Dr Rajendra Prasad Mathur MD, DM, FICP, ISN Scholar Seniour
consultant & HOD, Batra hospital Heart and Kidney: Protect Your
Kidneys to Save Your Heart
Slide 2
Overview CKD Global and Indian scenario World Kidney Day CVD
and Kidney Proteinuria and CVD Treatment of CKD reduce CVD risk
Conclusions
Slide 3
Slide 4
Now we know why the titanic sank !!
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CKD A scary Challenge for Us all !! CKD Chronic kidney
disease
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CKD A Silent Killer CKD Increased DeathCKD at a glance CKD A
Global Pandemic CKD 1-2 are asymptomatic Third after CVD, Cancer 1
in 10 Indians have CKD 10 million people of CKD Term CRF no longer
used Dialysis death rate 100 x Small in Creat - in CV
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ESRD versus Total CKD ESRD - end-stage renal disease
Slide 8
Global profile of ESRD
Slide 9
India: Kidney disease burden India is the worlds largest
democracy with a population of around 1.13 billion and faces
tremendous challenges to provide basic healthcare for its masses
The incidence rates of ESRD in India 232 per million population
(age adjusted rate) NDT Plus 2010; 3: 203207
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India: Kidney disease burden The Indian CKD registry is an
initiative by the Indian Society of Nephrology, and out of the
latest total of 35 697 CKD patients, 26 609 (74.5%) amongst the CKD
patients were not receiving any form of RRT (renal replacement
therapy) and only 880 (2.5%) received renal transplantation (RT) It
is estimated that >90% of patients with ESRD in South Asia die
within months of diagnosis because they cannot afford treatment NDT
Plus 2010; 3: 203207
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World Kidney Day World Kidney Day (WKD) Annual event jointly
sponsored by the International Society of Nephrology and the
International Federation of Kidney Foundations, Inception in 2006
Being celebrated 2 nd Thursday every March Nephrol Dial Transplant
2011;26: 395398
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World Kidney Day World Kidney Day (WKD) Grown dramatically to
become The most widely celebrated event associated with kidney
disease in the world and The most successful effort to raise
awareness among both the general public and government health
officials about the dangers of kidney disease, especially chronic
kidney disease (CKD) Nephrol Dial Transplant 2011;26: 395398
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World Kidney Day 2011 Theme World Kidney Day (WKD) This year on
10 th March, 2011 WKD was celebrated with theme Protect Your
Kidneys, Save Your Heart Nephrol Dial Transplant 2011;26:
395398
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Kidney disease is common, harmful and treatable
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Cardiovascular disease (CVD) and the kidney CVD The most common
of the chronic non-communicable diseases (NCDs) that impact global
mortality About 30% of all deaths worldwide and 10% of all healthy
life lost to disease are accounted for by CVD alone Nephrol Dial
Transplant 2011;26: 395398
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CVD and kidney The presence of CKD significantly increases the
risk of a CV event in both diabetes and hypertension However, less
well appreciated is that CKD alone is a strong risk factor for CVD,
independent of diabetes, hypertension or any other conventional CVD
risk factors This is especially true when an increase in
proteinuria, a major target of any CKD screening programme, is
present Nephrol Dial Transplant 2011;26: 395398
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CVD and kidney The 2030-fold increase in CVD in patients with
ESRD has long been recognized, but The increased risk for CVD
associated with lesser degrees of renal functional impairment was
definitively demonstrated only in 2004 Study by Go et al, published
in NEJM Nephrol Dial Transplant 2011;26: 395398
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CVD and kidney Go et al Study Methods: Estimated the
longitudinal GFR among 1,120,295 adults within a large, integrated
system of health care delivery in whom Serum creatinine had been
measured between 1996 and 2000 and who had not undergone dialysis
or kidney transplantation Examined the multivariable association
between the Estimated GFR and the risks of death, cardiovascular
events, and hospitalization N Engl J Med 2004;351:1296-305.
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CVD and kidney Go et al Results N Engl J Med
2004;351:1296-305.
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CVD and kidney Go et al Results N Engl J Med
2004;351:1296-305.
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CVD and kidney Go et al Results N Engl J Med
2004;351:1296-305.
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CVD and kidney Go et al Conclusions An independent, graded
association was observed between a reduced estimated GFR and the
risk of death, cardiovascular events, and hospitalization in a
large, community based population These findings highlight the
clinical and public health importance of chronic renal
insufficiency N Engl J Med 2004;351:1296-305.
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CVD and kidney Is this dramatic increase in CVD risk associated
with CKD really due to CKD or does it just reflect the coexistent
diabetes or hypertension that is present in a majority of these
patients? The independent effect of CKD alone has now been well
documented in many studies J Am Soc Nephrol 2006; 17: 20342047
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CVD and kidney The risk of cardiac death is increased (46%) in
people with a GFR between 30 and 60 mL/min (stage 3 CKD)
Independent of traditional CV risk factors including diabetes and
hypertension J Am Soc Nephrol 2008; 19: 158163
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CVD and kidney The increased risk for CV events and mortality
in people >55 years with CKD alone is equivalent, or even
higher, to that seen in patients with diabetes or previous
myocardial infarcts Am J Cardiol 2008; 102: 16681673
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CVD and kidney Both general * and high-risk populations **
exhibit an increased risk of CVD with CKD This increased risk for
CVD is not confined to the elderly in volunteers with an average
age of 45, The risk for myocardial infarct, stroke and all-cause
mortality was doubled in those with CKD *N Engl J Med 2004; 351:
12961305, Am J Kidney Dis 2008; 51: S38S45 **Arch Intern Med 2007;
167: 11221129 Am Heart J 2008; 156:277283
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Kidney dysfunction increases the risk of cardiovascular disease
significantly
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Proteinuria and CV risk In considering the value of
recommending screening for CKD along with conventional CVD risk
factors in selected individuals, the data showing that The risk of
CVD is better correlated with proteinuria (albuminuria) than with
GFR alone are particularly relevant because Proteinuria is
virtually always a marker of kidney disease and is not a
conventional CVD risk factor Nephrol Dial Transplant 2011;26:
395398
Slide 31
Proteinuria and CV risk With regard to proteinuria as a
predictor of later CVD, The PREVEND study showed A direct linear
relationship population even at levels of albumin excretion
generally considered within the normal range (1529 mg/day) and was
increased >6-fold when albumin excretion exceeded 300 mg/day
Circulation 2002; 106: 17771782
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Proteinuria and CV risk Recent data from the US NHANES database
as well as from Japan also document An independent effect of
albuminuria on risk of both CVD and all-cause mortality at all
levels of GFR In patients with congestive heart failure but without
diabetes, hypertension or reduced GFR, Increased urinary albumin
predicts both CV and all cause mortality Nephrol Dial Transplant
2011;26: 395398
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Proteinuria and CV risk Similar results are obtained studying
patients with coronary disease or previous myocardial infarcts in
whom Proteinuria conferred a greater risk of mortality than reduced
GFR, Although both adversely impacted outcomes BMJ 2006; 332:
1426
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Proteinuria and CV risk Of interest, not only the likelihood
but also the time to development of a CV event is accelerated
significantly by the presence of proteinuria at all levels of GFR
Nephrol Dial Transplant 2011;26: 395398
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Proteinuria and CV risk In non-diabetic subjects with normal
serum creatinine levels undergoing percutaneous coronary
interventions, ~78% have demonstrable CKD when screened more
stringently for renal function (eGFR and urine protein) Not only is
the presence of CKD a likely factor in accelerating development of
coronary disease in these patients but it has also been associated
with An increase in other risks including haemorrhagic
complications, contrast nephropathy, re-stenosis and death Nephrol
Dial Transplant 2011;26: 395398
Slide 36
Proteinuria and CV risk Thus, multiple studies now confirm that
Proteinuria is a graded risk factor for CVD independent of GFR,
hypertension and diabetes, and This risk extends down into ranges
of albumin excretion generally considered normal This increased CV
risk has been well demonstrated in several studies where only
dipsticks were used to screen for increased protein excretion
Nephrol Dial Transplant 2011;26: 395398
Slide 37
Get your blood pressure checked, blood and urine tests done for
early detection of kidney dysfunction
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Can treatment of CKD reduce CVD? Finally, and most importantly
from a clinical perspective, There are provocative data suggesting
that Renal-targeted interventions designed to reduce proteinuria
and slow progression of CKD can reduce CVD risk as well Nephrol
Dial Transplant 2011;26: 395398
Slide 39
Can treatment of CKD reduce CVD? Angiotensinconverting enzyme
inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs) are
of documented benefit in slowing progression of established
diabetic and non-diabetic CKD Lancet 1999; 354: 359364 Lancet 1998;
352: 12521256 Lancet 1997; 349: 18571863 N Engl J Med 2009; 361:
16391650
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Can treatment of CKD reduce CVD? Of interest related to slowing
progression, The incidence of CVD in CKD is significantly higher
with more rapid loss of GFR independent of other risk factors,
Suggesting that interventions that slow progression may also reduce
CVD JAm Soc Nephrol 2009; 20: 26172624
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Can treatment of CKD reduce CVD? A 44% reduction in CV
mortality over 4 years has been reported in patients screened from
a general population with no risk factors except increased albumin
in the urine and treated with renal-targeted ACEI therapy This
effect was seen primarily in people with albumin excretion rates of
>50 mg/day in a pilot study, and the Intervention was shown to
be cost-effective in that population Circulation 2004; 110:
28092816 Clin Ther 2006; 28: 432444
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Can treatment of CKD reduce CVD? CV end points were
significantly reduced in direct proportion to the reduction of
albuminuria with ACEI therapy, and Albuminuria proved to be the
only predictor of CV outcome Other studies have also demonstrated
that Changes in proteinuria (in diabetics) better predict outcomes
than changes in blood pressure (BP) achieved with ACEI therapy
Nephrol Dial Transplant 2011;26: 395398
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Can treatment of CKD reduce CVD? The potential benefit of
renal-targeted therapies has recently been highlighted by
observations that Higher doses of reninangiotensin system (RAS)
blockers than required for BP control alone can further reduce
proteinuria independent of effects on BP or GFR, and Addition of
salt restriction or diuretics, both very inexpensive interventions,
can further enhance the proteinuria-reducing effect of RAS blockade
Nephrol Dial Transplant 2011;26: 395398
Slide 44
Can treatment of CKD reduce CVD? Data are not yet available to
establish that Sscreening for CKD and subsequent interventions will
reduce CV mortality and be cost-effective in younger people (
CKD Management Goals 1. Blood pressure < 125/75 HT is both a
cause and consequence 2. Glycemic control Hb A1c < 6.5 3.
Hemoglobin level > 11 g% 4. Calcium x Phosphorous product <
50 Normal values : GFR 120 to 150 ml/min/1.73m2 Ca 9 to10.5mg%, Ph
3 to 4.5mg%, Ca x Ph < 50 iPTH 150 to 300 pg/ml
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Early treatment makes a difference in CKD Brenner, et al.,
2001
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CKD death Stages in Progression of Chronic Kidney Disease and
Therapeutic Strategies Complications Screening for CKD risk factors
CKD risk reduction; Screening for CKD Diagnosis & treatment;
Rx. comorbid conditions; progression Estimate progression; Rx.
complications; Prepare for replacement Replacement by dialysis
& transplant Normal Increased risk Kidney failure Damage
GFR
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Stage-wise management of CKD Stage 0 Test for CKD, Management
of Risk Factors Stage 1 Manage co-morbidity, Rx. of CVD and RF
Stage 2 Slow rate of loss of Kidney function - ACEi Stage 3 Prevent
Anemia, Bone effects, Ca x Ph Stage 4 Preparation for RRT; refer to
nephrology Stage 5 RRT PD, HD or RT Donor / Cadavre
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Conclusions We now appreciate that kidney disease is not rare
some 10% of the population has evidence of renal dysfunction And we
know these individuals are not of concern just because a few will
progress to ESRD, but more because They carry a greatly enhanced
risk of premature death from CVD, the single largest and most
expensive healthcare threat we confront at a global level
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Conclusions Just as progress is being made in treating most of
the traditional CV risk factors, CKD has emerged as yet another one
that causes substantial vascular toxicity independently
Fortunately, there is good news as well. Bio markers of CKD
(proteinuria and eGFR) are easy and relatively inexpensive to
detect, and one of these, Proteinuria, emerges early in the
evolution of generalized vascular disease.
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Conclusions There is now compelling evidence that including
Selective screening for CKD in global health programmes designed
primarily to reduce CVD will significantly improve the outcomes of
not only renal disease but especially also the NCDs like diabetes
and CVD that dominate future healthcare strategies Kidney-targeted
detection and prevention programmes seem to offer a valuable
opportunity to institute early preventive measures that go beyond
traditional cardioprotective approaches
Slide 57
Conclusions Kidney disease is indeed common, harmful and
treatable and that Protecting your kidneys is an important health
strategy that may save your heart
