Learning objectives

  1. To discuss the changing demographics of patients diagnosed with chronic kidney disease.
  2. To describe the role of evidence-based guidelines in the management of said patients.
  3. To outline future directions in the pursuit of quality care in chronic kidney disease.

Summary

Since its emergence as a medical specialty in the 1960s, the focus of nephrology has changed dramatically in the past decade. What started as a discipline to provide dialysis and transplant care to patients with kidney failure in the 1970s has evolved to that of the detection and treatment of the much larger number of prevalent cases at earlier stages of the disease, in order to prevent its adverse outcomes (kidney failure, cardiovascular disease, and premature death) that occur in the course of gradual loss of kidney function. The changing demographics of chronic kidney disease (CKD) care has led to the adoption of a public health approach to the worldwide epidemic of CKD.

Key Words: Chronic kidney disease; prevalence of chronic kidney disease; dialysis; end stage renal disease; chronic renal failure; clinical practice guidelines.

From: Nutrition and Health: Nutrition in Kidney Disease Edited by: L. D. Byham-Gray, J. D. Burrowes, and G. M. Chertow © Humana Press, Totowa, NJ

1. introduction

Whereas diseases of the kidney have tormented humans for ages and medical interest in their care and treatment can be traced to antiquity, nephrology as the science that deals with the kidneys, especially their function and diseases, is a relatively new discipline of medicine (1,2). Historically, dialysis is the single most important development that focused attention on the kidneys and their failure to function (3). What started in the 1960s as an exploratory effort to sustain life evolved in the 1970s into life saving renal replacement therapy (RRT) for patients whose kidney disease had progressed to kidney failure (4). Since the inception of the Medicare End Stage Renal Disease (ESRD) program in 1972, the number of patients on maintenance dialysis has increased in the United States and the other parts of the world (5). Currently, well over 1.3 million individuals in the world are alive on maintenance dialysis and about one-third as many with a kidney transplant (Table 1). With reported annual growth rates of about 5-8% per year, it is projected that the number of dialysis patients worldwide will double in the next decade (6). What has become evident recently is the much larger number of individuals with kidney disease who are not on dialysis (~50-100 fold greater than the number of ESRD patients on dialysis), a condition that affects their quality of life (Fig. 1) and whose proper care will significantly impact the healthcare system worldwide (6-8).

Table 1

Treated end stage renal failure at year end in 2004

Transplant

Table 1

Treated end stage renal failure at year end in 2004

Transplant

Region

ESRD n(pmp)

Dialysis n (pmp)

n (pmp)

North America

492 (1505)

337 (1030)

154 (470)

Europe

473 (585)

324 (400)

149 (185)

Japan

261 (2045)

248 (1945)

13 (100)

Asia (excluding Japan)

237 (70)

196 (60)

41 (10)

Latin America

205 (380)

170 (320)

35 (65)

Africa

61 (70)

57 (65)

50 (5)

Middle East

54 (l90)

39 (140)

15 (55)

Total

1783 (280)

1371 (215)

412 (65)

ESRD, end stage renal failure; n, number of patients in thousands; pmp, prevalence in patients per million population. (reproduced with modification from Grassman et al. (5)).

ESRD, end stage renal failure; n, number of patients in thousands; pmp, prevalence in patients per million population. (reproduced with modification from Grassman et al. (5)).

1 GFR 10-20

  • GFR 20-30
  • GFR 30-40
  • GFR 40-50
  • GFR 50-60

1 GFR 10-20

  • GFR 20-30
  • GFR 30-40
  • GFR 40-50
  • GFR 50-60

Fig. 1. Odds of having symptoms that affect quality of life and well being in 1284 patients in the MDRD study. Controlled for age, gender, race, education, income, and smoking. GFR, glomerular filtration rate in ml/min/1.73 m2. Reproduced with permission from Rocco et al. (7).

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