高血压英文课件ChronicKidneyDiseaseintheUnited

U.S.Department of Healthand Human ServicesNational Institutes of HealthNational Institute of Diabetes and Digestive and Kidney DiseasesChronic Kidney Disease in the United States.Chronic Kidney Disease in the Reasons for a National Kidney Disease Education Program1)Kidney failure is a public health problem2)Economical,effective testing and therapy exist3)Testing and therapy are inadequately applied.Reasons for a National Kidney ESRD Rates Continue to RiseUSRDS,2004.ESRD Rates Continue to RiseUSRKidney Failure Compared to Cancer Deaths in the U.S.in 2000(in Thousands)Seer,2004Lung CancerKidneyFailureColorectalCancerBreastCancerProstate Cancer571004130160.Kidney Failure Compared to CaPrevalence of Renal Insufficiency in U.S.Thus,about 8 million Americans have a GFR less than 60 mL/min/1.73 m2.Plus 11 million more have a GFR over 60 but have persistent microalbuminuria.Coresh,et al.,2005GFR(mL/min/1.73 m2)59-3029-15Number of People7.7 Million360,000.Prevalence of Renal InsufficiIncident Counts&Adjusted Rates,By Primary DiagnosisUSRDS,2004.Incident Counts&Adjusted RatIncidence of Kidney Failure(per million population,1990,by HSA,unadjusted)USRDS,2000.Incidence of Kidney Failure(pIncidence of Kidney Failure(per million population,2000,by HSA,unadjusted)USRDS,2000.Incidence of Kidney Failure(pThe Risk of Kidney Failure is Not UniformRelative risks compared to Whites:African Americans3.8 XNative Americans2.0 XAsians/Pacific Islander1.3 XThe relative risk of Hispanics compared tonon-Hispanics is about 1.5 XUSRDS,2004.The Risk of Kidney Failure isCosts of Kidney Failure are High(in$billions for 2002)Kidney FailureCareTotal NIHBudget25.223.2Kidney Failure Accounts for 6%of Medicare PaymentsLost Income for Patients is$2-4 Billion/YrUSRDS,2004.Costs of Kidney Failure are HiCKD Predicts CVDGo,et al.,2004Age-Standardized Rate of Cardiovascular Events(per 100 person-yr)Estimated GFR(mL/min/1.73 m2).CKD Predicts CVDGo,et al.,20Treatment to Prevent Progression of CKD to Kidney FailureIntensive glycemic control lessens progression from microalbuminuria in type 1 diabetes-DCCT,1993Antihypertensive therapy with ACE Inhibitors lessens proteinuria and progression-Giatras,et al.,1997-Psait,et al.,2000-Jafar,et al.,2001Low protein diets lessen progression-Fouque,et al.,1992-Pedrini,et al.,1996-Kasiske,et al.,1998 Meta-AnalysesMeta-Analyses.Treatment to Prevent ProgressiCKD is Not Being Recognized or TreatedMost practices screen fewer than 20%of their Medicare patients with diabetes*Patients are referred late to a nephrologist,especially African-American menLess than 1/3 of people with identified CKD get an ACE InhibitorKinchen,et al.,2002;McClellan et al.,1997*Data provided by the USRDS based on 5 percent Medicare enrollment and claims data.CKD is Not Being Recognized oIs“System Level”Action Necessary?Universal medical coverage?Disease management teams?Improved reimbursement for prevention?Other?.Is“System Level”Action NeceAge-Adjusted Cardiovascular Death is Declining.Age-Adjusted Cardiovascular DParallels Between Hypertension in 1972 and Kidney Disease in 2005Recent documentation of effective therapyTreatment of a silent disease to reduce risk for a disastrous outcomeSimple screeningAdvantages for patients,physicians,industry.Parallels Between HypertensionWho to Test for Chronic Kidney DiseaseRegular testing of people at risk DiabetesHypertensionRelative with kidney failureCardiovascular disease.Who to Test for Chronic KidneHow to Test for Chronic Kidney Disease*In individuals with diabetes:“Spot”urine albumin to creatinine ratioIn others at risk:“Spot”urine albumin to creatinine ratio OR standard dipstick(Bouleware,et al.,2003)Estimate GFR from serum creatinine using the MDRD prediction equation*24 hour urine collections are NOT needed.Diabetics should betested once a year.Others at risk testing less frequently as long asnormal.How to Test for Chronic KidneAt What Level of Creatinine Does a 65-Year-Old Diabetic,Hypertensive White Woman Weighing 50 Kilograms Have CKD?77%said:Creatinine 1.5 mg/dlCreatinine=1.0 for GFR=59 mL/min/1.73 m2GFR=37 mL/min/1.73 m2Ccreat=30 mL/min.At What Level of Creatinine DoWho Should be Treated forChronic Kidney DiseaseWith diabetes:With urine albumin/creatinine ratios more than 30mg albumin/1 gram creatinineWithout diabetes:With urine albumin/creatinine ratios more than 300mg albumin/1 gram creatinine corresponding to about 1+on standard dipstickOrAny patient:With estimated GFR less than 60 mL/min/1.73 m2.Who Should be Treated forChroHow to Treat for Chronic Kidney DiseaseMaintain blood pressure less than 130/80 mmHgUse an ACE Inhibitor or ARBMore than one drug is usually required and a diuretic should be part of the regimenContinue best possible glycemic control in individuals with diabetes.How to Treat for Chronic KidnHow to Treat for Chronic Kidney Disease(continued)Refer to dietician for a reduced protein dietConsult a nephrologist earlyTeam with the nephrologist for care if GFR is less than 30 mL/min/1.73 m2Monitor hemoglobin and phosphorous with treatment as neededTreat cardiovascular risk,especially smoking and hypercholesterolemia.How to Treat for Chronic KidnEarly Treatment Makes a DifferenceBrenner,et al.,2001.Early Treatment Makes a DiffeTarget AudiencesAfrican Americans with -Diabetes -Hypertension -Family history of kidney failurePrimary Care Providers.Target AudiencesAfrican AmericNKDEP Activities“You Have The Power To Prevent Kidney Disease”awareness campaignImproved laboratory measurements and routine reporting of kidney functionCKD quality indicators among Medicare beneficiaries hospitalized for cardiovascular disease Consult letter template for nephrologistsWorking with other non-profit,industry,and government groups.NKDEP Activities“You Have The PCP Must be Engaged1)7.7 million people with GFR 30-60 mL/min/1.73 m22)About 5,000 full-time nephrologists 3)Nearly 1,500 new patients per nephrologist4)Therefore,7 new patients per day per nephrologist.Obviously not possible.PCP Must be Engaged7.7 millionWhat can Primary Care Providers do?Recognize who is at riskProvide testing and treatmentEncourage labs to provide and report estimated GFR and spot urine albumin/creatinine ratios.What can Primary Care ProvideYou Have The Power To Prevent Kidney Diseasewww.nkdep.nih.gov.You Have The Power To PreventReferencesBouleware LE,Jaar BG,Tarver-Carr ME,Brancati FL,Powe NR.Screening for Proteinuria in US Adults:A cost-effectiveness analysis.Journal of the American Medical Association.2003 Dec;290(23):3101-3114.Brenner BM,Cooper ME,de Zeeuw D,Keane WF,Mitch WE,Parving HH,Remuzzi G,Snapinn SM,Zhang Z,Shahinfar S,the RENAAL Study Investigators.Effects of Losartan on Renal and Cardiovascular Outcomes in Patients with Type 2 Diabetes and Nephropathy.New England Journal of Medicine.2001 Sep 20;345(12):861-9.Coresh J,Astor BC,Greene T,Eknoyan G,Levey AS.Prevalence of Renal Insufficiency in the U.S.American Journal of Kidney Disease.2003 Jan;41(1):1-12.Coresh J,Byrd-Holt D,Astor BC,Briggs JP,Eggers,PW,Lacher DA,Hostetter TH.Chronic Kidney Disease Awareness.Prevalence,and Trends among U.S.Adults,1999 to 2000.Journal of the American Society of Nephrology.2005 Jan;16(1):180-8.Go AS,Chertow GM,Fan D,McCulloch CE,Chi-Yuan H.Chronic Kidney Disease and the Risks of Death,Cardiovascular Events,and Hospitalization.New England Journal of Medicine.2004 Sep 23;351(13):1296-1305.ReferencesBouleware LE,Jaar BReferences(continued)Kinchen KS,Sadler J,Fink N,Brookmeyer R,Klag MJ,Levey AS,Powe NR.The Timing of Specialist Evaluation in Chronic Kidney Disease and Mortality.Annals of Internal Medicine.2002 Sep 17;137(6):479-86.McClellan WM,Ramirez SP,Jurkovitz C.Screening for Chronic Kidney Disease:Unresolved Issues.Journal of the American Society of Nephrology.2003 Jul;14(7 Suppl 2):S81-7.Review.McClellan WM,Knight DF,Karp H,Brown WW.Early Detection and Treatment of Renal Disease in Hospitalized Diabetic and Hypertensive Patients:Important Differences Between Practice and Published Guidelines.1997 Mar;29(3):368-75.National Diabetes Information Clearing House.Diabetes Control and Complications Trial(DCCT).Bethesda(MD):National Institute of Diabetes and Digestive and Kidney Diseases,National Institutes of Health,US Department of Health and Human Services;1993(NIH Publication No.02-3874).Available from:http:/diabetes.niddk.nih.gov/dm/pubs/control/.References(continued)Kinchen References(continued)Ries LAG,Eisner MP,Kosary CL,Hankey BF,Miller BA,Clegg L,Mariotto A,Fay MP,Feuer EJ,Edwards BK(eds).SEER Cancer Statistics Review,1975-2000,National Cancer Institute.Bethesda,MD,http:/seer.cancer.gov/csr/1975_2000/,2003.U.S.Renal Data System,USRDS 2004 Annual Data Report:Atlas of End-Stage Renal Disease in the United States,National Institutes of Health,National Institute of Diabetes and Digestive and Kidney Diseases,Bethesda,MD,2004.U.S.Renal Data System,USRDS 2003 Annual Data Report:Atlas of End-Stage Renal Disease in the United States,National Institutes of Health,National Institute of Diabetes and Digestive and Kidney Diseases,Bethesda,MD,2003.U.S.Renal Data System,USRDS 2000 Annual Data Report:Atlas of End-Stage Renal Disease in the United States,National Institutes of Health,National Institute of Diabetes and Digestive and Kidney Diseases,Bethesda,MD,2000.References(continued)Ries LAG