Are CKD Patients Attaining Therapeutic Targets?

by Jon J. Snyder, PhD

From NHANES 2005–2010:
13.1% of people have CKD
8.5 % have CVD
9.3% have DM

Top 3 adverse effects of CKD:
CV dz
Premature death
Kidney failure

From KEEP data, risk of death in the CKD population is 16x greater than that of advancing to stage 5 CKD

Reference to Go et al. NEJM 2004; 351:1296–1305 — increasing CV disease with reduction of GFR across stages of CKD
Odds of Awareness, Treatment and Control of Complications of CKD — Snyder et al, 2008

Snyder JJ, Collins AJ. KDOQI hypertension, dyslipidemia, and diabetes care guidelines and current care patterns in the United States CKD population: National Health and Nutrition Examination Survey 1999–2004. Am. J. Nephrol. 2009;
30: 44–54.

Major KDOQI points:
-Monitor eGFR
-Control HTN
-Manage dyslipidemias –
-Monitor/manage disturbances of mineral metabolism
-Control DM
-Get and influenze immunization
-See a nephrologist

Hypertension
KDOQI — less than 130/80
KDIGO 2012 HTN guidelines — less than 140/90
HTN in CKD from NHANES data from ADR 2012
-about 75% measured/treated
-Only approx. 25% aware, treated and controlled
KEEP data across stages of CKD — approx. 20% were aware, treated and controlled

Dyslipidemia
Current ATP-III classification; (ATP-IV is eminent)
67% of NHANES population above target
-1/3 were unaware
-1/3 were aware, treated and controlled
-Less patients with eGFR 30mg/gm
SHARP simvastatin + ezetimibe vs placebo — across all ranges of pre-dialysis CKD there was benefit to treatment

Diabetics
-approx. 50% of CKD pts at goal A1C less than 7%, aware, treated and controlled
-? target overaggressive, so KDIGO recommends target of approx. 7% to prevent or delay progression of the complications of diabetes. Pulling back on the goal a bit.

Of patients with medicare claims and a dx code of 585.3 or higher in 2009, only 50–60% of these patients were referred to a nephrologist (same as % referred to a cardiologist). Need to further educate primary care physicians about timing of referral.