyroid hormone

• High acid build up in blood and high blood High acid build up in blood and high blood potassiumpotassium

• Urine with microalbuminuria, proteinuria or Urine with microalbuminuria, proteinuria or hematuriahematuria

Urinary Tract Urinary Tract ObstructionObstruction

• Blockade of the Blockade of the urinary tract from urinary tract from kidneys to urethrakidneys to urethra• Kidney stonesKidney stones• Enlarged prostateEnlarged prostate• CancerCancer• Abnormal AnatomyAbnormal Anatomy

Renal Ultrasound to Renal Ultrasound to diagnosediagnose

Kidney CystsKidney Cysts

• Simple cysts not Simple cysts not bad bad

• Genetic diseases Genetic diseases associated with associated with multiple kidney multiple kidney cysts can cause cysts can cause ESRDESRD

Which Patients Should Be Which Patients Should Be Screened Screened for CKD?for CKD?

Susceptibility Risk Factors Progression Factors

• Diabetes

• Hypertension

• Older age

• Family history of nephropathy

• Racial or ethnic minority

• Other: kidney-mass reduction, known kidney disease

• Higher level of proteinuria

• Higher BP

• Poor glycemic control

• Smoking

• Hyperlipidemia

• Drug use

Levey et al. Ann Intern Med. 2003;139:137-147. USRDS. 1999 Annual Data Report. Available at: www.usrds.org.

Primary Goals of Primary Goals of Management in CKDManagement in CKD

• Diabetes ControlDiabetes Control• Hypertension controlHypertension control

• Simplified BP goals: <130/80Simplified BP goals: <130/80• Reduction of proteinuria with ACE-Inhibitors Reduction of proteinuria with ACE-Inhibitors

or ARBsor ARBs• High proteinuria through time scars the High proteinuria through time scars the

kidneyskidneys• Anemia controlAnemia control• Maintaining Bone Health (Secondary Maintaining Bone Health (Secondary

hyperparathyroidism)hyperparathyroidism)• Prevent progression with decreased Prevent progression with decreased

phosphorous in the diet and vitamin Dphosphorous in the diet and vitamin D

Primary Goals of Primary Goals of Management in CKDManagement in CKD

• Quit SmokingQuit Smoking• Control High CholesterolControl High Cholesterol• Avoid NSAIDs and adjust other medications Avoid NSAIDs and adjust other medications

for decreased renal functionfor decreased renal function• Low-potassium diet for blood potassium highLow-potassium diet for blood potassium high• Avoid iodine contrast injection in veins for Avoid iodine contrast injection in veins for

certain procedures unless absolutely certain procedures unless absolutely necessarynecessary

• Avoid dehydrationAvoid dehydration

ESRD and HemodialysisESRD and Hemodialysis

• When eGFR < 15 When eGFR < 15 ml/min and feeling ml/min and feeling sick for kidney failure sick for kidney failure (UREMIA)(UREMIA)

• Three times a week Three times a week for 3-4 hours at a for 3-4 hours at a timetime

• Can be done at home Can be done at home and at nightand at night

• Need arm “fistula” Need arm “fistula” placedplaced

ESRD and Peritoneal ESRD and Peritoneal DialysisDialysis

• Putting dialysis Putting dialysis fluid into the fluid into the abdominal spaceabdominal space

• Peritoneal catheterPeritoneal catheter• Advantage of Advantage of

dialyzing dialyzing continuously, at continuously, at work and home. work and home.

• Can perform at Can perform at nightnight

Renal TransplantationRenal Transplantation

• A great option A great option • Can be put on Can be put on

waiting list for a waiting list for a cadaveric kidneycadaveric kidney

• Can have a living Can have a living related or related or unrelated person unrelated person donate if they are donate if they are healthy enoughhealthy enough

Prevention of CKDPrevention of CKDMost ImportantMost Important

• Adhering to a low-fat, low-salt dietAdhering to a low-fat, low-salt diet• Controlling blood pressureControlling blood pressure• Regular exercise Regular exercise • Avoid the on-set of diabetesAvoid the on-set of diabetes• Avoid smokingAvoid smoking• Regular annual check-ups with your Regular annual check-ups with your

Primary Care Provider to screen for Primary Care Provider to screen for kidney disease with urine and blood workkidney disease with urine and blood work