ckdinform: a pcp’s guide to ckd detection and delaying ... - module 2 - 3... · a pcp’s guide...
TRANSCRIPT
CKDinform:APCP’sGuidetoCKDDetectionandDelayingProgression
LearningObjectives• Describesuitablescreeningtools,suchasGFRandACR,for
properutilizationinclinicalpracticerelatedtothediagnosisandmonitoringofCKD.
• DefineandclassifyCKD,basedonGFRandalbuminuriacategories,inordertoguideappropriatetreatmentapproaches.
• Recognizeevidence-basedmanagementstrategiesthatwillhelpdelayCKDprogressioninat-riskpatientsandimproveoutcomes.
CaseQuestion1A55year-oldCaucasian-Americanman,withahistoryoftype2diabetes(15years),hypertension(3years)dyslipidemia(5years)andcardiovasculardisease(myocardialinfarction3yearsago).HewasrecentlydiagnosedwithCKD.HismostrecentlabsrevealaneGFRof45ml/min/1.73m2 andanACRof38mg/g.Whichofthefollowingshouldbeavoided?
A.ACEandARBincombination
B.Dailylow-doseaspirin
C.NSAIDs
D.Statins
E.AandC
Allofthefollowingadultpatientsshouldbereferredfornephrologyconsultation,EXCEPT?
A.Initialvisit:eGFR26&3monthslater:eGFR28(mL/min/1.73m2)
B.Initialvisit:eGFR55,&3monthslater:eGFR43confirmedwithrepeateGFR45(mL/min/1.73m2)
C.Initialvisit:ACR450&3monthslater:ACR355(mg/g)onbothdatestheeGFR >60mL/min/1.73m2
D.Initialvisit:eGFR >60&3monthslater:eGFR >60(mL/min/1.73m2)withpersonalhistoryofAutosomalDominantPolycysticKidneyDisease
E.Initialvisit:eGFR42&3monthslater:eGFR44(mL/min/1.73m2)onbothdatestheACR<30mg/g
CaseQuestion2
StepstoCKDPatientCare1. DoesthepatienthaveCKD?2. AssessGFR,albuminuria.3. Determineetiology.4. Assessforevidenceofprogression.5. Assessforassociatedcomplications.6. Patienteducation.7. Assesslifeexpectancyandpatientwishesfor
dialysis/transplantation.
DefinitionofChronicKidneyDisease
• CKDisdefinedasabnormalitiesofkidneystructureorfunction,presentfor>3months,withimplicationsforhealth.
KidneyDisease:ImprovingGlobalOutcomes(KDIGO)CKDWorkGroup.KidneyIntSuppls.2013;3:1-150.
AssignAlbuminuriaCategory
AlbuminuriaCategoriesinCKD
Category ACR(mg/g) TermsA1 <30 NormaltomildlyincreasedA2 30-300 Moderatelyincreased*A3 >300 Severelyincreased**
*Relativetoyoungadultlevel.ACR30-300mg/gfor>3monthsindicatesCKD.**Includingnephroticsyndrome(albuminexcretionACR>2220mg/g).
KidneyDisease:ImprovingGlobalOutcomes(KDIGO)CKDWorkGroup.KidneyIntSuppls.2013;3:1-150.
AssignGFRCategoryGFRCategoriesinCKD
Category GFR Terms ClinicalPresentations
G1 ≥90 Normalorhigh Markersofkidneydamage(nephroticsyndrome,nephriticsyndrome,tubularsyndromes,urinarytractsymptoms,asymptomaticurinalysisabnormalities,asymptomaticradiologicabnormalities,hypertensionduetokidneydisease)
G2 60-89 Mildlydecreased*
G3a 45-59 Mildlytomoderatelydecreased
• Mildtoseverecomplications:o Anemiao Mineralandbonedisorder
§ Elevatedparathyroidhormoneo Cardiovasculardisease
§ Hypertension§ Lipidabnormalities
o Lowserumalbumin
G3b 30-44 Moderatelytoseverelydecreased
G4 15-29 Severelydecreased
G5 <15 Kidneyfailure • Includesalloftheabove• Uremia
GFR=mL/min/1.73m2
*RelativetoyoungadultlevelIntheabsenceofevidenceofkidneydamage,neitherGFRcategoryG1norG2fulfillthecriteriaforCKD.RefertoanephrologistandprepareforkidneyreplacementtherapywhenGFR<30mL/min/1.73m2.
KidneyDisease:ImprovingGlobalOutcomes(KDIGO)CKDWorkGroup.KidneyIntSuppls.2013;3:1-150.
ClassificationofCKDBasedonGFRandAlbuminuriaCategories:“HeatMap”
CKD is classified based on: • Cause (C) • GFR (G) • Albuminuria (A)
Albuminuria categories Description and range
A1 A2 A3
Normal to mildly
increased
Moderately increased
Severely increased
<30 mg/g <3 mg/mmol
30-299 mg/g 3-29
mg/mmol
≥300 mg/g ≥30
mg/mmol
GFR
cat
agpr
oes
(ml/m
in/1
.73
m2 )
Des
crip
tion
and
rang
e
G1 Normal or high ≥90 1 if CKD Monitor
1 Refer*
2
G2 Mildly decreased 60-89 1 if CKD Monitor
1 Refer*
2
G3a Mildly to moderately decreased
45-59 Monitor
1 Monitor
2 Refer
3
G3b Moderately to severely decreased
30-44 Monitor
2 Monitor
3 Refer
3
G4 Severely decreased 15-29
Refer* 3
Refer* 3
Refer 4+
G5 Kidney failure <15 Refer 4+
Refer 4+
Refer 4+
Colors: Represents the risk for progression, morbidity and mortality by color from best to worst. Green: low risk (if no other markers of kidney disease, no CKD); Yellow: moderately increased risk; Orange: high risk; Red, very high risk.
Numbers: Represent a recommendation for the number of times per year the patient should be monitored.Refer: Indicates that nephrology referral and services are recommended.
*Referring clinicians may wish to discuss with their nephrology service depending on local arrangements regarding monitoring or referral.
Adapted from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.
ScreeningTools:eGFR• Consideredthebestoverallindexofkidneyfunction.• Normal GFRvariesaccordingtoage,sex,andbodysize,and
declineswithage.• TheNKFrecommendsusingtheCKD-EPI Creatinine
Equation(2009)toestimateGFR.OtherusefulcalculatorsrelatedtokidneydiseaseincludeMDRDandCockcroft-Gault.
• ForGFRcalculatorssearch:GFRcalculator– TheNationalKidneyFoundation
SummaryoftheMDRDStudyandCKD-EPIEstimatingEquations:https://www.kidney.org/sites/default/files/docs/mdrd-study-and-ckd-epi-gfr-estimating-equations-summary-ta.pdf
eGFR,SCrComparison
Age Weight in lbsHeight in Ft/in
Sex Race SCr mg/dl
eGFR ml/minper CKD-EPI
eGFRAdj for BSA
25 2856’
M AA 1.6 68 97
49 1805’4’’
F Hispanic 1.6 38 41
67 1555’8’’
M Asian 1.6 44 46
92 985’1’’
F Caucasian 1.6 28 22
AverageMeasuredGFRbyAgeinPeopleWithoutCKD
CoreshJ,etal.AmJKidneyDis.2003;41(1):1-12.
UseTheseEquationsCautiously,ifatallin….• Patientswhohave/are:
o Poornutrition/lossofmusclemasso Amputationo Chronicillnesso NotAfricanAmericanorCaucasiano Changingserumcreatinineo Obeseo Veryelderly,young
ClinicalEvaluationofPatientswithCKD
• Bloodpressure• HbA1c• Serumcreatinine
o UseaGFRestimatingequationorclearancemeasurement;don’trelyonserumcreatinineconcentrationalone.
o Beattentivetochangesincreatinineovertime--evenin“normal” range.
• Urinalysiso Urinesedimento Spoturineforprotein-to-creatinineoralbumin-to-creatinineratio.
• Albuminuria/Proteinuria• Electrolytes,bloodglucose,CBC
• Dependingonstage:albumin,phosphate,calcium,iPTH• Renalimaging• DependingonageandH&P
o Lightchainassay,serumorurineproteinelectrophoresis(SPEP,UPEP)
o HIV,HCV,HBVtestso Complements,otherserologies—limitedroleunlessspecificreason
ClinicalEvaluationofPatientswithCKD
• Standardurinedipsticksdetecttotalprotein>30mg/dL-notsensitiveenoughfor“microalbuminuria” screening.
• Untimed,random“spot” urineforalbumin-to-creatinineorprotein-to-creatinineratio(firstmorningvoidpreferred).
ClinicalEvaluationofPatientswithCKD
• NormalAlbuminuriao Albumin-to-creatinineratio<30mg/gcreatinine
• ModeratelyIncreasedAlbuminuriao Albumin-to-creatinineratio30-300mg/gcreatinineo 24-hoururinealbumin30-300mg/d
• SeverelyIncreasedAlbuminuriao Albumin-to-creatinineratio>300mgalbumin/gcreatinineo 24-hoururinealbumin>300mg/d
• Proteinuriao (+)urinedipstickat>30mg/dlo >200mgprotein/gcreatinineo 24-hoururineprotein>300mg/d
Definitions:AlbuminuriaandProteinuria
SlowingProgressionofCKD
CKD- ProgressionofKidneyFailureConceptVariabledependingonseveralfactorsincluding(1)typeofdiseaseand(2)howwellitistreated
100
90
80
70
60
50
40
30
20
10
Years
Stage2
Stage3
Stage4
Stage5(Dialysis)
GFR
0 1 2 3 4 5 6 7
BloodPressureandCKDProgression
• ControlofBPmoreimportantthanexactlywhichagentsareused.o Avoidanceofside-effectsisimportant.
• Withproteinuria:diuretic +ACEior ARB.• Noproteinuria:nocleardrugpreference
o ACEior ARBoktouse.
Fujisaki K, et al. Impact of combined losartan/hydrochlorothiazide on proteinuria in patients with CKD and hypertension. Hypertens Res. 2014;37:993-998.
SlowingCKDProgression:ACEi/ARB• Checklabsafterinitiation.
o Iflessthan25%SCrincrease,continueandmonitor.o Ifmorethan25%SCrincrease,stopACEiandevaluateforRAS.
• Continueuntilcontraindicationarises,noabsoluteeGFR cutoff.• BetterproteinuriasuppressionwithlowNadietanddiuretics.• Avoidvolumedepletion.
GoalsforRenoprotection
• Targetbloodpressureinnon-dialysisCKD.1o ACR<30mg/g:≤140/90mmHg.o ACR30-300mg/g:≤130/80mmHg.*o ACR>300mg/g:≤130/80mmHg.o Individualizetargetsandagentsaccordingtoage,coexistentCVD,andothercomorbidities.
• AvoidACEiandARBincombination.3,4
o Riskofadverseevents(impairedkidneyfunction,hyperkalemia).
*Reasonabletoselectagoalof140/90mmHg,especiallyformoderatealbuminuria(ACR30-300mg/g).21) KidneyDisease:ImprovingGlobalOutcomes(KDIGO)BloodPressureWorkGroup.KidneyIntSuppl.
(2012);2:341-342.2) KDOQICommentaryonKDIGOBloodPressureGuidelines.AmJKidneyDis.2013;62:201-213.3) KunzR,etal. AnnInternMed.2008;148:30-48.4) MannJ,etal.ONTARGETstudy.Lancet.2008;372:547-553.
RelationshipBetweenAchievedBPandDeclineinKidneyFunctionfromPrimaryRenalEndpointTrials
UpdatefromKalaitzidisRandBakrisGLIn:HandbookofChronicKidneyDisease.DaugirdasJ(Ed.)2011.
NormaldeclineinGFR
Nondiabetes
MDRD.NEnglJMed.1993AIPRI.NEnglJMed.1996REIN.Lancet.1997AASK.JAMA.2002HouFF,etal.NEnglJMed.2006ParsaAet.al.NEJM2013
DiabetesCaptoprilTrial.NEnglJMed.1993HannadoucheT,etal.BMJ.1994BakrisG,etal.KidneyInt.1996BakrisG,etal.Hypertension.1997IDNT.NEJM.2001RENAAL.NEJM.2001ABCD.DiabetesCare(Suppl).2000
ARBsandProgressionofDiabeticNephropathy
Parving HH, et al. N Engl J Med. 2001
• Mostplacebo-controlledstudiesintype2DMhavebeeninpatientswitheithermoderatealbuminuria(A2)orestablishednephropathytreatedwithARB.
• ARBandACEiappeartobeequivalentformoderatealbuminuria(A2)andproteinuriareduction.
Managing Hyperglycemia• Hyperglycemiaisafundamentalcauseofvascularcomplications,
includingCKD.• Poorglycemiccontrolhasbeenassociatedwithalbuminuriain
type2diabetes.• Riskofhypoglycemiaincreasesaskidneyfunctionbecomes
impaired.• Decliningkidneyfunctionmaynecessitatechangestodiabetes
medicationsandrenallycleareddrugs.• TargetHbA1c~7.0%.
o Canbeextendedabove7.0%withcomorbiditiesorlimitedlifeexpectancy,andriskofhypoglycemia.
NKF KDOQI. Diabetes and CKD: 2012 Update.Am J Kidney Dis. 2012;60:850-856.
OtherGoalsofCKDManagement
• NSAIDavoidance• Limitsodiumintaketo<90mmol(2gmsodium;or5gmsodiumchlorideorsalt)perday.
• CVDmanagement:lipids,ASA(secondaryprevention),etc.
LipidDisordersinCKD
• Usestatinaloneorstatin+ezetimibeinadults>50yrswithCKD3-5(ND).
• Usestatinaloneinadults>50yrswithCKD1-2.• Inadults<50yrsusestatinaloneifhistoryofknownCAD,
MI,DM,stroke.• Treataccordingtoa“fireandforget” ratherthan“treatto
target” strategy.o TreatCKDpatients(Nondialysis)withstatinsorStatin/exterminate
combinationswithouttheneedforfollowupbloodtests.
KidneyDisease:ImprovingGlobalOutcomes(KDIGO)LipidWorkGroup.KidneyIntSuppl.2013;3:259-305.http://kdigo.org/home/2013/11/04/kdigo-announces-publication-of-guideline-on-lipid-management/
LipidDisordersinCKD
A 32% reduction in LDLà17% reduction in primary outcome (nonfatal MI, coronary death, nonhemorrhagic stroke, arterial revascularization).
No reduction in CKD progression, overall or CAD mortality, other individual CAD end-points.
BaigentC,etal.StudyofHeartandRenalProtection(SHARP).Lancet. 2011;11:60739-60743.
10-YearCoronaryRiskBasedonAgeandOtherPatientCharacteristics
CABG,coronaryarterybypassgrafting;CHD,coronaryheartdisease;CKD,chronickidneydisease;CVA,cerebrovascularaccident;DM,diabetesmellitus;MI,myocardialinfarction;PTCA,percutaneoustransluminalcoronaryangioplasty;TIA,transientischemicattack.
1)KidneyDisease:ImprovingGlobalOutcomes(KDIGO)LipidWorkGroup.KidneyIntSuppl.2013;3:259-305.2)HemmelgarnBR,etal. Overviewofthealbertakidneydiseasenetwork. BMCNephrol.2009:30:10.
Future10-yearcoronaryriskbasedonvariouspatientcharacteristics.Dataareunadjustedratesfrom1,268,029participantsintheAlbertaKidneyDiseasecohort.1,2
OverviewofManagingCKDComplications
ComplicationsofKidneyFailureStartinStage3andProgress
Kidney Failure
Malnutrition
Bone DiseaseBrittle bones and fractures
Anemia/blood lossDecrease production of red blood cells
Fluid OverloadWater Overload Acid Base Imbalance
Acidic BloodElectrolyte Abnormalities
HypertensionCardiac DiseaseVascular Disease
AnemiainCKD• InitiateirontherapyifTSAT≤30%andferritin≤500ng/mL(IViron
fordialysis,oralfornon-dialysisCKD).• IndividualizeESAtherapy– StartESAifHb<10g/dl,andmaintain
Hb<11.5g/dl.EnsureadequateFestores.o AppropriateironsupplementationisneededforESAtobe
effective.• ESAusuallynotrequiredfornephrogenicanemiauntillateCKD
4/CKD5.• Diagnosticworkupofanemiaisparticularlyimportantifseverity
ofanemiaisdisproportionatetoCKDstaging.• Importanttoavoidtransfusionintransplantcandidates.
o IftransfuseduseleukocytefiltertoreduceHLAsensitization.
CKD-MBDTesting
CKD Stage Calcium, Phosphorus
PTH25(OH)D
Stage 3 Every 6-12 months
Once then based on CKD
progressionOnce, then based on level and treatments
Stage 4 Every 3-6 months Every 6-12 months
Stage 5 Every 1-3 months Every 3-6 months
UseCKDprogression,presenceorabsenceofabnormalities,treatmentresponse,andsideeffectstoguidetestingfrequency.
CKD-MBD:ChronicKidneyDisease– MineralandBoneDisorder
CKD-MBD
• TreatwithD3asindicatedtoachievenormalserumlevels.• 2000IUD3po qdischeaperandbetterabsorbedthan
50,000IUofD2monthlydose.• Limitphosphorusindiet,withemphasisondecreasing
packagedproducts- RefertorenalRD.• Mayneedphosphatebinders.• DEXAdoesn’tpredictfractureriskinCKD3-5.
MetabolicAcidosis• OftenbecomesapparentatGFR<25-30ml/min/1.73m2.
• Moreseverewithhigherproteinintake.• Maycontributetobonedisease,proteincatabolism,andprogressionofCKD.• CorrectionofmetabolicacidosismayslowCKDprogressionandimprovepatients
functionalstatus.1,2
AdultswithCKD(eGFR15-30ml/min/1.73m2)withbicarbonate16-20mmol/L;treatedwithsodiumbicarbonatefor2yearstonormalizeserumbicarbonateconcentration.2
1) Mahajan,etal.KidneyInt.2010;78:303-309.2) deBrito-AshurstI,etal.JAmSocNephrol.
2009;20:2075-2084.
MetabolicAcidosis• Maintainserumbicarbonate> 22mmol/L.
o Startwith0.5-1mEq/kgperday.o Sodiumbicarbonatetablets:
• 325mg,625mgtablets;1g=12mEq.o Sodiumcitratesolution:
• 1mEq/ml.• Avoidifonaluminumphosphatebinders.
o Bakingsoda:• 54mmol/leveltsp.
Hyperkalemia• Firsttryreductionofdietarypotassium.• StopNSAIDs,COX-2inhibitors.• Stoppotassiumsparingdiuretics.
o Aldactone• Stoporreducebetablockers.• Avoidsaltsubstitutesthatcontain
potassium.• StoporreduceACEi/ARBs.
AcuteManagementofHyperkalemia
Treatment Expectedserum K+↓
Peakeffect Duration Mechanism
IV Calciumchloride
None Instant Transient Stabilizemyocardium
Insulin +dextrose 0.5-1mEq/L 30-60 mins 4-6hrs Cellularshift
B2-adrenergicagonists
0.5-1 mEq/L 30mins 2hrs Cellularshift
Sodiumbicarbonate
Variabledependingon
acidosis
4h Cellularshift
Loop/thiazidediuretics
Hours ↑renalK+excretion
KamelKS,WeiC.NephrolDialTransplant.2003;18:2215-2218.
ChronicManagementofHyperkalemia• Looporthiazidediuretics.• Laxatives:
o Aseffectiveascationexchangeresinsinsorbitol.o Thosethatinducesecretorydiarrheamaybemoreeffective(e.g.
bisacodyl).o DiphenoliclaxativesmaystimulatecolonicK+secretion.
• Cationexchangeresins:o Sodiumpolystyrenesulfonateo Mechanism:
• Theoretical:BoundNa+exchangedforK+incolonic/rectallumen.
• Likely:Accompanyingsorbitolinducesdiarrhea.o Usuallyrequiresmultipledoses.o Riskofbowelnecrosisorperforation.
RiskFactorsforInfectioninPeoplewithCKD• Advancedage
• Highburdenofcoexistingillnesses(e.g.,diabetes)
• Hypoalbuminuria
• Immunosuppressivetherapy
• Nephroticsyndrome
• Uremia
• Anemiaandmalnutrition
• Highprevalenceoffunctionaldisabilities
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.
VaccinationinCKD• AnnualinfluenzavaccineforalladultswithCKD,unless
contraindicated.
• PolyvalentpneumococcalvaccinewheneGFR <30ml/min/1.73m2
andathighriskofpneumococcalinfection(e.g.,nephroticsyndrome,diabetes,receivingimmunosuppression),unlesscontraindicated.Offerrevaccinationwithin5years.
• HepatitisBimmunizationwhenGFR<30ml/min/1.73m2.Confirmresponsewithappropriateserologicaltesting.
• Useofalivevaccineshouldconsiderthepatient’simmunestatus(e.g.,immunosuppression).
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.
MalnutritionandCKD• Malnutritionorproteinenergywasting(PEW)iscommonin
CKD,andisassociatedwithpoorpatientoutcomes.• MalnutritioninCKDbeginsasearlyasstages3and4.Risk
increaseswithprogressionofthedisease.• PreventingPEWormalnutritionmayrequireclinical
interventionstoassessnutritionalstatus,individualizestrategiesforpreventionandtreatment,providepatientinstruction,andpromotepatientadherence.
• Aspecialty-trainedregistereddietitiancanhelpaddressthenutritionalaspectssothatproteinwastingcanbediminished.
NKF KDOQI. Am J Kidney Dis. 2000;35(suppl 2):S1-S3.NKF KDOQI. Am J Kidney Dis. 2007;49(suppl 2):S1-S179.
ABalancedApproachtoNutritioninCKD:MacronutrientCompositionandMineralContent*
NKFKDOQI.AmJKidneyDis.2007;49(suppl2):S1-S179.
Adapted from DASH (dietary approaches to stop hypertension) diet.*Adjust so total calories from protein, fat, and carbohydrate are 100%. Emphasize such whole-food sources as fresh vegetables, whole grains, nuts, legumes, low-fat or nonfat dairy products, canola oil, olive oil, cold-water fish, and poultry.
*(CKDStages1-4)
EducationandCounseling• Ethical,psychological,andsocialcare(e.g.,socialbereavement,
depression,anxiety).• Dietarycounselingandeducationonotherlifestylemodifications
(e.g.,exercise,smokingcessation).• Involvethepatient,familyandchildrenifpossible.• Offerliteratureinbothtraditionalandinteractiveformats.• Useeducationalmaterialswritteninthepatient’slanguage.• Assesstheneedforlow-levelreadingmaterials.• Useinternetresourcesandsmartphoneappsasappropriate.• Usevisualaidssuchashandouts,drawings,CDs,andDVDs.• Involveotherhealthcareprofessionalsineducating
patients/families.• Beconsistentintheinformationprovided.
MentalHealthCounseling• Psychiatricillnesseslikedepressionareassociatedwithmany
chronicdiseases.• DepressionislinkedtoearlyCKD,progressiveCKD,kidney
failure,hospitalizationandincreasedmortality. 1-4
• PatientswithGFR<60mL/min/1.73m2shouldundergoregularassessmentforimpairmentoffunctioningandwell-being.5
1) PalmerS,etal. AmJKidneyDis.2013;62:493-505.2) HedayatiS,etal.AmJKidneyDis.2009;54(3):424-32.3) KimmelP,etal.KidneyInt.2000;57:2093-2098.4) TsaiY,etal.AmJKidneyDis.2012;60:54-61.5) NKFKDOQI.AmJKidneyDis.2002;39(2Suppl1):S1-266.
CKDCareAmongSpecialPopulations
ConsiderationsforCKDManagementinOlderAdults• Morethan36millionadultsarenowovertheageof65,and~50%have
twoormorechronicdiseases.1
• Managementrequiresanindividualizedapproach,withattentiontouniqueconsiderationsforolderadults.
• TreatmentofhypertensioninolderadultshasbeenshowntoreduceCVmorbidityandmortality.However,olderfrailadultsshouldbemonitoredforriskofhypotension.2,3
• Lessstringentglycemicgoalscanbeappropriateforolderadultswithothercomorbidities,orthoseathigherriskforhypoglycemia.4
• Exercisecanhavemultiplebenefits.Aweightcontrolprogramshouldbeindividuallytailoredtopreservebodycellmassandfunction,whilelosingfatmass.5,6
1. U.S.CensusBureau.Populationbyageandgender2008.www.census.gov.2. KatzP,GilbertJ.GeriatricsandAging.2008;11:509-514.3. AronowW.ClinGeriatrMed.2008;11(8):457-463.4. NKFKDOQI.AmJKidneyDis.201260:850-856.5. HornickT,AronD.ClevClinJMed.2008;75:70-78.6. NHLBI.ww.nhlbi.nih.gov.
IncidenceofESRDVariesWidelybyRaceandEthnicity
*Adjustedforageandsex;thestandardpopulationwastheU.S.populationin2011.Panelb:~Estimateshownisimpreciseduetosmallsamplesizeandmaybeunstableovertime.ThelineforNativeAmericanshasadiscontinuitybecauseofunreliabledataforthatyear.Abbreviations:AfAm,AfricanAmerican;ESRD,end-stagerenaldisease;NAm,NativeAmerican.USRDSADR2014.
(a)IncidentCases (b)IncidenceRates
Trends in (a) ESRD incident cases, in thousands, and (b) adjusted* ESRD incidence rate, per million/year, by race, in the U.S. population, 1980-2012.
Additional Online Resources for CKD Learning
• NationalKidneyFoundation:www.kidney.org
• UnitedStatesRenalDataService:www.usrds.org
• CDC’sCKDSurveillanceProject:http://nccd.cdc.gov/ckd
• NationalKidneyFoundation:www.kidney.org
• UnitedStatesRenalDataService:www.usrds.org
• NationalKidneyDiseaseEducationProgram(NKDEP):http://nkdep.nih.gov