Epidemiology of

Chronic Kidney Disease

 Definition
Chronic Kidney Disease is
defined as a slow lose of renal
function over time. This leads
to a decreased ability to
remove waste products from the
body and perform homeostatic
functions.
 Chronic kidney disease (CKD) is a
global health burden with a high
economic cost to health systems and
is an independent risk factor for
cardiovascular disease (CVD).
Chronic kidney disease is
associated with age-related renal
function decline accelerated in
hypertension, diabetes, obesity and
primary renal disorders.
 Clinical Definition
CKD is defined by indicators of
kidney damageimaging or
proteinuria (commonly using
albumin to creatinine ratio,
ACR)and decreased renal
function represented by GFR.
GFR of less than 60 ml/minute
per 1.73m2 per body surface area
(normal is 125ml/min) .
Presence of kidney damage,
regardless of the cause, for
three or more months
 Epidemiology
About one in ten people suffer from
chronic kidney disease. African
Americans, American Indians,
Hispanics, and South Asians,
particularly those from Pakistan,
Sri Lanka, Bangladesh and India, are
at high risk of developing CKD.
Chronic kidney disease was the cause
of 956,000 deaths globally in 2013,
up from 409,000 deaths in 1990
 Epidemiology
CKD affects about 26 million people
in the US
In Indonesia it affected 12,5% of
population (2015)
Approximately 19 million adults are
in the early stages of the disease
On the rise do to increasing prevalence
of diabetes and hypertension
Total cost of ESRD in US was
approximately $40 billion in 2008
 Epidemiology
The mean (95%CI) global prevalence
of CKD was 13, 4% for the forty-
four populations that measured
prevalence by all 5 stages (1 to 5)
and 10,6% in the sixty-eight
populations
These estimates indicate that CKD
may be more common than diabetes,
which has an estimated prevalence
of 8,2%
 Epidemiology
In Japan CKD was more prevalent
in women than in men, in contras
with Europe.
Developed areas such as Europe,
USA, Canada and Australia had
higher rates of CKD prevalence
in comparison to areas where
economies are growing such as
sub Saharan Africa, India etc
 Pathophysiology
Repeated injury to kidney
 KIDNEY
150gm: each kidney
1700 liters of blood filtered 180 L
of G. filtrate 1.5 L of urine / day.
Kidney is a retro-peritoneal organ
Blood supply: Renal Artery & Vein
One half of kidney is sufficient
reserve
kidney function: Filtration, Excretion,
Secretion, Hormone synthesis.
 Kidney
Location:
Kidney Anatomy:
 Symptoms
Hematuria
Flank pain
Edema
Hypertension
Signs of uremia
Lethargy and fatigue
Loss of appetite
If asymptomatic may have elevated
serum creatinine concentration or
an abnormal urinalysis
 Recognizing Renal Failure,
Clinical Features
Mild to Moderate renal failure:
Usually no symptoms
Severe renal failure: non specific
Pale, fatigueability & shortness of
breath
Hypertension, headaches
Polyuria/nocturia
Body itch
Poor appetite, nausea, vomiting
Hyperventilation
Swelling of the face and legs
 Recognizing Renal Failure,
Investigations
Urinalysis:
Urine dipstick & microscopic exam
=> Ptu, Htu, pyuria, glycosuria
Blood chemistry:
s.Creatinine, urea (or BUN)
Electrolytes (Na+, K+, CO2, Ca++, Ph--)
GFR:
Estimated or measured
Ultrasound
Morphologic evaluation
Abnormal findings

Azotemia: BUN, creatinine

Uremia: azotemia + more problems

Acute renal failure: oliguria

Chronic renal failure: prolonged uremia

 Glomerular Filtration
Rate GFR
Normal values:
In males 120 20 mL/minute
In females 115 20 mL/minute.
Creatinine Clearance (24-h urine collection)
Creatinine Clearance in Severe CKD:
Overestimate GFR due to the tubular
secretion
To correct this overestimation:
Take the average of urea and creatinine
clearances
Or give oral cimetidine 1200 mg, 3h before
collection
Determine the cause of
CKD
A specific diagnosis is needed:
To consider specific TRT:
obstructive uropathy, analgesic NP,
drug-related IN, RPGN, SLE, vasculitis,
accelerated HTN, tuberculosis, myeloma,
amyloid, ..
To be aware of potential
complications:
SLE, DM..
To advise the family:
PKD or other familial renal disease.
 Which patients are at
increased risk for CKD?
Risk factors

Diabetes
Hypertension
Autoimmune diseases
Systemic infections
UTI, nephrolithiasis, lower urinary-tract
obstruction
Hyperuricemia
Acute kidney injury
Family history of chronic kidney disease
 Convergence of Genetic
Factors
Genes for heart and vascular disease
Genes that maintain ionic balance
Genes for glomerulonephritis
Genes for diabetes
Genes that may be involved in inherited
renal diseases
 Classification of CKD by
Diagnosis
Diabetic Kidney Disease
Glomerular diseases (autoimmune diseases,
systemic infections, drugs, neoplasia)
Vascular diseases (renal artery disease,
hypertension, microangiopathy)
Tubulointerstitial diseases (urinary tract
infection, stones, obstruction, drug toxicity)
Cystic diseases (polycystic kidney disease)
Diseases in the transplant (Allograft
nephropathy, drug toxicity, recurrent diseases,
transplant glomerulopathy)
 Sociodemographic risk factors

Older age
Black race
Smoking
Heavy alcohol use
Obesity
NSAIDs
 What Should Patients and
Doctors Know
Prevention
Keep diabetes and blood pressure
controlled
If at risk perform screening tests
Reduce exposure to nephrotoxic drugs
Eat right and exercise
Know your family history
If you have a positive family history
ask doctor to perform common screening
tests for kidney function.
 Principles of
Management of CKD
1.
Patients
Early recognition of CKD
Estimate the severity of CKD
What is the cause of CKD?
2. Detection and correction of any
reversible cause. Avoidance of
additional renal injury
3. Institution of interventions to delay
progression
4. Treatment of complications
5. Planning for renal replacement
therapy
 Intervention
Renal Diet
Protein Restriction
High calories
Low potassium
Low salt
Low phosphate
 Intervention:
Controlling BP in CKD
Target BP:
CKD: <130/85 mm Hg
If proteinuria: <125/75 mm Hg
Benefits
Slows the progression of CKD,
especially if proteinuria
Reduces the cardiovascular
complications

Zabetakis PM, Nissenson AR. Am J Kid Dis. 2000;36(suppl):S31-S38.

BP is Poorly Controlled
in CKD

< 130/85
11%

< 140/90
27%

> 140/90
62%

Coresh J, et al. Arch Intern Med. 2001;161:1207-1216.

 Diabetes
Hyperglycemia is associated with development and
progression of diabetic nephropathy
Good glycemic control reduces CKD risk
Maintain hemoglobin A1c ~7% with dietary interventions,
oral hypoglycemic medications, and insulin

Hypertension
Hastens renal function decline

Treatment reduces CV risks but not CKD risk

Maintain blood pressure <140/90 mm Hg with lifestyle

modification and antihypertensive drug therapy
 Prevention
Quit smoking, and exercise 30 min/d on most days
Limit alcohol intake
Maintain BMI within normal range
Eat a diet high in fruits, vegetables, and whole
grains
DASH diet recommended if GFR >60 mL/min per 1.73 m 2
and high normal blood pressure or stage 1
hypertension
If hypertension present: restrict salt intake <2.0
g/d
Most patients with CKD should avoid high-protein
diets
Stage 4 or 5: consider low-protein diet (0.6
g/kg/d)
 Prevention
Nephrotoxic medications
Aminoglycoside antibiotics, amphotericin B, NSAIDS,
radiocontrast agents
If radiocontrast agents essential: give sodium
bicarbonate or 0.9% normal saline IV before and after
procedure for patients at increased risk for contrast
nephropathy
Consider N-acetylcysteine before and after radiocontrast
only in high-risk patients
Avoid high doses of gadolinium contrast in stages 4 and
5 due to risk for nephrogenic systemic fibrosis
Adjust dosing of other medications to avoid other AEs
 Planning for Renal
Replacement Therapy
Options of RRT should be discussed:
Difference modalities of dialysis
HD, PD
Transplantation
Possibility of preemptive Tx
Outcomes are optimal when RRT is
initiated in a planned manner
HD => need for A-V fistula (4-6 months)
Tx: work-up