Epidemic of kidney disease is increasing heart attacks, strokes
Chronic kidney disease (CKD) is becoming more widespread, with increasingly dire consequences. The nephrology update moderator, Ronald Falk, FACP, will discuss the latest studies on CKD to provide internists with a rounded picture of the prevalence and risk of this serious disease.
Chronic kidney disease
CKD is an epidemic that is becoming more prevalent each decade, and with it comes substantial increased risk of cardiovascular disease. A study in the Journal of the American Medical Association by Coresh et al (2007;298:2038-2047) showed that 13% of the U.S. population had CKD in 2004—an increase from 10% in 1994—partly because of the pervasiveness of diabetes and hypertension.
The good news is that internists can screen patients using the SCORED system (Screening for Occult Renal Disease), a simple prediction model for CKD. In the Archives of Internal Medicine (2007;167:374-381), Bang and colleagues discuss the system, which makes it easy for any patient or physician to determine the risk of CKD without laboratory tests.
Some experts, including Dr. Falk, who is chief of the division of nephrology and hypertension and professor of medicine at University of North Carolina Hospitals and director of the UNC Kidney Center, advocate two simple laboratory tests in conjunction with the screening model: estimated glomerular filtration rates (GFR) and measuring the amount of albumin in the urine.
CKD significantly increases risk of heart attack and stroke, independent of other variables, according to Baber and others in Kidney International (2007;73:615-621). The researchers showed coronary artery calcification and other nontraditional cardiovascular risk factors in the patients studied. This is not the first time the connection between CKD and heart events has been made, but this study reinforces and expands on previous data. Dr. Falk will discuss the additional details at the update.
Diabetes and hypertension are the leading causes of CKD. “Patients with type 2 diabetes develop kidney disease at an alarming rate. The diabetic epidemic is leading to an epidemic of chronic kidney disease,” Dr. Falk said.
“As physicians, we need to focus on lifestyle modification early on. We need to get our youth up off of their Xboxes and into exercise programs.” He further encouraged patients to ask their physicians about their risk for kidney disease at routine office visits to increase awareness. Patients can take the SCORED test in a few moments and immediately learn their risk for CKD. A copy of the SCORED test is provided in Dr. Falk’s handout.
Nephrogenic systemic fibrosis
Patients with CKD have a 2.4% risk of developing an extremely serious disease, nephrogenic systemic fibrosis (NSF), when they receive gadolinium for an MRI. Anecdotal evidence had physicians on alert, but this case-controlled study in the Clinical Journal of the American Society of Nephrology by Deo et al (2007;2:264-267) firmly establishes the risk. NSF is a debilitating disease that has no consistently successful treatment. Dr. Falk recommended getting “tremendously well-defined informed consent” for patients with CKD who must undergo MRI using gadolinium. The current recommendations have not yet been clearly defined.
The confounding issue for physicians is determining which imaging study to use in this patient population, because contrast in a CT scan can cause kidney dysfunction. “We don’t yet know how to solve this imaging question, but every practicing doctor needs to know the risks,” Dr. Falk said.
Colonoscopy and kidney injury
Oral phosphosoda bowel preparations can cause phosphate-induced acute kidney injury, according to a study by Brunelli and others in the Journal of the American Society of Nephrology (2007;18:3199-3205). The retrospective study of 9,700 patients who underwent colonoscopy and then serum creatinine testing showed the use of oral sodium phosphate tablets significantly increased the risk for acute kidney injury in a general population. Physicians will need to carefully consider what kind of bowel purgative should be used in patients getting colonoscopy.
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