SHOWREEL EASD 2002

50 %
50 %
Information about SHOWREEL EASD 2002
Entertainment

Published on November 13, 2007

Author: Joshua

Source: authorstream.com

Slide1:  Diabetic renal disease: guidelines, outcomes and new strategies Introduction :  Introduction Norbert Lameire University Hospital, Ghent, Belgium Current and projected prevalence rates for diabetes worldwide:  80 60 40 20 0 Estimated prevalence (millions) 1995 2000 Africa Americas Eastern Med. Europe Southeast Asia 70 50 30 10 Western Pacific 2025 World Health Organization Statistics, 2000 Current and projected prevalence rates for diabetes worldwide Slide4:  Diabetes: an Epidemic with Worldwide Dimensions Annual change in the number of patients starting dialysis therapy in Japan:  Annual change in the number of patients starting dialysis therapy in Japan Kikkawa et al NDT 1998 Chronic glomerulonephritis Diabetic nephropathy 80 0 60 1984 20 40 2000 Percent of all patients Year 1986 1988 1990 1992 1994 1998 1996 Slide6:  “The opening of McDonalds in Tokyo is a terrible revenge for Pearl Harbour” Diabetes: the most common cause of ESRD:  Diabetes: the most common cause of ESRD Primary diagnosis for patients who start dialysis United States Renal Data System 2000 No. of patients 95% CI 1984 1988 1992 1996 2000 2004 2008 0 100 200 300 400 500 600 700 r2=99.8% 243,524 281,355 520,240 No. of dialysis patients (thousands) Diabetes 50.1% Hypertension 27% Glomerulonephritis 13% Other 10% Percentage of patients with diabetes as cause of ESRD:  Percentage of patients with diabetes as cause of ESRD Diabetic ESRD patients are at particularly high risk of cardiovascular complications:  Foley et al Diabetologia 1997 p = 0.04 p < 0.00001 p = 0.003 Diabetic ESRD patients are at particularly high risk of cardiovascular complications 38 18 24 50 32 48 Concentric LVH Ischaemic heart disease Cardiac failure Non-diabetic ESRD Diabetic ESRD Prevalence at initiation of dialysis (%) 60 40 30 20 10 0 50 First- and second-year death rates, by primary diagnosis: haemodialysis Incident patients, adjusted for age, gender, & race:  350 100 300 89 200 First- and second-year death rates, by primary diagnosis: haemodialysis Incident patients, adjusted for age, gender, & race First-year death rates Second-year death rates Deaths per 1,000 patient years 250 150 98 97 96 95 94 93 92 91 90 88 97 96 95 94 93 92 91 90 89 Year Diabetes (332) Hypertension (269) Glomerulonephritis (152) Other (223) Diabetes (296) Hypertension (296) Glomerulonephritis (180) Other (267) United States Renal Data System 2000 350 100 300 200 250 150 Late referral (1–4 months) as percentage of new patients admitted for RRT Data from 1995–1998:  Late referral (1–4 months) as percentage of new patients admitted for RRT Data from 1995–1998 * <6 months % 60 40 30 20 10 0 50 US Cnd Bra EU Fra Eng CH Esp* Lameire et al Kidney Int 2002 Correlation between predialysis nephrological care duration (PNCD), CV comorbidity and 5 year mortality:  Correlation between predialysis nephrological care duration (PNCD), CV comorbidity and 5 year mortality Jungers et al NDT 2001 <6 6–35 36–71 72 Duration of PNCD (months) 50 40 30 20 10 0 % CV comorbidity Mortality Optimal pre-ESRD treatment:  Optimal pre-ESRD treatment GFR (ml/min) 100 80 50 30 40 20 10 5 Start of specialised follow up Unbiased choice of modality!!! TP candidate ? Hepatitis B immunisation Vitamin D metabolites, calcium carbonate Acidosis correction Start of dialysis Put patient on TP waiting list Slow progression of CRF and cardio-vascular disease Vascular access if needed BP HbA1C ACE or ARB PR EPO Slide14:  Today, we’re making a scrumptious, sodium free, low potassium, low phosphorus, low carbohydrate and lipid-free chicken casserole Anaemia in diabetic nephropathy:  Anaemia in diabetic nephropathy Anaemia is prevalent in diabetic nephropathy associated with cardiovascular damage detrimental effects begin long before dialysis is required Anaemia is a modifiable risk factor Epoetin therapy is effective for the correction of anaemia in diabetic patients will early intervention translate into improved patient outcomes? Epoetin in predialysis: LVH regression:  Portolés et al AKJD 1997 Epoetin in predialysis: LVH regression Main findings Partial anaemia correction Hb 11.7 g/dl Partial LVMI regression (by ECHO) Early functional changes in cardiac output (by ECHO) No major changes in BP control (by 24 hours ABPM) Without adverse effects Potential benefits of early epoetin treatment :  Potential benefits of early epoetin treatment Regression or prevention of LVH (Hayashi et al 2000, Portolés et al 1997, Valderrábano 2000) A delayed deterioration of renal function (Kuriyama et al 1997, Jungers et al 2001) Reduced mortality in incident ESRD patients (Fink et al 2001) A call to action:  A call to action Closer collaboration between diabetologists and nephrologists is necessary to facilitate earlier referral Earlier referral and adequate management of modifiable risk factors (such as anaemia) will lead to improved care, better patient outcomes The first steps have been taken…… Programme:  Programme Slide20:  Diabetic renal disease: guidelines, outcomes and new strategies Screening and management of patients with early chronic kidney disease:  Screening and management of patients with early chronic kidney disease Jérôme Rossert The University of Paris Paris, France The proportion of dialysis patients with diabetic nephropathy (DN) is increasing rapidly:  The proportion of dialysis patients with diabetic nephropathy (DN) is increasing rapidly 110 80 60 40 20 0 Patients per 1 000 000 persons 1984 1994 Spain Sweden Italy Japan USA 100 70 50 30 10 90 Ritz et al AJKD 1999 Aetiology of renal failure in Europe – patients starting dialysis in 1999:  0 % of patients Diabetic nephropathy Chronic glomerulonephritis Vascular nephropathy Tubular interstitial nephropathy Polycystic kidney disease Valderrábano et al NDT in press Aetiology of renal failure in Europe – patients starting dialysis in 1999 5 10 15 20 25 Chronic kidney disease:  Chronic kidney disease Who should be screened for renal disease? How do we screen for renal disease? Why screen patients for early renal disease? course and consequences of renal disease can be influenced significantly if managed early Chronic kidney disease:  Chronic kidney disease Who should be screened for renal disease? How do we screen for renal disease? Why screen patients for early renal disease? course and consequences of renal disease can be influenced significantly if managed early Who to screen?:  Who to screen? Patients at risk of developing renal disease Arterial hypertension or CVD Diabetes mellitus Age >60 years Family history of renal disease Recurrent urinary tract infections Exposure to certain drugs or chemicals Chronic kidney disease:  Chronic kidney disease Who should be screened for renal disease? How do we screen for renal disease? Why screen patients for early renal disease? course and consequences of renal disease can be influenced significantly if managed early How to screen:  How to screen Screen for: Presence of proteinuria/albuminuria Abnormal urinary sediment Altered kidney function How to screen – proteinuria/albuminuria :  How to screen – proteinuria/albuminuria Adapted from ADA guidelines Diabetes Care 2002 Routine urinalysis at diagnosis (type 2 patients) Protein How to screen – proteinuria:  How to screen – proteinuria Assess proteinuria/albuminuria in a random spot urine sample Use either a dipstick or the protein/albumin to creatinine ratio In the absence of proteinuria, a specific search for microalbuminuria should be done in patients with diabetes How to screen – albuminuria:  Normal Microalbuminuria Clinical albuminuria <3.4 3.4–33.9 ≥34 <1.9 <2.8 1.9–28 2.8–40 >28 >40 How to screen – albuminuria Spot urine sample (μg/μmol) Definition ADA K/DOQI men women men women men women How to screen – urinary sediment:  How to screen – urinary sediment Urinary sediment should be analysed for the presence of RBC or WBC on a spot urine sample In some chronic kidney diseases, abnormalities other than proteinuria are present prior to reduction in GFR Use either a dipstick or a microscopic analysis How to screen – kidney function:  How to screen – kidney function Serum creatinine should not be used alone Kidney function should be assessed by estimating the level of GFR from serum creatinine Cockcroft and Gault formula [140 – age] x weight Serum creatinine (μmol/l) x 1.04 (women) 1.23 (men) Stages of chronic kidney disease (K/DOQI):  *May be normal for age Stages of chronic kidney disease (K/DOQI) 1 2 3 4 5 Stage Description GFR (ml/min/1.73m2) Kidney damage + normal or ↑ GFR Mild ↓ GFR Moderate ↓ GFR Severe ↓ GFR Kidney failure ≥90 60–89* 30–59 15–29 <15 or dialysis K/DOQI clinical practice guidelines AJKD 2002 Chronic kidney disease:  Chronic kidney disease Who should be screened for renal disease? How do we screen for renal disease? Why screen patients for early renal disease? course of renal disease can be influenced significantly if managed early blood pressure control blockage of the renin/angiotensin system Control of blood pressure:  Control of blood pressure K/DOQI, JNC VI proteinuria <1 g/d BP ≤130/85 mmHg (MAP ≤100 mmHg) proteinuria ≥1 g/d BP ≤125/75 mmHg (MAP ≤92 mmHg) ADA diabetic nephropathy guidelines BP <130/80 mmHg Blood pressure and proteinuria in the progression of CKD – the MDRD study:  Blood pressure and proteinuria in the progression of CKD – the MDRD study Peterson et al Ann Intern Med 1995 Rate of GFR decline (ml/min/yr) 0 –18 –3 Mean follow-up MAP (mmHg) 86 –15 –12 –9 –6 92 98 107 Protein excretion (g/d) 0–0.25 0.25–1.00 1.00–3.00 3.00 ARBs and progression of CKD – the RENAAL study :  40 20 0 –20 –40 –60 Change in the level of proteinuria (%) Losartan Placebo p<0.001 ARBs and progression of CKD – the RENAAL study Brenner et al N Engl J Med 2001 0 12 24 36 48 Month 30 20 10 Doubling of serum creatinine (%) Losartan Placebo 30 20 10 End-stage renal disease (%) Losartan Placebo RR 28% p=0.002 RR 25% p=0.006 0 Blockage of the renin-angiotensin system:  Blockage of the renin-angiotensin system ACE inhibitors or ARBs should be given to patients with incipient or overt diabetic nephropathy proteinuria ≥1 g/d hypertension + renal insufficiency Probably benefical to increase dosage until proteinuria is minimal Sodium restriction and diuretics increase anti-proteinuric effect After treatment initiation or dosage change, check BP, potassium, serum creatinine Preventing an acute decline in GFR:  Preventing an acute decline in GFR Avoid Acute volume depletion Obstruction of the urinary tract Nephrotoxic drugs radiocontrast agents NSAIDs aminoglycoside antibiotics, etc. Chronic kidney disease:  Chronic kidney disease Who should be screened for renal disease? How do we screen for renal disease? Why screen patients for early renal disease? course of renal disease can be influenced significantly if managed early patients with renal disease are at very high risk of CV disease It is essential to treat all modifiable CV risk factors End-stage renal disease and cardiovascular mortality:  35–44 45–54 55–64 65–74 75–84 General population >85 Adapted from Foley et al AJKD 1998 100 0.001 25–34 Age (years) 0.01 0.1 1 10 Annual mortality (%) Renal replacement therapy End-stage renal disease and cardiovascular mortality Management of dyslipidaemia:  Management of dyslipidaemia For patients with LDL >2.6 mmol/l (1 g/l) or HDL <1 mmol/l (400 mg/l) or TG >2.1 mmol/l (1.8 g/l) Dietary counselling, increase physical activity If this is insufficient, treat with statins or fibrates alone if isolated hypertriglyceridaemia Chronic kidney disease:  Chronic kidney disease Who should be screened for renal disease? How do we screen for renal disease? Why screen patients for early renal disease? course of renal disease can be influenced significantly if managed early patients with renal disease are at very high risk of CV disease consequences of renal disease appear early and can be prevented or treated Preventing and treating the consequences of renal impairment:  Preventing and treating the consequences of renal impairment Management of anaemia Management of calcium and phosphate disorders, renal osteodystrophy Correction of acidosis Haemoglobin by estimated GFR – NHANES III:  Hsu et al JASN 2002 *p<0.05 vs Hb at GFR >80 ml/min Data adapted (Hb 13.0 g/dl used as reference point) Haemoglobin by estimated GFR – NHANES III 16 14 12 10 8 Mean Hb (g/dl) 15 13 11 9 20.1–30 20.0 30.1–40 40.1–50 50.1–60 60.1–70 70.1–80 Men Women * * * * * * * * * * Estimated GFR (ml/min) Haemoglobin by estimated GFR – PRESAM:  Haemoglobin by estimated GFR – PRESAM 16 14 12 10 8 Mean Hb (g/dl) 40.0–49.9 15 13 11 9 30.0–39.9 20.0–29.9 10.0–19.9 <10.0 Estimated GFR (ml/min) Valderrábano et al NDT in press Anaemia management:  Anaemia management Treatment with epoetin should be considered when Hb is <11 g/dl Usual Hb target is 12–12.5 g/dl Correction of anaemia improves quality of life functional status cardiovascular status progression of renal disease? Preventing and treating the consequences of renal impairment:  Preventing and treating the consequences of renal impairment Management of anaemia Management of calcium and phosphate disorders, and of renal osteodystrophy Correction of acidosis PTH levels in patients with CKD:  PTH levels in patients with CKD iPTH (pg/ml) 0 50 100 150 200 250 300 350 400 0 20 40 60 80 100 120 140 Glomerular filtration rate (ml/min/1.73 m2) Normal range Management of calcium and phosphate:  Management of calcium and phosphate Dietary counselling Non-aluminium-containing phosphate binders Dietary counselling Active vitamin D metabolites, and/or latent vitamin D When phosphate levels are >1.5 mmol/l When PTH levels are >2.5 times above normal and phosphate levels are <1.5 mmol/l Monitor calcium, phosphate, Ca x P, vitamin D and PTH levels Preventing and treating the consequences of renal impairment:  Preventing and treating the consequences of renal impairment Management of anaemia Management of calcium and phosphate disorders, and of renal osteodystrophy Correction of acidosis Serum bicarbonate levels should be maintained ≥22 mmol/l, using supplements Chronic kidney disease:  Chronic kidney disease Who should be screened for renal disease? How do we screen for renal disease? Why screen patients for early renal disease? course of renal disease can be influenced significantly if managed early patients with renal disease are at very high risk of CV disease consequences of renal disease appear early and can be prevented or treated patients can be prepared for renal replacement therapy (RRT) if needed Preparing patients for RRT:  Preparing patients for RRT Vein preservation always try to preserve the cephalic veins for a fistula Immunisation screen for hepatitis immunise against hepatitis B, if needed Counselling psychological support socio-economic and family counselling early planning for RRT Summary:  Summary The earliest markers of kidney disease appear first to the diabetologist, providing the best opportunity to: Decrease the risk of CV disease particularly important for patients with diabetes, who are at higher risk Slow the progression of renal disease Minimise the consequences of renal disease Slide56:  Early identification of patients with diabetic nephropathy and early collaboration between diabetologists and nephrologists provides the best chance to combat the growing global burden Slide57:  Diabetic renal disease: guidelines, outcomes and new strategies Outcomes of anaemia management in diabetic populations:  Outcomes of anaemia management in diabetic populations Stephen Thomas King’s College Hospital, London, UK Stages of diabetic nephropathy in type 1 diabetes:  Stages of diabetic nephropathy in type 1 diabetes Adapted from Mogensen et al Diabetes 1983 *Years since diabetes diagnosed Definition of high risk urinary albumin excretion rate (AER):  Microalbuminuria Definition of high risk urinary albumin excretion rate (AER) Mortality in type 2 diabetes with and without microalbuminuria:  Mattock et al Diabetes 1998 Mortality in type 2 diabetes with and without microalbuminuria Microalbuminuria and type 2 diabetes:  MacLeod et al Diabetologia 1995 *p=0.02; **p=0.009 Microalbuminuria and type 2 diabetes Cardiovascular burden is higher in diabetic end-stage renal disease:  Cardiovascular burden is higher in diabetic end-stage renal disease Foley et al Diabetologia 1997 Baseline cardiac disease in patients with diabetes vs non-diabetic patients on dialysis Anaemia is more severe in diabetic nephropathy:  Anaemia is more severe in diabetic nephropathy *p<0.005 vs type 2 diabetes Serum creatinine and presence of diabetes are independent risk factors for anaemia (r2 = 0.49, p<0.001) Ishimura et al J Nephrol 1998 Anaemia occurs early in diabetic nephropathy:  Anaemia occurs early in diabetic nephropathy *Anaemia = Hb <11.5 g/dl women, <12.0 g/dl men Bosman et al Diabetes Care 2001 Diabetic nephropathy vs glomerulonephritis Erythropoietin (EPO):  Erythropoietin (EPO) 90% produced by the peri-tubular fibroblasts in the kidneys and <10% by the liver in response to anaemia and hypoxia Release is modulated through the sympathetic nervous system (β-adrenergic receptors) Anaemia associated with EPO deficiency usually occurs at a GFR below 35–40 ml/min EPO deficiency in diabetes mellitus:  EPO deficiency in diabetes mellitus Kojima et al Anaemia due to reduced serum erythropoietin levels in non-uraemic patients with diabetes Ishimura et al Diabetes increases the severity of anaemia in predialysis patients with renal failure Yun et al EPO responsiveness to anaemia reduced in patients with diabetes prior to advanced diabetic nephropathy Kojima et al Diabetes Res Clin Pract 1995; Ishimura et al J Nephrol 1998; Yun et al Diabetes Res Clin Pract 1999 Relationship between haemoglobin concentration and EPO level:  Relationship between haemoglobin concentration and EPO level Erslev NEJM 1991 Serum EPO (mU/ml) 5 7 9 11 13 15 10 000 10 1000 100 Haemoglobin concentration (g/dl) Relationship between haemoglobin concentration and EPO level:  Bosman et al Diabetes Care 2001 DN patients Controls Relationship between haemoglobin concentration and EPO level log10 (serum EPO) 6 4 2 6 8 10 12 14 16 Haemoglobin concentration (g/dl) EPO-deficiency anaemia in early diabetic nephropathy:  EPO-deficiency anaemia in early diabetic nephropathy Rampersad et al Diabet Med 2002 Rampersad et al Determined sample prevalence of EPO-deficiency anaemia in 74 patients with diabetic nephropathy EPO-deficiency anaemia in early diabetic nephropathy:  EPO-deficiency anaemia in early diabetic nephropathy Rampersad et al Diabet Med 2002 Patient characteristics EPO-deficiency anaemia in early diabetic nephropathy :  EPO-deficiency anaemia in early diabetic nephropathy Rampersad et al Diabet Med 2002 Patient characteristics: 12 with anaemia (Hb <13 g/dl men, <12 g/dl women) All normochromic and normocytic Mean Hb 11 (± 0.9) g/dl Mean EPO 11 (± 4) mU/ml EPO-deficiency anaemia in early diabetic nephropathy:  EPO-deficiency anaemia in early diabetic nephropathy Rampersad et al Diabet Med 2002 Haemoglobin concentrations and EPO levels 5 10 000 1 1000 100 Serum EPO (mU/ml) 10 5 7 9 11 13 15 Haemoglobin concentration (g/dl) Patient characteristics: 12 with anaemia (Hb <13 g/dl men, <12 g/dl women) All normochromic and normocytic Mean Hb 11 (± 0.9) g/dl Mean EPO 11 (± 4) mU/ml EPO-deficiency anaemia in early diabetic nephropathy:  Rampersad et al Diabet Med 2002 EPO-deficiency anaemia in early diabetic nephropathy Comparison of patients with/without EPO-deficiency anaemia EPO-deficiency anaemia in early diabetic nephropathy:  EPO-deficiency anaemia in early diabetic nephropathy Rampersad et al Diabet Med 2002 Haemoglobin level correlates with creatinine clearance in diabetic nephropathy 7 300 0 200 100 11 13 15 17 19 CrCl (ml/min) 9 r = 0.467 p = 0.01 Haemoglobin concentration (g/dl) EPO-deficiency anaemia in early diabetic nephropathy:  Rampersad et al Diabet Med 2002 HR = heart rate EPO-deficiency anaemia in early diabetic nephropathy Autonomic neuropathy EPO-deficiency anaemia in early diabetic nephropathy:  EPO-deficiency anaemia in early diabetic nephropathy Rampersad et al Of 12 patients with anaemia, 11 had EPO-deficiency anaemia 8F / 1M, type 1; 2M type 2 ‘Sample prevalence’, 11/74 x 100 = 15% 25% of type 1 patients, 5% of type 2 patients Ghirlanda et al 11/206 (5%) patients with type 1 diabetes and autonomic neuropathy had EPO-deficiency anaemia Rampersad et al Diabet Med 2002; Ghirlanda et al Diabet Med 2000 EPO-deficiency anaemia in early diabetic nephropathy:  EPO-deficiency anaemia in early diabetic nephropathy Affects a significant proportion of patients with diabetes size of the problem will increase due to the diabetes pandemic Occurs early in the course of renal complications of diabetes Correlates well with declining renal function Affected patients are at increased cardiovascular risk Study summary Epoetin therapy corrects anaemia associated with diabetes:  Epoetin therapy corrects anaemia associated with diabetes Rarick et al Epoetin therapy in 6 patients with type 1 diabetes, unexplained anaemia and serum creatinine <177 mol/l Treatment resulted in normalised haematocrit and improved QoL Winkler et al Epoetin therapy in 5 patients with type 1 diabetes, EPO-deficiency anaemia and serum creatinine <122 mol/l Treatment led to increase in haemoglobin and improvement in well-being Rarick et al Diabetes Care 1998; Winkler et al Diabet Med 1999 Epoetin treatment for orthostatic hypotension (OH) in diabetes mellitus:  Hoeldtke et al NEJM 1993; Winkler et al Diabetes Care 2001 Epoetin treatment for orthostatic hypotension (OH) in diabetes mellitus Hoeldtke et al 9 weeks of epoetin treatment (50 IU/kg) in 8 patients with OH (4 with type 1 diabetes and autonomic neuropathy [DAN]) Standing SBP increased from 81 to 100 mmHg Standing DBP increased from 46 to 63 mmHg Supine hypertension in 3 patients Orthostatic dizziness improved in 6 of the 8 patients Winkler et al Epoetin treatment (25 IU/kg SC thrice weekly) for 3 months in 4 female patients with type 1 DAN and EPO-deficiency anaemia with pronounced symptomatic OH Small significant rise in standing SBP which fell again after epoetin withdrawal Epoetin in diabetic macular oedema and renal insufficiency:  Friedman et al AJKD 1995 Epoetin in diabetic macular oedema and renal insufficiency Friedman et al Epoetin was administered to 5 patients with diabetes, anaemia and uraemia for 1 year Improvement of macular oedema ? Less tissue and cellular hypoxia Polycythaemia in CAPD patients:  Bender et al Adv Perit Dial 1991 Polycythaemia in CAPD patients Over 8 years, 4 out of 123 patients on CAPD (3%) were identified as having Hct >50% for 1 month or longer All 4 patients had type 1 diabetes (4 out of 47 patients with diabetes, 8.5%) Prior to the development of polycythaemia, ferritin levels were low and ferrous sulfate therapy was initiated when Hct values 36–40% Complications: gangrenous feet requiring amputation in 2 patients, CVA (1 fatal) in 2 patients, and splenic infarct in 1 patient Volume depletion and iron therapy may play a role Conclusions Anaemia...:  Conclusions Anaemia... Is a significant problem in early diabetic nephropathy May be more common in type 1 diabetes than in type 2 diabetes More common in women than men Correlates with declining renal function Conclusions Epoetin...:  Conclusions Epoetin... Is effective for correction of anaemia associated with diabetes Early treatment with epoetin may be important for cardiovascular protection Slide85:  A multidisciplinary approach is needed to optimise the care of patients with diabetic nephropathy Slide86:  Diabetic renal disease: guidelines, outcomes and new strategies New strategies: ACORD trial (Anaemia CORrection in Diabetes):  New strategies: ACORD trial (Anaemia CORrection in Diabetes) Maurice Laville Edouard-Herriot Hospital, Lyon, France A deadly combination:  A deadly combination Diabetes Cardiovascular disease Renal insufficiency A deadly combination:  A deadly combination Diabetes Cardiovascular disease Renal insufficiency Cardiovascular mortality rates are higher among dialysis patients :  Cardiovascular mortality rates are higher among dialysis patients Male 0.001 0.01 0.1 1 10 100 Annual mortality (%) Dialysis General population Female Foley et al AJKD 1998 25–34 35–44 45–54 55–64 65–74 75–84 >85 Age Life expectancy of ESRD patients Patients treated at home or in out-centre facilities:  Life expectancy of ESRD patients Patients treated at home or in out-centre facilities Arkouche et al Kidney Int 1999 0 0 0.2 0.4 0.6 1.0 0.8 5 10 15 20 25 Survival time (years) Proportional survival Others CGN Vascular Unknown Diabetes Mortality in diabetic ESRD patients Medicare haemodialysis cohort (n=70,000):  Ma et al JASN 1999 Mortality in diabetic ESRD patients Medicare haemodialysis cohort (n=70,000) Death rate (per 1000 treatment years) Non-diabetics 214.7 192.0 170.6 161.4 Diabetics 342.7 298.2 258.3 234.6 Percentage of death (diabetics) All cause 28.1 25.1 22.2 20.3 CV cause 12.1 11.5 10.3 9.7 <27 33–36 Mortality risk* 27–30 30–33 Haematocrit (%) Cardiovascular burden at dialysis initiation:  Cardiovascular burden at dialysis initiation Parfrey et al Curr Opin Nephrol Hypertens 1995; Harnett et al Kidney Int 1995 0 80 LVH CHF MI CAD Prevalence (%) 60 40 20 Factors associated with LV growth in CKD patients:  Factors associated with LV growth in CKD patients Levin et al AJKD 1999 Hb ( of 0.5 g/dl) 1.32 (1.1, 1.59) 0.004 SBP ( of 5 mmHg) 1.11 (1.02, 1.21) 0.015 LVMI at baseline 0.85 (0.76, 0.96) 0.011 OR (95% CI) p-value Factor A deadly combination:  A deadly combination Diabetes Cardiovascular disease Renal insufficiency Anaemia Epoetin therapy correlates with improved survival in dialysis patients:  Epoetin therapy correlates with improved survival in dialysis patients Locatelli et al NDT 1998 0 1.0 General mortality (n=5302) Odds-ratio (mortality) 0.6 0.4 0.2 0.8 CV mortality (n=5302) Epoetin-treated Untreated Hospitalisation days per patient-year 20 p<0.001 p<0.05 0 10 5 15 <27 27–32 >32 Haematocrit (%) Patients with diabetes = 7.6% Benefits of early epoetin treatment :  Benefits of early epoetin treatment Anaemia is an independent predictor of non-elective hospitalisation prior to RRT (Holland & Lam 2000) An early anaemia treatment results in: reduced mortality in incident ESRD patients (Fink et al 2001, Xue et al 2001) delayed deterioration of renal function (Kuriyama et al 1997, Jungers et al 2001) regression or prevention of LVH (Hayashi et al 2000, Portolés et al 1997, Valderrábano 2000) Benefits of early epoetin treatment – regression of LVH:  Portolés et al AJKD 1997 LVM index (g/m2) Benefits of early epoetin treatment – regression of LVH 100 180 220 260 Baseline Hb = 9.0 g/dl 6 months Hb = 11.7 g/dl Mean value 178.2 147.3 n=11 140 p<0.05 Epoetin Anaemia and its treatment in diabetic nephropathy:  Anaemia and its treatment in diabetic nephropathy Anaemia appears to be a relatively early feature in patients with diabetic nephropathy1 Anaemia is more severe in diabetic patients with nephropathy than in non-diabetic patients2 Epoetin is effective for the correction of anaemia in diabetic patients Studies in CKD support benefit of early treatment for CV protection 1. Bosman et al Diabetes Care 2001 2. Ishimura et al J Nephrol 1998 The Anaemia CORrection in Diabetes (ACORD) study:  The Anaemia CORrection in Diabetes (ACORD) study The ACORD study is investigating the effects of anaemia correction with SC epoetin beta (NeoRecormon®) on cardiac structure cardiac function in patients with early diabetic nephropathy Slide101:  Europe Asia Austria Denmark Italy Sweden Singapore Thailand Greece Spain Total 40 centres United Kingdom Germany n=160 ACORD trial: Background Optimal haemoglobin level for DN patients is unclear and may depend on the time of intervention:  15 10 5 Hb (g/dl) ACORD trial: Background Optimal haemoglobin level for DN patients is unclear and may depend on the time of intervention Time / creatinine ACORD trial: Background:  ACORD trial: Background cardiac / renal disease progression 'Late' correction of anaemia in patients with advanced cardiac disease  Improved QoL  Limited reversibility of LVH  Without survival benefit ACORD trial: Background:  15 10 5 Hb (g/dl) Time / creatinine ACORD trial: Background ACORD trial: Background:  ACORD trial: Background ACORD: 15-month, open-label, randomised, multicentre study :  Inclusion: Hb 11.0–12.5 g/dl CrCl 30 ml/min Hb (g/dl) m f Time n=160 Randomisation 16 ACORD: 15-month, open-label, randomised, multicentre study 14 12 10 8 6 16 14 12 10 8 6 ACORD: Inclusion criteria:  ACORD: Inclusion criteria Diabetic for >5 years with stable glycaemic control for at least 3 months Proteinuria 500 mg/24 h at screening CrCl 30 ml/min Hb 11 to 12.5 g/dl at screening ACORD: Exclusion criteria:  ACORD: Exclusion criteria Non-renal causes of anaemia Advanced CVD (e.g. CHF NYHA III and IV) Rapid progression of renal failure Blood transfusion, overt GI bleeding, MI, unstable angina, stroke in last 3 months Ferritin <50 mg/ml Previous treatment with an erythropoietic substance ACORD: 15-month, open-label, randomised, multicentre study :  Inclusion: Hb 11.0–12.5 g/dl CrCl 30 ml/min Hb (g/dl) m f Time n=160 Randomisation 16 ACORD: 15-month, open-label, randomised, multicentre study 14 12 10 8 6 16 14 12 10 8 6 ACORD: Schedule of major efficacy assessments :  ACORD: Schedule of major efficacy assessments Baseline Month 6 Month 15 Hb Iron status Renal function Echocardiogram Ambulatory BP monitoring ACORD: Treatment:  ACORD: Treatment SC NeoRecormon® self-administered once weekly with Reco-Pen® Starting dose 2,000 IU weekly NeoRecormon® supplied in 10,000 and 20,000 IU cartridges to allow fine tuning of dose adjustments with a precision of 250 IU and 500 IU, respectively ACORD: Dose adjustment:  ACORD: Dose adjustment If Hb >15 g/dl interrupt treatment until Hb 14 g/dl then 50% of previous dose Change in Hb (g/dl/4wk) <0.5 >1.0 Increase dose Reduce dose ACORD: Efficacy:  ACORD: Efficacy Primary variable Change in left ventricular mass index (LVMI) from baseline to 15 months post-randomisation Secondary variables LV volume, fractional shortening, change in renal function % patients with stable Hb (13–15 g/dl) Mean weekly epoetin dose to maintain stable Hb Ambulatory BP monitoring ACORD: Safety:  ACORD: Safety Adverse events Laboratory parameters Vital signs Anti-erythropoietin antibodies ACORD: Data analysis:  ACORD: Data analysis Primary efficacy and safety analysis on the intent-to-treat population An additional per protocol analysis for the main efficacy variables based on all patients without major protocol violation Summary (1):  Summary (1) The worldwide diabetes epidemic is a major public health concern The number of patients admitted for RRT with comorbid diabetes has increased significantly over the last decade Management of modifiable risk factors can prevent cardiovascular and renal disease in patients with diabetes Summary (2):  Summary (2) Anaemia correction in CKD patients represents an opportunity to modify the course of the disease and improve cardiovascular health in patients with diabetes The ACORD study will provide valuable information on the benefits of early anaemia correction with epoetin beta for reduction of cardiovascular risk in patients with early diabetic nephropathy Slide118:  Diabetic renal disease: guidelines, outcomes and new strategies

Add a comment

Related presentations

Related pages

VRAY BLOG TUTORIALES NOTICIAS: VRay Showreel 2016

VRay Showreel 2016 julio ... donde se gradúa en el 2002. ... Colabora con el departamento de la EASD de Valencia en la investigación de nuevas ...
Read more

VRAY BLOG TUTORIALES NOTICIAS

VRay Showreel 2016. ... donde se gradúa en el 2002. ... Colabora con el departamento de la EASD de Valencia en la investigación de nuevas formas de ...
Read more

VRAY BLOG TUTORIALES NOTICIAS: septiembre 2014

VRAY FILM AND VFX SHOWREEL 2014. Buenas noches a tod@s, ...
Read more

Actas de Palermo - Scribd

EASD Escola D'Art I ... Encuentro Latinoamericano de Diseño 2010 Comunicaciones enviadas para su publicación en Actas de Diseño 9 Design. 2002 ...
Read more

148 Libro - scribd.com

EASD Escola D'Art I Superior de Disseny de València. Universidad Latina de América ... (Moura. “direito de vernaculania. Ao contrário.. 2002: ...
Read more

Launch Relaunch - Englisch-Übersetzung – Linguee Wörterbuch

Viele übersetzte Beispielsätze mit "Launch Relaunch" – Englisch-Deutsch Wörterbuch und Suchmaschine für Millionen von Englisch-Übersetzungen.
Read more

Paramount Comedy channel ident (Matt Oxborrow) - YouTube

2D animated channel idents created for Paramount Comedy channel. 12foot6 ... Gràfica Audiovisual EASD Serra i ... Ident (2002 ) - Duration: 0 ...
Read more

ᐅ Saa › Test Vergleich & Öffnungszeiten - StadtBranche.de

ᐅ Saa › Test Vergleich & Öffnungszeiten Erfahrung Vergleich Öffnungszeit ᐅ Testbericht Bewertung
Read more