End Stage Renal Disease

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Not all patients with CKD go on to develop ESRD; in fact, most die of other, nonrenal causes, especially from cardiovascular disease. However, patients with ESRD who do undergo cardiac catheterization and PCI represent an important group that may be at risk

Table 5-3.

Stages of Chronic Kidney Disease (CKD), Action Recommendations, and Prevalence

CKD Stage

Description GFR (mL/min/1.73 m2)

Action Recommendation

Prevalence (%)

1

Kidney damage with normal or >90

Diagnosis and treatment

2.8

increased GFR

Treatment of coexisting conditions

Slowing progression

CVD risk reduction

2

Kidney damage with mild decrease in 60-89

Estimation of progression

2.8

GFR

3

Moderate decrease in GFR 30-59

Evaluation and treatment of

3.7

complications

4

Severe decrease in GFR 15-29

Referral to nephrologist

0.1

Consideration for renal

replacement therapy

5

Kidney failure <15 or dialysis

Replacement (if uremia present)

0.2

CVD, cardiovascular disease; GFR, glomerular filtration rate.

Adapted from National Kidney Foundation: K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002;39:S1-S266.

CVD, cardiovascular disease; GFR, glomerular filtration rate.

Adapted from National Kidney Foundation: K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002;39:S1-S266.

Figure 5-4. Cardiovascular mortality in the general population (GP, data from the National Center for Health Statistics) compared with patients with end-stage renal disease treated by dialysis (data from United States Renal Data System, 1994-1996). (From Sarnak MJ, Levey AS, Schoolwerth AC, et al: Kidney disease as a risk factor for development of cardiovascular disease: A statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 2003;108:2155.)

Rights were not granted to include this figure in electronic media Please refer to the printed publication.

for intraprocedural as well as short- and long-term complications.

Overall, the epidemiology of ESRD is better understood than that of CKD. In the United States, both the incidence and the prevalence of ESRD have doubled in the past decade and are expected to increase significantly in the future.23 In 2003, more than 450,000 people required dialysis or transplantation for ESRD in the United States; however, by 2030, estimates suggest that this number will increase to more than 2 million people.23 The dramatically increased rates of cardiovascular disease and accelerated atherosclerosis have long been recognized in ESRD.39 More than 50% of deaths among patients with ESRD are caused by cardiovascular events, and more than 20% of cardiac deaths can be attributed to acute myocardial infarction.40 The 2-year mortality rate after myocardial infarction among patients with ESRD is approximately 50%, twice the mortality rate after myocardial infarction in the general popula-tion.33,40 This excess cardiovascular mortality risk ranges from 500-fold higher in individuals aged 25 to 35 years to fivefold higher in individuals older than 85 years of age (Fig. 5-4).41

In most patients who are receiving chronic dialysis, postprocedure dialysis is not routinely needed after exposure to contrast agents.42,43 But the studies in this area involved only a selected group of patients. So, although it appears that most patients can be maintained on their routine schedule for dialysis, special care and attention may be needed for specific groups, such as those with poor cardiac function or evidence of residual renal function, which is more common among patients treated with peritoneal dialysis.

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