Chronic kidney disease:
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CKD: Staging System and Prevalence
Stage Description
GFR
U.S Prevalence
(ml/min/1.73 m2) (1000s)
China Prevalence
(1000s)
1
Kidney Damage with
 90
Normal or  GFR
5,600
62,894
2
Kidney Damage with
60-89
Mild  GFR
5,700
37,516
3
Moderate  GFR
30-59
7,400
17,655
4
Severe  GFR
15-29
300
1103
5
Kidney Failure
< 15 or Dialysis
391
331
NKF-K/DOQI, 2002; Zhang et al, Lancet 2012
Future definitions of CKD may also
incorporate information on proteinuria
GFR
stage
1
Description
Range
(ml/min/
1.73m2)
High and
optimal
Composite ranking by adjusted relative risk
Composite ranking by unadjusted absolute risk
Albuminuria stage
Description and range of proteinuria stages,
ACR or dipstick
A1
A2
A3
Optimal and
high-normal
High
Very high and
nephrotic
<10
mg/g
10-29
mg/g
30-299
mg/g
300-1999
mg/g
≥2000
mg/g
Range
(ml/min/
1.73m2)
> 105
> 90
90-104
75-89
2
Mild
60-89
60-74
3a
Mild to
moderate
45-59
45-59
3b
Moderate
to severe
30-44
30-44
4
Severe
15-29
15-29
5
Kidney
failure
< 15
< 15
Levey, Ann Intern Med 2011
Normal
Mild
Heavy
10-29
mg/g or
negative
30-300
mg/g or
trace to 1+
>300
mg/g or
≥ 2+
CKD and ESRD are associated with
exceedingly high mortality
ESRD vs general population
60
Stage 3-4 CKD vs general population (GP)
Expected remaining life-years
Mortality rate per 1000 pt-yr
Europe
US Whites
50
GP males
Stage 3 males
Stage 4 males
200
40
GP females
Stage 3 females
Stage 4 females
General population
150
30
17.6
13.9
10.6
20
10
250
Dialysis
100
7.8
50
2.5
0
0
20 25 30 35 40 45 50 55 60 65 70 75 80
Age (years)
Jager, from ERA-EDTA and USRDS data
Alberta Kidney Disease Network, unpublished data
20-25
30-35 40-45 50-55 60-65
Age groups
70-75 80-85
Proteinuria by dipstick further increases
N=920,985
the risk of poor outcomes
10
8
Proteinuria
12
All cause mortality
Normal
Mild
Heavy
Adverse clinical outcomes
(per 1000 patients-years)
Adverse clinical outcomes
(per 1000 patients-years)
12
6
4
2
≥60
80
45-59.9
30-44.9
eGFR (mL/min/1.73m2)
6
4
2
≥60
15-29.9
80
End stage renal disease
Adverse clinical outcomes
(per 1000 patient-years)
Adverse clinical outcomes
(per 1000 patient-years)
8
Normal
Mild
Heavy
0
0
60
10
Acute myocardial infarction
Proteinuria
Proteinuria
Normal
Mild
Heavy
40
20
0
≥60
45-59.9
30-44.9
eGFR (mL/min/1.73m2)
Hemmelgarn, JAMA 2010
15-29.9
45-59.9
30-44.9
eGFR (mL/min/1.73m2)
15-29.9
Doubling of serum creatinine
Proteinuria
60
Normal
Mild
Heavy
40
20
0
≥60
45-59.9
30-44.9
eGFR (mL/min/1.73m2)
15-29.9
mild: trace or 1+; heavy: ≥2+
What do people with CKD die from?
Cardiovascular disease is a major cause
ESRD, USA
All other
33.0%
Malignancy
4%
Withdrawal
9%
USRDS, 2010 ADR
National Vital Statistics Report, CDC 2010
General population, USA
Cardiovascular
disease
42.0%
All other
33.1%
Self-harm
1.4%
Alzheimers
3.1%
Infection
12%
Cardiovascular
disease
31.0%
Malignancy
23.2%
Infection
3.6%
Lung disease
5.3%
Risk factors for CKD are similar to
those for other NCDs
• Diabetes
• Age, minority status
• Hypertension
• UTI, nephrolithiasis
• Relative with CKD
• Acute renal failure
• CV disease
• UT obstruction
• Chronic infections
• Nephrotoxins
• Smoking, obesity,
dyslipidemia
NKF-K/DOQI, 2002
CKD often coexists with other NCDs
Hypertension
Diabetes
CKD
Cardiovascular disease
This suggests that addressing CKD will improve
outcomes for other NCDs also
ESRD is increasingly common worldwide
Frequency of ESRD
2,500,000
1,490,000
426,000
1990
2000
2010
9
Lysaght, J Am Soc Nephrol, 2002
The global burden of CKD is greatest in
developing countries and in the poor
Territories are sized in proportion to the absolute number of people who die of CKD each year.
Even within countries, burden of CKD is concentrated among the poorest.
Renal replacement is available only to a wealthy few.
White et al, WHO Bull 2008; Nugent et al, NCP 2011
Most people affected by CKD are unaware
Individuals who were aware
that they had CKD
eGFR (ml/min/1.73 m2)
- NHANES 1988-94 and 1999-2000 surveys in the US general population (19,589);Adults
aged 20 years and older;
- China National Survey of Chronic Kidney Disease; Adults aged 18 years and older;
- Self-reported awareness of CKD
- Awareness of CKD is even lower in developing countries
Coresh et al, JASN 2005; Zhang et al. Lancet, 2012
Detecting CKD is cheap and efficient
• Kidney function (eGFR) estimated using simple
equations applied to results of blood test
(serum creatinine; $0.75)
• Albuminuria detected using semi-quantitative
urine dipstick ($0.02) or quantitative urine
albumin:creatinine ratio ($2.50)
• Consistent presence of low eGFR or abnormal
albuminuria indicates presence of CKD
NKF-K/DOQI, 2002
Inexpensive treatments for CKD
improve CV and renal outcomes
•
•
•
•
•
•
Control of hypertension
ACEI or ARB use
Statin use
Control of blood sugar (in diabetic patients)
Smoking cessation
Prevention of obesity
Remuzzi, Lancet 2012
Summary
• CKD is common, expensive, and associated with
very poor outcomes
• CKD often coexists with other NCDs
• Many of the affected are unaware…but CKD is
cheaply and easily detected using routine tests
• Effective and cost-effective treatments for CKD
are available
• Detection and management of CKD should be
integrated into national NCD programs