1. Prevalance of Chronic Kidney Disease 26 million people have diagnosed chronic kidney 26 million people have diagnosed chronic kidney disease (CKD) ( National Kidney Foundation data 1/29/2009) disease (CKD) ( National Kidney Foundation data 1/29/2009) The awareness of Kidney Disease The awareness of Kidney Disease It is estimated that 10-20 million people unaware It is estimated that 10-20 million people unaware they have CKD (National Institute of Diabetes and Digestive Kidney Disease data summer 2010 ) they have CKD (National Institute of Diabetes and Digestive Kidney Disease data summer 2010 ) Cause of this problem: Reliance Cause of this problem: Reliance of many primary medical providers on the serum of many primary medical providers on the serum creatinine alone. eGFR more accurate creatinine alone. eGFR more accurate estimate. estimate.

2. Prevalance continued eGFR is calculated by the MDRD equation eGFR is calculated by the MDRD equation which uses age, weight, gender and which uses age, weight, gender and serum creatinine serum creatinine Levey AS, Bosch JP, Lewis JB et all: (ann Intern Med 1999 130(6):461-470 Levey AS, Bosch JP, Lewis JB et all: (ann Intern Med 1999 130(6):461-470 Example: 70 yoF with creatinine of 1.2 Example: 70 yoF with creatinine of 1.2 has GFR of 45ml/min; has GFR of 45ml/min; a 20 yo M with same creatinine has GFR a 20 yo M with same creatinine has GFR of >100ml/min of >100ml/min

3. Prevalance of CKD in Older Population Prevalance of CKD in Older Population NHANES analysis 1999-2004 NHANES analysis 1999-2004 Those age 65 + have 44.7% CKD Those age 65 + have 44.7% CKD Of these 54.6% have diabetes Of these 54.6% have diabetes The 33.1% of non diabetic The 33.1% of non diabetic population has CKD population has CKD Of those in 74-80 age group Of those in 74-80 age group 43.8% have CKD 43.8% have CKD ( 2008 USRDS Annual Data Report) ( 2008 USRDS Annual Data Report)

4. Functions of the kidneys Red blood cell production via erythropoeitin Red blood cell production via erythropoeitin Hypertension control through the renin Hypertension control through the renin angiotension hormonal regulation of salt angiotension hormonal regulation of salt balance and vasoconstriction balance and vasoconstriction PTH regulation of calcium and phosphorus PTH regulation of calcium and phosphorus metabolism metabolism Waste and fluid filtration Waste and fluid filtration Electrolyte balance Electrolyte balance

5. StagesDescriptionGFRTreatment 1 Kidney damage with normal GFR or hyperfiltration >90 >90 Identify risk of progressive renal disease. Monitor regularly, treat HTN. 2 Kidney damage with mild decrease in GFR 60-89 60-89 Identify risk of progressive renal disease. Monitor regularly, treat HTN 3 Moderate decrease in GFR Proteinuria Hypertension 30-60 30-60 Refer if GFR declines>25%/yr Consider ACEI ARB 4 Severe decrease in GFR 15-30 15-30 PTH, calcium, hgb and HTN 5 Kidney failure <15 (or dialysis) Dialysis/or transplant

6. Treatment by stages Stage 1 and 2 if proteinuria present Stage 1 and 2 if proteinuria present Evaluate for risk of progression Manage hypertension if present Stage 3 Stage 3 Use of angiotension converting enzyme inhibitors to control hypertension and proteinuria, Use of angiotension converting enzyme inhibitors to control hypertension and proteinuria, Identify and treat anemia and hyperparathyroidism, Identify and treat anemia and hyperparathyroidism, Decrease medication doses as appropriate, adjust insulin dose, Educate on meal planning Decrease medication doses as appropriate, adjust insulin dose, Educate on meal planning Appointments every 3-4 months with lab testing Appointments every 3-4 months with lab testing Begin education regarding end stage Begin education regarding end stage

7. Stages continued Stage 4 Stage 4 Same medical management as in stage 3 Same medical management as in stage 3 Appointments every month with lab testing as GFR declines Appointments every month with lab testing as GFR declines Appointment to discuss end stage renal disease treatment options in Appointment to discuss end stage renal disease treatment options in detail with patient and family; access placement for dialysis; initiate transplant workup if patient is a candidate detail with patient and family; access placement for dialysis; initiate transplant workup if patient is a candidate Manage fluid status; need ongoing evaluation Manage fluid status; need ongoing evaluation of edema of edema Stage 5 Initiate dialysis or transplant Stage 5 Initiate dialysis or transplant Close monitoring of weights, evaluation of edema, and potassium, Close monitoring of weights, evaluation of edema, and potassium, and phosphorus consumption and phosphorus consumption

8. Treatment considerations by stage for insulin and oral agent use StageGFR Insulin or oral agent 1 & 2 1 & 2 Greater than 90 Usual management 3 60 – 90 May have lower medication dose requirement 430-60 Same as in stage 3 515-30 May require higher medication dose requirement