Rhode Island Kidney Care Connection
Furthering Kidney Health for Patients
With Diabetes
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The '30-20-10' Rule for Renal Care
From the January 2010 Issue of Renal and Urology News
Despite the well-documented advantages of permanent access placement, 82% of patients initiating hemodialysis (HD) in the United States in 2006 did so with a catheter. Even in patients followed by a nephrologist for at least six months, the rate of patients starting dialysis with a catheter was 75%. HD catheters are associated with the worst mortality risk by access type, and changing to a fistula, graft, or peritoneal dialysis (PD) catheter can significantly improve patient survival. In light of these findings, we discuss some important access-management strategies that health-care providers should keep in mind for patients with progressive CKD.
Timely referral and access to nephrology services remains the foundation for the optimal management of CKD. Estimated glomerular filtration rate (eGFR) should be monitored routinely in patients with advanced or progressive CKD. Recently, the members of the American Clinical Laboratory Association (ACLA) unanimously agreed to report eGFR whenever a measurement of creatinine is reported. Based on eGFR values, we advocate a "rule of 30-20-10" mnemonic that corresponds to eGFR action thresholds in the preparation of patients for possible dialytic therapy.
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Relation Between Kidney Function, Proteinuria, and Adverse Outcomes
JAMA 2010; 303(5):423-429
Context
The current staging system for chronic kidney disease is based primarily on estimated glomerular filtration rate (eGFR) with lower eGFR associated with high risk of adverse outcomes. Although proteinuria is also associated with adverse outcomes, it is not used to refine risk estimates of adverse events in this current system.
To determine the association between reduced GFR, proteinuria, and adverse clinical outcomes.
Design, Setting, and Participants
Community-based cohort study with participants identified from a province-wide laboratory registry that includes eGFR and proteinuria measurements from Alberta, Canada, between 2002 and 2007. There were 920,985 adults who had at least one outpatient serum creatinine measurement and who did not require renal replacement treatment at baseline. Proteinuria was assessed by urine dipstick or albumin-creatinine ratio (ACR).
Main Outcome Measures
All-cause mortality, myocardial infarction, and progression to kidney failure.
Results
The majority of individuals (89.1%) had an eGFR of
60mL/min/1.73 m2 or greater. Over median follow-up of 35 months (range, 0-59 months), 27,959 participants (3.0%) died. The fully adjusted rate of all-cause mortality was higher in study participants with lower eGFRs or heavier proteinuria. Adjusted mortality rates were more than two-fold higher among individuals with heavy proteinuria measured by urine dipstick and eGFR of 60 mL/min/1.73 m2 or greater, as compared with those with eGFR of 45 to 59.9 mL/min/1.73 m2 and normal protein excretion (rate, 7.2 [95% CI, 6.6-7.8] vs 2.9 [95% CI, 2.7-3.0] per 1000 person-years, respectively; rate ratio, 2.5 [95% CI, 2.3-2.7]). Similar results were observed when proteinuria was measured by ACR (15.9 [95% CI, 14.0-18.1] and 7.0 [95% CI, 6.4-7.6] per 1000 person-years for heavy and absent proteinuria, respectively; rate ratio, 2.3 [95% CI, 2.0-2.6]) and for the outcomes of hospitalization with acute myocardial infarction, end-stage renal disease, and doubling of serum creatinine level.
Conclusion
The risks of mortality, myocardial infarction, and progression to kidney failure associated with a given level of eGFR are independently increased in patients with higher levels of proteinuria.
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This material was prepared by Quality Partners of Rhode
Island, the Quality Improvement Organization for Rhode Island, under
contract with the Centers for Medicare & Medicaid Services (CMS),
an agency of the U.S. Department of Health and Human Services.
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World Kidney Day
March 11, 2010
World Kidney Day (WKD) is a global health awareness campaign focusing on the importance of our kidneys and reducing the frequency and impact of kidney disease and its associated health problems worldwide. The 2010 campaign will focus on diabetes, the leading cause of Chronic Kidney Disease.
As a medical or allied health professional, you are at the forefront of combating kidney disease around the world through early detection and prevention.
www.worldkidneyday.org |
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Events &
Continuing Education
Opportunities
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Contact Us
For information or technical assistance on Quality Partners' Chronic Kidney Disease Project, please contact Lynn Pezzullo.
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