chronic kidney disease - aventri · - jafar, et al., 2001 • blood pressure below 130/80 is...

3/17/2017

1

Chronic Kidney Disease

Halting the Progression of

chronic kidney disease

Jayant Kumar, MDRenal Medicine Assoc., Albuquerque, NM

Definition ofChronic Kidney Disease

AJKD 2002: 39(2)

Stages of Chronic Kidney Disease

AJKD 2002: 39(2)

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2

USRDS ADR, 2007

Prevalence of ESRD has been rising steadily

1.11.6

2.42.9

3.9

5.5

17.918.6

0

5

10

15

20

Pati

en

ts W

ho

Are

Aw

are

of

Weak o

r F

ail

ing

Kid

neys*

(%)

Awareness of Early-Stage CKD Is Low

in the US Population

*Proportion of patients who were told they had weak or failing kidneys, eGFR (mL/min/1.73 m2).

Coresh et al. J Am Soc Nephrol. 2005:16:180-188.

<30 30+ <30 30+ <30 30+ F MSex:Albuminuria:

eGFR: 90+ 60-89 30-59 30-59

M450

© 2005 The Johns Hopkins University School of Medicine.

USRDS ADR, 2007

Diabetes and hypertension are leading causes of kidney failure

Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race.

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3

AJKD 2002: 39(2)

Stages of CKD:

A Clinical Action Plan

AJKD 2002: 39(2)

Incident ESRD patients; rates adjusted for age & gender.

Incidence varies widely by race and ethnicity

Rate

per m

illi

on

po

pu

lati

on

Af Am

N Am

Hispanic

Asian

White

Non-Hispanic

USRDS ADR, 2007

3/17/2017

4

USRDS ADR, 2006

CKD is disproportionately costly

Distribution of costs for CKD, HTN, & diabetic patients in Medicare population, 2004.

26 million Americans have CKD or albuminuria

Coresh, et al., 2007

10.1

15.5

0.7

0

5

10

15

20

25

Persistent

albuminuria with

eGFR ≥ 60

eGFR of 30-59 eGFR of 15-29

Millions o

f people

But few are aware of it – even those with eGFR less than 30

0

10

20

30

40

50

60

eGFR of 30-59 eGFR of 15-29

Percen

t R

eport

Bein

g A

ware o

f

Havin

g W

eak o

f Failin

g K

idn

eys

Men

Women

Coresh, et al., 2007

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5

CKD is prevalent in CVD

Ix, et al., 2003; Anavekar, et al., 2004; Shlipak, et al., 2004.

0

20

40

60

CAD

CrCl ≤60 mL/min

AMI

GFR <60 mL/min

CHF

GFR ≤60 mL/min

23%

46%

33%

Pati

en

ts W

ith

CK

D (

%)

In addition to ESRD, CKD leads to CVD

Go, et al., 2004

1.0

2.8

3.4

2.0

1.4

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

≥ 60 45-59 30-44 15-29 < 15

Ad

juste

d H

azard

Ratio

eGFR

Adjusted* hazard ratio for CVD events

People with CKD do progress to kidney

failure–especially those middle-aged and

younger

Levey, et al., 2006

0

10

20

30

40

50

60

70

80

Progressed to Kidney

Failure

Died Before Kidney

Failure

Died After Kidney

Failure

Pro

po

rtio

n o

f p

ati

en

ts

Long term (7 year) follow up of 408 non-diabetic CKD patients (mean initial GFR=39, mean initial age=52 year old)

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Younger people with CKD are more

likely to develop ESRD before death

Copyright ©2007 American Society of NephrologyO'Hare, 2006

Annual mortality by age group and eGFR.

Incidence of ESRD has leveled off, perhaps because of better use of preventive measures

Incident ESRD patients; rates adjusted for age, gender & race.

0

50

100

150

200

250

300

350

400

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05

Rate

per m

illi

on

po

pu

lati

on

USRDS ADR, 2007

Adherence to treatment guidelines –room for improvement

0

10

20

30

40

50

60

70

80

95 96 97 98 99 00 01 02 03

The percentage of diabetic CKD patients receiving ACE-Is/ARBs has been slow to improve

Percen

t o

f p

ati

en

ts

USRDS ADR, 2007

3/17/2017

7

2 simple tests will identify CKD in adults

• eGFR - Estimated GFR from serum

creatinine using the MDRD equation

• UACR - Urine albumin to creatinine ratio

on a “spot” urine sample• 24-hour urine collections are NOT needed

- Diabetics should be tested once a year. Others at risk

can be tested less frequently as long as normal.

• MDRD estimating equation is not applicable to

children

• Updated Schwartz formula provides reasonable

estimate in children with mild-moderate CKD

(GFR – 15-75 mL/min/1.73 m2)

Updated Schwartz Formula

eGFR = k * Ht/Scr

Where k=0.4, Ht in cm and Scr in mg/dL and measured by

enzymatic methodology

Estimation of GFR in children

Caveats to eGFR

• An estimate based on population data--not

the patient’s actual GFR

• Not reliable when used with patients:

– with GFR above 60 ml/ min/1.73 m2

– with rapidly changing creatinine levels

(e.g., acute renal failure in the ICU)

– with extremes in muscle mass, e.g.

cachexia or paraplegia

– under age 18

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Diabetes

The Leading Cause of Kidney

Failure

Increased Mortality in Patients With Diabetes

and CKD: 2-Year Clinical Outcomes

CKD identified as ICD-9-CM diagnosis code, includes CKD from diabetes, hypertension,

obstructive uropathy, and other diagnosis codes reported on USRDS ESRD registration forms.

DM = diabetes mellitus; ESRD = end-stage renal disease; ICD-9-CM = International Statistical

Classification of Diseases, 9th Revision, Clinical Modification.Collins et al. Kidney Int. 2003;64(suppl 87):S24-S31.

+ DM,

- CKD

- DM,

+CKD

+ DM,

+ CKD

Medical Cohort

Pati

en

ts (

%)

0

20

40

60

80

100

84.067.6 61.6

No Events

29.515.7

32.3

Death

ESRD, CKD Stage 5

0.3

2.96.1

M9


Proteinuria Predicts Stroke and CHD

Events in Patients With Type 2 Diabetes

P<0.001

40

30

20

10

0

Stroke CHD

Events80604020

0

0.5

0.6

0.7

0.8

0.9

1.0

Su

rviv

al C

urv

es f

or

CV

Mo

rtality

Overall: P<0.001

Incid

en

ce (

%)

Follow-Up (mo)

CHD = coronary heart disease; Prot = urinary protein excretion; CV = cardiovascular.Miettinen et al. Stroke. 1996;27:2033-2039.

Prot 150-300 mg/LProt <150 mg/L Prot >300 mg/L

0 100

M49


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9

Evidence for Effects of Good Glycemic Control on

Complications, Including Nephropathy

DCCT = The Diabetes Control and Complications Trial.DCCT Study Group. N Engl J Med. 1993;329:977-986; Ohkubo. Diabetes Res Clin Prac. 1995;28:103-117;

UKPDS Study Group. Lancet. 1998;352:837-853.

M463

Trial

Complication

DCCT

A1C: (9 7%)

N = 1441

Kumamoto

(9 7%)

N = 110

UKPDS

(8 7%)

N = 5102

Retinopathy 76% 69% 17-21%

Nephropathy 54% 70% 24-33%

Neuropathy 60% – –


• Intensive glycemic control lessens progression from microalbuminuria in Type 1 diabetes–goal in Type 2 is less clear- DCCT, 1993

- ACCORD, 2008

• Antihypertensive therapy with ACE Inhibitors or ARBs lessens proteinuria and progression- Giatras, et al., 1997

- Psait, et al., 2000

- Jafar, et al., 2001

• Blood pressure below 130/80 is beneficial- Sarnak, et al., 2005

We can have an impact on progression of CKD

KDOQI Guideline 2012 update, A1C

• 2.1: We recommend a target hemoglobin A1c (HbA1c) of 7.0% to

prevent or delay progression of the microvascular

complications of diabetes, including DKD. (1A)

• 2.2: We recommend not treating to an HbA1c target of <7.0% in

patients at risk of hypoglycemia. (1B)

• 2.3: We suggest that target HbA1c be extended above 7.0% in

individuals with co-morbidities or limited life expectancy and

risk of hypoglycemia. (2C)

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KDOQI Practice update 2012, Lipids

• 4.1: We recommend using LDL-C lowering medicines, such as

statins or statin/ezetimibe combination, to reduce risk of major

atherosclerotic events in patients with diabetes and CKD,

including those who have received a kidney transplant. (1B)

• 4.2: We recommend not initiating statin therapy in patients with

diabetes who are treated by dialysis. (1B)

KDOQI Guideline 2012, Albuminuria

• 6.1: We recommend not using an angiotensin-converting

enzyme inhibitor (ACE-I) or an angiotensin receptor blocker

(ARB) for the primary prevention of DKD in normotensive

normoalbuminuric patients with diabetes. (1A)

• 6.2: We suggest using an ACE-I or an ARB in normotensive

patients with diabetes and albuminuria levels >30 mg/g who are

at high risk of DKD or its progression. (2C)

KDOQI 2012, use of hypoglycemics

• Insulin, all kinds: No adjustment for GFR

• 1st gen. sulfonylureas: avoid use

• 2nd gen sulfonylureas: Glipizide (no adjustment), Glyburide (avoid

use), Glimperide (start at 1 mg daily)

• Metformin: Do not use if SCr ≥ 1.5 mg/dL men, ≥ 1.4 in women

• Thiazolidinediones: No adjustment

• DPP-4 inhibitors: Linagliptin (no adjustment), Sitagliptin GFR 30-50,

50 mg/d, GFR <30, 25 mg

• Incretin mimetic: Exenatide (Byetta). Not recommended GFR <30,

Liraglutide, No data with CKD

3/17/2017

11

Hypertension

The Second Leading cause of

Kidney Failure

Recommendations for BP and

RAS Management in CKD

BP = blood pressure; RAS = renin angiotensin system; CCB = calcium channel blocker;

BB = b-blocker; JNC 7 = The Seventh Report of the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure.

ADA. Diabetes Care. 2005;28(suppl 1); Chobanian et al. JAMA. 2003;289:2560-2572; Kidney Disease Outcomes

Quality Initiatives (K/DOQI). Am J Kidney Dis. 2004;43(5 suppl 1):S1-S290.

Patient

GroupGoal BP(mm Hg) First Line Adjunctive

+ Diabetes <130/80 ACE-I or ARB Diuretics then CCB or BB

Diabetes

+ Proteinuria<130/80 ACE-I or ARB Diuretics then CCB or BB

Diabetes

Proteinuria<130/80

No specific preference:

Diuretics then ACE-I, ARB, CCB, or BB

EXPECT TO NEED TO USE 3+ AGENTS TO ACHIEVE GOALS

Recommendations largely consistent across JNC 7, ADA, and K/DOQI

M60


ACEI/ARB & Reduced Risk of Rapid GFR

Decline, Kidney Failure, or Death

-50

-40

-30

-20

-10

0

Co

mp

osite R

isk (%

)*

Wright et al for the AASK Study Group. JAMA. 2002;288:2421-2431. [AASK - African American Study of Kidney Disease and Hypertension]Brenner et al for the RENAAL Study Investigators. N Engl J Med. 2001;345:861-869. [RENAAL = Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan]Lewis et al for the Collaborative Study Group. N Engl J Med. 2001;345:851-860.[IDNT = Irbesartan in Diabetic Nephropathy Trial.]

Ramipril vs

Amlodipine

P = 0.004

Ramipril vs

Metoprolol

P = 0.04

Losartan vs

Placebo

P = 0.02

-38

-22

-16

Irbesartan vs Placebo

P = 0.02

-20

Irbesartan vs Amlodipine

P = 0.006

-23

AASK (N=1094) RENAAL (N=1513) IDNT (N=1722)


3/17/2017

12

Relationship Between Achieved BP

and GFR

-14

-12

-10

-8

-6

-4

-2

0

95 98 101 104 107 110 113 116 119

eG

FR

(m

L/m

in/1

.73 m

2)

per

y

MAP = Mean Arterial Pressure*

r = 0.69

P<0.05

Untreated

Hypertension

130/80 140/90

*MAP = [SBP + (2 × DBP)]/3 mm Hg.

Summary of 9 studies used in figure.

Parving et al. 1989; Viberti et al. 1993; Klahr et al. 1993; Hebert et al. 1994; Lebovitz et al. 1994;

Moschio et al. 1996; Bakris et al. 1996; Bakris et al. 1997; GISEN Group. 1997.Bakris et al. Am J Kidney Dis. 2000;36:646-661.

M465


Anemia

Close association with CKD stage

*NHANES participants aged ≥20 y with anemia as defined by WHO criteria: hemoglobin (Hgb)

<12 g/dL for women, and Hgb <13 g/dL for men. USRDS 2004 Annual Data Report. The data reported here have been supplied by the USRDS. The interpretation and

reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or

interpretation of the U.S. government. Available at: www.usrds.org. Accessed 3/28/05.

Anemia Prevalence by CKD Stage

Pati

en

ts W

ith

An

em

ia*

(%)

0

10

20

30

40

50

60

70

1 2 3 4-5

NHANES IIINHANES 1999-2000

CKD Stage

M71


3/17/2017

13

Anemia Treatment Eligibility

Serum Creatinine (2.0 mg/dl or above) or

Creatinine Clearance (45 ml/min or below)

and

Hemoglobin (10g/dl or below) or

Hematocrit (30% or below) or

Symptoms of anemia

Consequences of Anemia in CKD

Reduced oxygen delivery to tissues

Decrease in Hgb compensated by increased cardiac output

Progressive cardiac damage and progressive renal damage1

Increased mortality risk2

Reduced quality of life (QOL)3

Fatigue

Diminished exercise capacity

Reduced cognitive function

Left ventricular hypertrophy (LVH)4

1. Silverberg et al. Blood Purif. 2003;21:124-130. 2. Collins et al. Semin Nephrol. 2000;20:345-349; 3. The US

Recombinant Human Erythropoietin Study Group. Am J Kidney Dis. 1991;18:50-59; 4. Levin. Semin Dial.

2003;16:101-105.

M76


Impact of treatment

Risk of ESA use includes increase cardio-

vascular events like MI/Stroke, worsening

HTN and progression of solid tumors

Maximize iron stores before using ESA

Read the FDA black box warning and consent

patients before ESA use

ESA use and correction of Hb above 10

decreases transfusion need and hence better

chance to get kidney transplant

3/17/2017

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Secondary

Hyperparathyroidism

An Early and Modifiable

Complication of CKD

Calcitriol Decline and iPTH Elevation

as CKD Progresses

N = 150.

iPTH = intact PTH. Adapted from Martinez et al. Nephrol Dial Transplant. 1996;11(suppl 3):22-28.

eGFR (mL/min/1.73 m2)

152535455565758595105

100

200

300

400

0

10

20

30

40

50

iPT

H(p

g/m

L)

Calc

itri

ol

1,2

5(O

H) 2

D3

(pg

/mL

)

Stage 3

7.4 million

Stage 2

5.7 million

Stage 4

300,000

CKD Stage 1

5.6 million

25

65

Low-Normal

Calcitriol

High-Normal

PTH

M236


Feedback Loops in SHPT

Ca = calcium; CVD = cardiovascular disease; P = phosphorus.

Courtesy of Kevin Martin, MB, BCh.

PTH

Bone Disease

Fractures

Bone pain

Marrow fibrosis

Erythropoietin resistance

Serum P1,25D

Calcitriol

Renal Failure

PTH

Systemic Toxicity

CVD

Hypertension

Inflammation

Calcification

Immunological

25D

Ca++

Decreased Vitamin D Receptors and Ca-Sensing Receptors


3/17/2017

15

-2.25

-2.00

-1.75

-1.50

-1.25

-1.00

-0.75

-0.50

-0.25

0.00

Spine Hip Arm

Bo

ne M

inera

l D

en

sit

y,

Z-S

co

re

PTH <60 pg/mL PTH 60-120 pg/mL PTH >120 pg/mL

Bone Loss Correlates With Severity of

SHPT in CKD Stages 3 and 4

*P<0.05 compared with patients with PTH in the normal range.

Z-Score = comparison to the mean value for women at a similar risk, including age, weight,

and ethnicity.Rix et al. Kidney Int. 1999;56:1084-1093.

*

*

*

M93


Bone-Fracture Rate Increases as CKD Progresses:

Fractures in Patients on Dialysis

*Ratio of observed incidence of hip fracture in patients with kidney failure to expected incidence

of hip fracture in the general population.

Adapted from Alem et al. Kidney Int. 2000;58:396-399.

0

5

10

100

<45 45-54 55-64 65-74 75-84 Total

Age (y)

Ob

serv

ed

/Exp

ecte

d

Incid

en

ce o

f H

ip F

ractu

re*

Male Relative Risk = 4.4Female Relative Risk = 4.4

Overall

15

20

80

100 8799

2520

10 10

7.56.4

2.4 2.54.4 4.4

M305


Cardiovascular Outcomes Worsen With CKD

Progression: 3-Y Follow-Up by eGFR Levels

CHF = congestive heart failure.Anavekar et al. N Engl J Med. 2004;351:1285-1295.

0

10

20

30

40

50

60

Composite

End Point

Death From

CV Causes

Reinfarction CHF Stroke Resuscitation

Es

tim

ate

d E

ve

nt

Ra

te (

%)

75

60-74

45-59

<45P<0.001

eGFR (mL/min/1.73 m2)

M42


3/17/2017

16

Early treatment can make a difference

100

10

0

No Treatment

Current Treatment

Early Treatment

4 7 9 11

Time (years)

Kidney Failure

GFR

(m

L/m

in/1

.73

2)

What can primary care providers do?

• Recognize and test at-risk patients

• Educate patients about CKD and treatment

• Focus on good glycemic control in people with

diabetes

• For those with CKD:

– Blood pressure below 130/80

– Use an ACE inhibitor or ARB

– More than one drug is usually required

– A diuretic should be part of the regimen

What can primary care providers do?(Continued)

• Monitor eGFR and UACR

• Treat cardiovascular risk, especially with smokers

and hypercholesterolemia

• Screen for anemia (Hgb), malnutrition (albumin),

metabolic bone disease (Ca, Phos, PTH)

• Refer to dietitian for nutritional guidance

• Consult or team with a nephrologist

• Encourage labs to report estimated eGFR and

urine albumin/creatinine ratios

3/17/2017

17

Nephrology referral suggestions

• To assist with diagnostic challenge (e.g. decision

to biopsy)

• To assist with therapeutic challenge (e.g. blood

pressure)

• Rapid decay of estimated GFR

• Most primary kidney diseases, (e.g.

glomerulonephridites)

• Preparation for renal replacement therapy,

especially when GFR less than 30

Nephrology referral suggestions, cont.

• Regardless of when you refer:

• Obtaining preliminary evaluation (e.g.

ultrasound, screening serologies)

• Providing consultant with patient history

including serial measures of renal function

Primary care providers –First line of defense against CKD

• Primary care professionals can play a significant

role in early diagnosis, treatment, and patient

education

• Therapeutic interventions for diabetic CKD are

similar to those required for optimal diabetes care

• Control of glucose, blood pressure, and

lipids

• A greater emphasis on detecting CKD, and

managing it prior to referral, can improve patient

outcomes

CKD is Part of Primary Care

3/17/2017

18

References

Anavekar NS, McMurray JJ, Velazquez EJ, Solomon SD, Kober L, Rouleau JL, White HD, Nordlander

R, Maggioni A, Dickstein K, Zelenkofske S, Leimberger JD, Califf RM, Pfeffer MA. Relation between

renal dysfunction and cardiovascular outcomes after myocardial infarction. New England Journal of

Medicine. 2004 Sep 23;351(13):1285-95.

Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, Van Lente F, Levey AS. Prevalence of

chronic kidney disease in the United States. Journal of the American Medical Association. 2007 Nov

7;298(17):2038-47.

Giatras I, Lau J, Levey AS. Effect of angiotensin-converting enzyme inhibitors on the progression of

nondiabetic renal disease: a meta-analysis of randomized trials. Angiotensin-Converting-Enzyme

Inhibition and Progressive Renal Disease Study Group. Annals of Internal Medicine. 1997 Sep

1;127(5):337-45.

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.

Hogg RJ, Furth S, Lemley KV, Portman R, Schwartz GJ, Coresh J, Balk E, Lau J, Levin A, Kausz AT,

Eknoyan G, Levey AS; National Kidney Foundation's Kidney Disease Outcomes Quality Initiative.

National Kidney Foundation's Kidney Disease Outcomes Quality Initiative clinical practice guidelines for

chronic kidney disease in children and adolescents: evaluation, classification, and stratification.

Pediatrics. 2003 Jun;111(6 Pt 1):1416-21.

References

Ix JH, Shlipak MG, Liu HH, Schiller NB, Whooley MA. Association between renal insufficiency and

inducible ischemia in patients with coronary artery disease: the heart and soul study. Journal of the

American Society of Nephrology. 2003 Dec;14(12):3233-8.

Jafar TH, Schmid CH, Landa M, Giatras I, Toto R, Remuzzi G, Maschio G, Brenner BM, Kamper A,

Zucchelli P, Becker G, Himmelmann A, Bannister K, Landais P, Shahinfar S, de Jong PE, de Zeeuw D,

Lau J, Levey AS. Angiotensin-converting enzyme inhibitors and progression of nondiabetic renal

disease. A meta-analysis of patient-level data. Annals of Internal Medicine. 2001 Jul 17;135(2):73-87.

Erratum in: Ann Intern Med 2002 Aug 20;137(4):299.

Levey AS, Greene T, Sarnak MJ, Wang X, Beck GJ, Kusek JW, Collins AJ, Kopple JD. Effect of dietary

protein restriction on the progression of kidney disease: long-term follow-up of the Modification of Diet in

Renal Disease (MDRD) Study. American Journal of Kidney Diseases. 2006 Dec;48(6):879-88.

National Diabetes Information Clearinghouse. 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/.

National Kidney Disease Education Program. Manuscript submitted for review. 2008.

National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation,

classification, and stratification. American Journal of Kidney Diseases. 2002 Feb;39(2 Suppl 1):S1-266.

References

O'Hare AM, Bertenthal D, Covinsky KE, Landefeld CS, Sen S, Mehta K, Steinman MA, Borzecki A,

Walter LC. Mortality risk stratification in chronic kidney disease: one size for all ages? Journal of the

American Society of Nephrology. 2006 Mar;17(3):846-53.

Sarnak MJ, Greene T, Wang X, Beck G, Kusek JW, Collins AJ, Levey AS. The effect of a lower target

blood pressure on the progression of kidney disease: long-term follow-up of the modification of diet in

renal disease study. Annals of Internal Medicine. 2005 Mar 1;142(5):342-51.

Shlipak MG, Smith GL, Rathore SS, Massie BM, Krumholz HM. Renal function, digoxin therapy, and

heart failure outcomes: evidence from the digoxin intervention group trial. Journal of the American

Society of Nephrology. 2004 Aug;15(8):2195-203.

Stevens LA, Fares G, Fleming J, Martin D, Murthy K, Qiu J, Stark PC, Uhlig K, Van Lente F, Levey AS.

Low rates of testing and diagnostic codes usage in a commercial clinical laboratory: evidence for lack of

physician awareness of chronic kidney disease. Journal of the American Society of Nephrology. 2005

Aug;16(8):2439-48.

U.S. Renal Data System, USRDS 2006 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, 2006.

U.S. Renal Data System, USRDS 2007 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, 2007.

chronic kidney disease - aventri · - jafar, et al., 2001 • blood pressure below 130/80 is...

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