1. High Risk Group of CKD : Early Detection !
Diagnosis of CKD
High Risk Group of CKD : Early Detection ! DM
Hypertension
Glomerulonephritis
Family history of CKD
Old age
Others
Obesity, metabolic syndrome, glucose intolerance
Connective tissue disease
Chronic pyelonephritis, history of nephrolithiasis
Abnormality in lipid metabolism, hyperuricemia : controversy
Most common causes of ESRD in Korea

2. Classification (Stages) of CKD
Classification of CKD
Classification (Stages) of CKD
CKD stage is classified according to the eGFR
Approach at each stage is different.
Stage
Description
eGFR
Prevalence 1
Kidney damage without ↓GFR
> 90
Diagnosis and treatment 2
Kidney damage with mild ↓GFR
Evaluation of renal function 3
Moderate ↓ GFR
Evaluation of complications and management 4
Severe ↓ GFR
Preparation of renal replacement therapy 5
Kidney failure
< 15
Start of renal replacement therapy
* mL/min/1.73m2

3. Why is CKD important? Clinical Importance of CKD
Relatively rapid increase in number of ESRD patients
: Big socioeconomic problems
Prevalence of cardiovascular disease (CVD) and mortality increases as renal function is deteriorated. !!
CKD : Common disease (10 % of general population)
CKD : Dangerous disease (CKD → ESRD, CVD)
CKD : Treatable disease (correctable risk factors)
Treat CKD , Stop ESRD !!

4. The Prevalence of CKD in Korea
Clinical Importance of CKD
The Prevalence of CKD in Korea
CKD 3
115 (4.86 %)
CKD stage > 3
120 (5.07%)
CKD 4
4 (0.17 %)
CKD 2
158 (6.68%)
2000
CKD 5
1 (0.04 %)
CKD 1
48 (2.03%)
1600
Persons
1200
800
Non-CKD : 2,039 (86.2%)
400
> < 60
CKD stage 1-5 : 13.8 %
CKD stage 3 or more : 5.07 %
eGFR (ml/min/1.73 m2)
2008, Korean Society of Nephrology

5. The Prevalence of CKD Clinical Importance of CKD Norway* USA** Korea#
Stage 1 (%)
1.6
2.8
2.03
Stage 2 (%)
2.2
6.68
Stage >3 (%)
4.36
3.83
5.07
Sum (%)
8.0
9.4
13.78
* Hallan SI et al. JASN 2006;17;2275, subjects aged 20 years or more
** Coresh J et al. JASN ;180, subjects aged 20 years or more ( )
*,**,# ACR cut-off value: mg albumin/g creatinine

6. Overview of Renal Replacement Therapy in Korea
Clinical Importance of CKD
Overview of Renal Replacement Therapy in Korea
대한신장학회 투석환자 등록사업(2013)

7. Number of ESRD Patients (Worldwide)
Clinical Importance of CKD
Number of ESRD Patients (Worldwide)
International Comparison (USRDS)

8. Distribution of Patients & Insurance Cost
Clinical Importance of CKD
Distribution of Patients & Insurance Cost
Population/year
(42 million)
Costs/year
(20 billion US dollars)
Neurology disorder 4.65%
Neurology disorder 2.23%
ESRD 0.18%
ESRD 3.09%
GI tract disease 52.52%
GI tract disease %
Respiratory tract disease %
Respiratory tract disease %
Cardiovascular disease 13.29%
Cardiovascular disease %
Cancer 4.03%
Cancer %
Percent
Percent
Health Insurance Review & Assessment Service, 2006

9. Total Expenditures per Person per Year
Clinical Importance of CKD
Total Expenditures per Person per Year
Costs/Person/year
Neurology disorder 200
ESRD 8,000
GI tract disease 108
Respiratory tract disease 89
Cardiovascular disease 371
Cancer 1,283
US dollar
Health Insurance Review & Assessment Service, 2006

10. 5 Year Survival Rate of ESRD Patients (age > 65)
Clinical Importance of CKD
5 Year Survival Rate of ESRD Patients (age > 65)

11. CKD/ESRD : CVD↑ → Increased Mortality
Clinical Importance of CKD
CKD/ESRD : CVD↑ → Increased Mortality
Overall mortality rate ↑
Cardiovascular mortality rate ↑
Hospitalization rate ↑
Total 1,120,000 subjects

12. Management of CKD Management of CKD Purpose Multidisciplinary approach
Prevention of progression to ESRD
Prevention and management of CVD
Multidisciplinary approach

13. Identification of Causes of CKD
Management of CKD
Identification of Causes of CKD
Irreversible factors
Reversible factors
Old age
Sex : male
Race : Black
Genetic factors
Congenital or acquired renal parenchymal damage
High glucose
Hypertension
Proteinuria
Abnormality in lipid metabolism
Obesity
Smoking

14. Lifestyle modification
Management of CKD
Lifestyle modification
Exercise
Prevention and management of hypertension : min/day, times/week
Smoking
Risk factor of CKD progression, risk factor of CVD
Obesity
BMI < 25
Alcohol
Male g, female g

15. Diet Management of CKD Water intake Salt Potassium
8 glasses of water is good for health ? → no evidence except some special conditions (renal stone, etc)
Salt
< 5 g/day is recommended
< 2 g/day : retards CKD progression
Potassium
Restriction in only advanced CKD patients

16. Diet Management of CKD Ca/P Calories/Lipid Protein
Low protein diet in CKD patients
< mg/day in advanced CKD patients
→ prevention of secondary hyperparathyroidism
Calories/Lipid
Calories: kcal/kg/day (DM kcal), Lipid 20 – 30 % of total calories
Protein
Protein restricted diet : g/kg/day (normal 0.93 g)

17. Management of Complications of CKD
Management of CKD
Management of Complications of CKD
DM control in CKD
HbA1C = 7.0 %
Hypertension control in CKD
Target BP : < 130/80 mmHg, < 125/75 mmHg (if proteinuria > 1g/day)
ACE inhibitor / ARB
Check serum creatinine/K in weeks after the start of medication
Lipid control in CKD
LDL < 100 mg/dL
Anemia correction in CKD
Use of recombinant erythropoietin: Target Hb g/dL (?)
Cautions in prescription in CKD patients
NSAIDs, radiocontrast agents, aminoglycoside antibiotics etc

18. End Stage Renal Disease(ESRD)
Indices eGFR < 3-4 mL/min/1.73m2 uremic symptoms
Dialysis is needed in case of :
Imbalance of water-electrolyte (severe edema, volume overload, hyperkalemia)
Severe acidosis
Uremic serositis
Neurologic symptoms

19. Management of ESRD Management of ESRD CKD ESRD Dialysis
Conservative management
ESRD
Renal Replacement Therapy (RRT)?
Dialysis
Transplantation
Indication ?
Hemodialysis
Peritoneal dialysis
Living donor
Cadaver donor

20. Decision of Modalities in RRT: Individual
Management of ESRD
Decision of Modalities in RRT: Individual
Is dialysis indicated in this patient ?
What kind of RRT is the most appropriate for this patient ?
Where does this patient live ?
Possibility of transplantation ?

21. Mechanisms of Hemodialysis
Management of ESRD : Hemodialysis
Mechanisms of Hemodialysis
Removal of waste products
Diffusion and convection through dialyzer membrane
Removal of water
Ultrafiltration by transmembrane pressure
Replacement of bicarbonate
Bicarbonate moves into blood by diffusion from the dialysate.

22. History of Hemodialysis
Management of ESRD : Hemodialysis
History of Hemodialysis
Willem Kolff (Netherlands) introduced the rotating drum hemodialysis system using cellophane membranes and an immersion bath and the first recovery of an acute renal failure patient treated with hemodialysis was reported in 1943

23. History of Hemodialysis
Management of ESRD : Hemodialysis
History of Hemodialysis
Paul E. Teschan, MD (right), operating the Kolff-Brigham dialysis machine during the Korean War

24. Management of ESRD : Hemodialysis

25. Dialyzer Membrane Management of ESRD : Hemodialysis Dialyser
Fiber Bundle
Fiber
Membrane

26. Management of ESRD : Hemodialysis
Dialyzer Membrane

27. Management of ESRD : Hemodialysis

28. Management of ESRD : Hemodialysis

29. Arteriovenous fistula (AVF)
Management of ESRD : Hemodialysis
Arteriovenous fistula (AVF)
Blood flow more than 200mL/min is necessary for the adequate hemodialysis
Vein
Artery
To the blood
To the machine

30. Management of ESRD : Hemodialysis

31. Mechanisms of Peritoneal Dialysis
Management of ESRD : Peritoneal Dialysis
Mechanisms of Peritoneal Dialysis
Removal of waste products
Diffusion and convection through peritoneal membrane
Removal of water
Osmotic gradient (difference of glucose concentration between peritosol and blood) : ultrafiltration
Replacement of bicarbonate
Bicarbonate moves into blood by diffusion from the peritosol (peritoneal dialysate)

32. Management of ESRD : Peritoneal Dialysis

33. O Management of ESRD : Peritoneal Dialysis Peritosol bag
Peritoneal membrane
Catheter
Dain bag
peritosol

34. Management of ESRD : Peritoneal Dialysis
Normal Exit site infection

35. Management of ESRD : Peritoneal Dialysis

36. Management of ESRD : Transplantation

37. Management of ESRD : Transplantation
Aorta
IVC
Transplanted
Kidney
Bladder

38. Overview of Kidney Transplantation in Korea
Management of ESRD : Transplantation
Overview of Kidney Transplantation in Korea
대한신장학회 투석환자 등록사업(2007)

39. Hemodialysis Management of ESRD Advantage Disadvantage
More intensive medical care
Intermittent therapy (only 3 times/week) : free except during dialysis
Rapid correction
Disadvantage
2 – 3 times/week (dependency)
Intermittent therapy
Restriction of diet and water is mandatory
Hemodynamic instability
Blood loss (hemolysis, anemia)
Possibility of machine problems
Use of anticoagulation

40. Peritoneal Dialysis Management of ESRD Advantage Disadvantage
Simple, mobile
Preservation of residual renal function
Hemodynamic stability
Less freq. severe arrhythmia (33 % vs. 4 %)
Higher employment
Less prevalent anti-HCV/HBV
Better survival after kidney TPL (?)
More economic (?)
Disadvantage
4 exchanges every day
Permanent catheter
 Body image changes
Risk of infection : Recurrent peritonitis
Some possible weight gain
Obesity/Hyperglycemia/hyperlipidemia
Slow removal of volume and solute
Low technique survival
Protein loss via PD fluid (10 g/day)
Anorexia

41. Kidney transplantation
Management of ESRD
Kidney transplantation
Advantage
Nearly normal renal function
Middle molecule clearance
Hormone
No need for dialysis
More free time
Nearly normal diet
Nearly normal everyday life
Disadvantage
Risks of major operation
Risk of rejection
Life-long use of immunosuppressant
Side effects of medication
Decreased immune response
Change of body image

42. Thanks for your attention !