CKDASIA–WHAT’SCOMMONAND

WHAT’SDIFFERENTFROMTHEWEST?KunitoshiIseki

NakamuraClinic,Okinawa,Japan

KDIGO

CHRONICKIDNEYDISEASEMINARALANDBONEDISORDER

KidneyInt69：1945-1953,2006KidneyInt76(Suppl113):S1-S130,2009

CKD-MBD

BMD Bone Biopsy

Biomarkers?

KDIGO

KEYMESSAGES

•  ProspecLvestudiesevaluaLngBMDtesLnginadultswithCKDrepresenta

substanLaladvancesincetheoriginalguidelinefrom2009,makingareasonablecase

forBMDtesLngiftheresultswillimpactfuturetreatment.

•  Itisimportanttoemphasizetheinterdependencyofserumcalcium,phosphate,and

PTHforclinicaltherapeuLcdecision-making.

•  Phosphate-loweringtherapiesmayonlybeindicatedinthecaseof“progressiveor

persistenthyperphosphatemia”.

•  Newevidencesuggeststhatexcessexposuretoexogenouscalciuminadultsmaybe

harmfulinallseveriLesofCKD,regardlessofotherriskmarkers.

KDIGO2017ClinicalPracLceGuidelineUpdate

KDIGO

KEYMESSAGES•  Itisreasonabletolimitdietaryphosphateintake,whenconsideringallsourcesofdietaryphosphate(including“hidden”sources).

•  ThePRIMOandOPERAstudiesfailedtodemonstrateimprovementsinclinicallyrelevantoutcomesbutdiddemonstrateincreasedriskofhypercalcemia.Accordingly,rouLneuseofcalcitrioloritsanalogsinCKDG3a-G5isnolongerrecommended.

•  Noconsensuswasreachedtorecommendcinacalcetasfirst-linetherapy

forloweringPTHinallpaLentswithSHPTandCKDG5D.

KDIGO 2017 Clinical Practice Guideline Update

KDIGO

HIGHESRDINCIDENCEINASIA Incidence,pmp ％DM

•  Taiwan 476 45% •  Brunei 393 NA•  Thailand 338 40%•  Singapore 319 66%•  Japan 290 44%•  Rep.ofKorea 285 48%•  Malaysia 261 64%•  Jalisco(Mexico) 411 62%•  USA 378 45%

China?India?USRDS2015

KDIGO

BETTERSURVIVALINJAPAN:WHY?

AmJKidneyDis44:S16-S21,2004

30

70

80

90

100

60

50

40

0 1.0 2.0 3.00 1.0 2.0 3.030

70

80

90

100

60

50

40

unadjusted adjusted

Japan

Europe

USA

Japan

Europe

USA

year year

SurvivalRate,%

KDIGO

ANNUALCRUDEDEATHRATEINJSDT

KDIGO

AGE-ADJUSTEDDEATHRISK(REF.2008)BYM.WAKASUGI

Male

Female

KDIGO

UNIQUETOJAPAN:PRACTICEPATTERN(DOPPS)Variables UniquetoJapan:pracLcepalern

VascularAccess AlmostallAVF

Anemia LowerHb,EPOdose,FeprescripLon

CKDMBD LowvitaminDinjecLon(vs.USA)

HDRegimen LowerBloodflowrate,lowKt/V

Dialysate HighNa,lowbicarbonate

CVD RelaLvelyhigherBP

Labs. Frequentschecks;CRP,ChestX-ray,vascularcalcificaLon

Conventional HD;4 hrs & 3/W. Watanabe Y, et al. Ther Apher and Dial 19 (Suppl 1): 67-92, 2015

KDIGO

CKD-MBDGUIDELINESANDNEWDRUGS

•  2014 May 12: Ferric Citrate Hydrate, po •  2016 Dec 19: Etelcalcetide Hydrochloride, iv •  2017 KDIGO CKD-MBD CPG. Kidney Int 7;1-59, 2017

2000 2002 2004 2006 2008 2010 2012 2014

CKD-MBD

For SHPT

Cinacalcet, po

KDIGO-GL

La-Carbonate

For CKD-MBD

Sevelamer

VDRA, iv

K/DOQI GL

Bixalomer

JSDT-CPG

KDIGO

JAPANESESOCIETYFORDIALYSISTHERAPY(JSDT):CPGFORCKD-MBD

•  Guidelineworkinggroup,JapaneseSocietyforDialysisTherapy:ClinicalpracLceguidelineforthemanagementofsecondaryhyperparathyroidisminchronicdialysispaLents. TherApherDial12:511-522,2008

•  ClinicalpracLceguidelineforthemanagementofchronickidneydisease-mineralandbonedisorder.　 TherApherDial17:247-288,2013

“JSDTrecommendedverydifferentPTHtargetfromtheKDIGOandemphasizedtheparathyroidintervenMonsintheirrecommendaMon.”

TsukamotoY.ClinCalcium24(12):1757-1761,2014

KDIGO

EVIDENCE-BASEDDIALYSIS？Pro:ThevalueofRCTindialysismethods(AjayKSingh&JameelaAKari)

Con:RCThavefailedinthestudyofdialysismethods

(ZbylutJTwardowski&MadhukarMisra)

PolarViewsinNephrology:Moderator’sview:

ArealternaLvedialysisstrategiessuperiortoconvenLonaldialysis:

whatPoppertellsus…(WimVanBiesen&NorbertLameire)

NORCTinDialysisTherapy！Experience-Based（ConvenLonalHD）

NephrolDialTransplant28:837-838,2013

KDIGO

NUMBEROFRANDOMIZEDCONTROLLEDTRIALS

Archdeaconetal.CJASN2013

KDIGO

SHIFTOURRESEARCHFOCUS1.  MorequalitaLvemethodsusedinsocialsciences2.  Morepa+ent-reportedoutcomes3.  Unmetneedsforstudiestoelucidateracialandethnicdifferencesin

QOLissues4.  Researchandpolicychangesshouldbedrivenbyexperienced

prac++onerswithcurrentpa+entcontacttoensurethattheyarerelevanttopa+entneeds

5.  SupportresearchtoimproveQOLanddiscouragecookie-cuFersurvivalstudies

6.  QOLmetrics(pain,depression,,,)needstobeincenLvizedinclinicalpracLcetodriverelatedresearchefforts.

LeeMBandBargmanJM.CJASN11:1083-7,2016

KDIGO

MULTIDIMENSIONALMEASUREOFDIALYSIS.HR,HEARTRATE.

PerlJ,etal.CJASN12:839-47,2017

KDIGO

PATIENTREPORTEDOUTCOME(PRO)•  Medicine:Efficacy,Safety,Outcome•  Outcome:-Hard:Death,CVD,ESRD-EffecLveness　（PRO)QOL(HRQOL)：SF-36,EQ-5D

Drug　A: Pulmonary hypertension 6 min walk distance: +31 meter (Effective!!) Cost: >250 dollars per day

KDIGO

STANDARDIZEDOUTCOMESINNEPHROLOGY(SONG)RandomizedtrialsprovidethemostreliableevidenceaboutthesafetyandeffecLvenessof intervenLons to improve health care and paLent outcomes. Unfortunately, thepotenLal for trials to inform treatmentdecisions remains limitedbecause theoutcomesreportedovendonotresonatewithwhatisdirectlymeaningfulandrelevanttopaLentsandtheirclinicians[1–3].Further, inconsistent reporLng of outcomes across trials prevents assessment of thecomparaLveeffectofintervenLons[4].Outcome repor+ngbias,whereby authors cherry-pick theoutcomes they report on thebasisoffavorableresults,mayalsooccurwhenthereisnotastandardizedlistofoutcomesmeasuredandreported[5,6].CollecLvelytheseproblemsmayunderminethereliabilityofpublishedtrials,leadingtoinefficientuseofscarceresearchandhealthcareresourcesandunintendedharmto...

TongA,CraigJ,NaglerEV,etal.NephrolDialTransplant32(12):1963-1966,2017

KDIGO

UNIQUENESSOFASIANPEOPLERELATEDTOCKD-MBDDiet&Dietaryhabit(protein,calorie,,,)Life-style(exercise,sleep,,)Socio-economicstatus

(family,income,educaLon,,)GeneLcs(ethnicdifference,,,)Others(drugs,publicsupport,,)

MoreInternaLonalCohortsstudieslikeDOPPS,ARC,andNaLonalregistriesarerequired.

KDIGO