9. ¡ The GFR is equal to the sum of the
filtration rates in all of the functioning
nephrons.
¡ GFR cannot be measured directly, but
could be estimated from the urinary
clearance of an ideal filtration
marker.
10. Gold
standard
•
Inulin
Alternative
•
Iothalamate
•
Iohexol
•
DTPA
•
EDTA
27. ATP
III
guideline
(2004)
NKF
K/DOQI
Guideline
(2007)
CKD
patients
are
not
managed
differently
from
other
patients
CKD
patients
are
considered
to
be
the
highest
risk
category
Evaluation
of
dyslipidemias
should
occur
every
5
years
Evaluation
of
dyslipidemias
should
occur
at
presentation,
after
a
change
in
status,
and
annually
Drug
therapy
considered
optional
for
LDL
100-‐129
mg/dL
Drug
therapy
should
be
used
for
LDL
100
to
129
mg/dL
after
only
3
months
of
TLC
Initial
drug
therapy
for
elevated
LDL
should
be
with
statin,
bile
acid
sequestrant,
or
nicotinic
acid
Initial
drug
thepapy
for
elevated
LDL
should
be
statin
Fibrates
are
contraindicated
in
CKD
1)For
patients
with
TG≥500
and
2)For
patients
with
TG≥200
mg/dL
with
non-‐HDL
C
≥130
mg/dL
who
do
not
tolerate
statins
Fibrates
may
be
used
in
Stage
5
CKD
No
preferences
for
which
fibrates
should
be
used
for
hypertriglyceridemia
Gemfibrozil
may
be
the
fibrate
of
choice
for
treatment
of
high
TG
in
patient
with
CKD
J
Gen
Intern
Med.2004
October;19(10):
1045-‐1052
AJKD,
VOL
49,
NO
2,
SUPPL
2,
FEBRUARY
2007
30. American
Journal
of
Kidney
Diseases,
Vol
41,
No
4,
Suppl
3
(April),
2003:
pp
838
31. ¡ Dyslipidemia
is
common
in
people
with
diabetes
and
CKD.
¡ The
risk
of
CVD
is
greatly
increased
in
this
population.
¡ People
with
diabetes
and
CKD
should
be
treated
according
to
current
guidelines
for
high-‐risk
groups.
http://www.kidney.org/professionals/KDOQI/guideline_diabetes/
32. ¡ 4.1
Target
LDL-‐C
in
people
with
diabetes
and
CKD
stages
1-‐4
should
be
<
100
mg/dL;
<70
mg/dL
is
a
therapeutic
option.
(B)
http://www.kidney.org/professionals/KDOQI/guideline_diabetes/
33. ¡ 4.2
People
with
diabetes,
CKD
stages
1-‐4,
and
LDL-‐C
≥
100
mg/dL
should
be
treated
with
a
statin.
(B)
http://www.kidney.org/professionals/KDOQI/guideline_diabetes/
34. ¡ 4.3
Treatment
with
a
statin
should
not
be
initiated
in
patients
with
type
2
diabetes
on
maintenance
hemodialysis
who
do
not
have
a
specific
cardiovascular
indication
for
treatment.
(A)
http://www.kidney.org/professionals/KDOQI/guideline_diabetes/
35. Very
high
risk
/CVD/
DM
Type
I
with
TOD
CKD
stage
III
–
IV
SCORE>10%
Target
70
mg/dl"
Or
>50%
LDL-‐C
ReducHon
European
Heart
Journal
(2011)
32,
1769–1818
36.
High
risk
/
SCORE
5-‐10%
Target
LDL-‐C
<
100
mg/dl"
European
Heart
Journal
(2011)
32,
1769–1818
37. European
Heart
Journal
(2011)
32,
1769–1818
All
DM
type
II
patients
LDL-‐C<100
mg/dl
Non
HDL-‐C
<130
mg/dl
Apo
B
<
100
mg/dl
DM
Type
II
&
CVD,
CKD,
CVD
with
age
>
40
yr
with
TOD
or
>
1
risk
LDL-‐C
goal
<
70
mg/dl
Non
HDL-‐C
<100
mg/dl
Apo
B
<
80
mg/dl
38. European
Heart
Journal
(2011)
32,
1769–1818
CKD
=
CAD
Risk
equivalent
LDL-‐C
lowering
is
useful
39. European
Heart
Journal
(2011)
32,
1769–1818
Mod
to
severe
CKD
LDL-‐C
target
70
mg/dl
Expert
:
StaHn
may
slow
rate
of
kidney
funcHon
loss
45. Factors that Cause False Positive Test
! poorly controlled diabetes
! morbid obesity
! acute illness, fever, UTI
! pregnancy, menstruation
! high protein diet
! CHF
! Hematuria
! major stress: surgery or anesthesia
53. NKF Recommended Statin Dosing Adjustments in Patients with CKD
Atorvastatin No dose adjustment
Fluvastatin No dose adjustments needed for mild to moderate kidney disease; use caution in
patients with severe kidney disease; fluvastatin not studied at doses >40 mg in these
patients
Lovastatin Use doses >20 mg/day cautiously in patients with GFR <30 mL/min
Pravastatin No dose adjustment
Rosuvastatin No dose adjustments needed for mild to moderate kidney disease; Starting dose 5 mg
and NOT to exceed 10 mg in patients with GFR < 30 mL/min, not on dialysis
Simvastatin Initiate starting dose of 5 mg daily in patients with severe kidney disease
National Kidney Foundation. Am J Kidney Dis. 2007;49(suppl 2);S1-S179.
54. NKF Recommended Statin Dosing Adjustments in Patients with CKD
Atorvastatin No dose adjustment
Fluvastatin No dose adjustments needed for mild to moderate kidney disease; use caution in
patients with severe kidney disease; fluvastatin not studied at doses >40 mg in these
patients
Lovastatin Use doses >20 mg/day cautiously in patients with GFR <30 mL/min
Pravastatin No dose adjustment
Rosuvastatin No dose adjustments needed for mild to moderate kidney disease; Starting dose 5 mg
and NOT to exceed 10 mg in patients with GFR < 30 mL/min, not on dialysis
Simvastatin Initiate starting dose of 5 mg daily in patients with severe kidney disease
National Kidney Foundation. Am J Kidney Dis. 2007;49(suppl 2);S1-S179.
60. Chronology
Blood
pressure
Albumin
excretion
GFR
Stage
1
Hyperfiltration
stage
At
time
of
diagnosis
Normal
<
30
mg/day
#
20-‐50
%
Stage
2
Silent
stage
or
normoalbuminuria
First
five
years
Normal
<
30
mg/day
1 Or
#20%
Stage
3
Incipient
or
microalbuminuria
6-‐15
years
High
30
-‐
300
mg/day
1
Stage4
Overt
nephropathy
or
macroalbuminuria
15-‐25
years
High
>300
mg/day
$ 12-‐15
ml/min/
year
Stage
5
End
stage
renal
disease
25-‐30
years
High
<10-‐15
ml/min
Mogensen,Diabetes,
1983.32
Suppl
2:p
62
63. Diabetes
without
screening
for
DN
within
12
months
Positive
for
urine
protein
UACR
or
urine
microalbumin
dipstick
UACR
<
30
mg/g
Or
Dipstick
<
20
mg/L
Rescreen
in
one
year
UACR
30-‐299
mg/gOr
Dipstick
>
29
mg/L
Repeat
microalbuminuria
test
twice
within
3-‐6
month
period
2
of
3
tests
positive
Serum
Creatinine
>
2
mg/L
Or
GFR
<
60
mL/min
Begin
treatment
UACR
>
300
mg/g
Or
Dipstick
>
100
mg/L
Suggest
other
CKD
DN
Other
CKD
Consult
nephrologist
Yes
No
No
Yes
Yes
No
64.
65. ¡ Patients
with
CKD
are
at
increased
risk
of
cardiovascular
disease.
¡ Statins
reduce
cardiovascular
deaths
in
patients
with
CKD
by
a
similar
rate
to
that
seen
in
the
general
population.
¡ Statins
are
safe
as
regards
major
side
effects
such
as
hepatotoxicity,
rhabdomyolysis,
and
treatment
withdrawal.
