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Sheffield Kidney Institute
Global Kidney Academy
CKD Micro-LectureCKD and CVD
Professor Meguid El Nahas, PhD, FRCPSheffield Kidney Institute
UK
Sheffield Kidney InstituteYach et al, 2004
20021990 2020Predicted
0
40
50
30
N°o
f dea
ths
(mill
ions
)
10
20
CHRONIC DISEASES DEATHS WORLDWIDE
Chronic diseases (NCD)
20021990 2020Predicted
0
40
50
30
N°o
f dea
ths
(mill
ions
)10
20
Communicable diseases
CKD as a Global Public Health ProblemCKD as a Global Public Health Problem
Sheffield Kidney Institute
Global deaths (58 million) by major cause 2005
CVD
30% CVD = 17,528,000 deaths
Yach et al, 2004
CKD as a Global Public Health ProblemCKD as a Global Public Health Problem
Sheffield Kidney InstituteThe oedematous woman - Gerard Dou 1662 (Louvre Museum)
Look at Urine and Diagnose Heart Disease
Sheffield Kidney InstituteHillege et al, 2002 Arnlov et al, 2005
Microalbuminuria and Survival
Sheffield Kidney Institute
Proteinuria and Survival in Diabetes
1.0
0.9
0.8
0.7
0.6
0.50 1 2 3 4 5 6
Years
Surv
ival
(all-
caus
e m
orta
lity)
Normoalbuminuria(n=191)
Microalbuminuria(n=86)
Macroalbuminuria(n=51)
Gall, MA et al. , 1995
CKD as a Global Public Health Problem
Sheffield Kidney Institute
Albuminuria
Inflammation EndothelialDysfunction
Cardio Kidney DamageCKD
CKD as a Global Public Health Problem
Sheffield Kidney Institute
CKD and CVD Risk
HOORN Study, Henry et al, 2002 Pooled Analysis, Weiner et al, 2004
eGFR<60
eGFR>60
CKD as a Global Public Health Problem
Sheffield Kidney Institute
CKD & CVD death39 studies, 1,371,990
Tonelli et al, 2006
CKD as a Global Public Health Problem
Sheffield Kidney Institute
Common factors associated with adverse outcomes in CVD and CKD
• Traditional– Age– Hypertension– Diabetes– Dyslipidemia– Family history– Smoking– Obesity
‘Non traditional’• Kidney function• Albuminuria/ Proteinuria
• Anemia• iPTH excess• Calcium phosphate
abnormalities
• Vitamin D deficiency
CKD as a Global Public Health Problem
Sheffield Kidney Institute
CKD + Anemia
Vlagopoulos et al, 2005
IHD
Stroke Death
CVD
CKD+anemia
CKD+anemia
CKD as a Global Public Health Problem
Sheffield Kidney Institute
Common factors associated with adverse outcomes in CVD and CKD
• Traditional– Age– Hypertension– Diabetes– Dyslipidemia– Family history– Smoking– Obesity
‘Non traditional’• Kidney function
• Albuminuria/ ProteinuriaAnemia
• iPTH excess• Calcium phosphate
abnormalities• Vitamin D
CKD as a Global Public Health Problem
Sheffield Kidney Institute
CKDMineral and Bone Disorder
CKD as a Global Public Health Problem
Sheffield Kidney Institute
Mineral and Bone DisorderCKD as a Global Public Health Problem
Sheffield Kidney Institute
Types of Vascular Calcification in CKD
Uremic arteriopathy Atherosclerosis
CKD as a Global Public Health Problem
Sheffield Kidney Institute
Vascular Calcifications
CKD as a Global Public Health Problem
Sheffield Kidney Institute
Control of vascular calcifications
SMC Osteoblast
InhibitorsFetuinMGlaPOsteoprotegerinOsteopontin
ActivatorsPhosphorusUremic toxinsPTHVitaminDOxLDL
- +
CKD as a Global Public Health Problem
Sheffield Kidney Institute
Heart Disease Fall
-70%/last 3 decades
CKD as a Global Public Health Problem
Sheffield Kidney Institute
CKD management guidelinesParameter Target Agent usedBP 130/80 mmHg or
125/75 in DM and those with proteinuria.Start with ACEI or ARBs if proteinuria or DM microalbuminuria - caution in the elderly and those with atherosclerosis. Monitor eGFR within 1-2 weeks of initiation, review if eGFR decreases by ≥15%, stop at ≥25%.
Proteinuria Lowest achievable ACEi/ ARBs
sCholesterol Refer to national guidelines
Lifestyle Standard CV risk reduction measures, including salt restriction
Avoid NSAIDs, COX2s and radiocontrast agents
Sheffield Kidney Institute
Evolution
CKD as a Global Public Health Problem
Sheffield Kidney Institute
CKD management guidelinesParameter Target Agent used
BP 130/80 mmHg or
125/75 in DM and those with proteinuria.
Start with ACEI or ARBs if proteinuria >1g/24hor DM
Proteinuria Lowest achievable<1g/24h
ACEi/ ARBs
sCholesterol Refer to national guidelines
Lifestyle Standard CV risk reduction measures, including salt restriction
Avoid NSAIDs, COX2s and radiocontrast agents
Sheffield Kidney Institute
CKD (Stages 3-5) management of complicationsComplication Target Management
Anaemia Hb 10.5-12.5 g/dl Replace deficienciesErythropoietin in CKD stage 4-5
Renal osteodystrophy
(Stages 4& 5 only)
Ca: 2.2-2.35 mmol/lPO4 <1.7 mmol/l
Calcium carbonate / alfacalcidolPhosphate binders
Acidosis Venous Bicarbonate > 22 mmol/l Sodium bicarbonate
Undernutrition Adequate calorie & normal protein intake
Infections Chest infectionsHepatitis B
Immunize: influenza & pneumococcusvaccination (CKD stages 4-5)
Sheffield Kidney Institute
CKDCVD
MINIMIZE
Sheffield Kidney Institute
CKD
=
Cardio-Kidney Damage
CKD as a Global Public Health Problem