Renal Disease in Asians 6 th Asian Health Symposium October 7, 2017 Division of Nephrology San Francisco, CA Department of Medicine Chi-yuan Hsu, MD, MSc Professor and Chief UCSF Division of Nephrology
Disclosures No relevant disclosures – author and peer reviewer: UpToDate – Medical advisory board member: Satellite Healthcare – Consultant: Merck, AstraZeneca/Ice Miller – donation of device for research: Microlife, Teco/Scanostics, Nova Biomedical
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies) 4. Resources and approach
The kidneys maintain stable internal milieu for the body
Glomerular filtration rate (GFR) • Considered single best index of kidney function • Usually estimated in clinical practice from serum Cr e.g. MDRD equation GFR (ml/min/1.73m 2 ) = 175*(Cr) -1.154 *(age) -0.203 [*0.742 if female] [*1.212 if black] • Correlates with complications with kidney disease e.g. metabolic derangement, retention of salt, need for dialysis
• Chronic kidney disease (CKD) • End-stage renal disease (ESRD) = kidney failure severe enough to be treated with dialysis or kidney transplant
• Chronic kidney disease (CKD) The critical importance of proteinuria, or albuminuria as a sign of kidney damage
Peterson Ann Intern Med 1995
Beyond Cr: proteinuria quantification Beyond dipstick urinalysis spot urine • protein (or albumin) to Cr ratio • A random urine protein (or albumin)/Cr ratio approximates gm of protein (or albumin) excreted per 24-hours (e.g. 300 mg/dl / 100 mg/dl ≈ 3 grams per day) • This is because many people make (and excrete in the urine) ~ 1 gm of Cr per day • So per 1 gm of Cr is per 24-hr (easier than 24-hour urine collections)
Why does proteinuria predict progression? A. Reflects intra-glomerular hypertension which is deleterious
Glomerular filtration, intra- glomerular pressure and proteinuria Afferent arteriole Efferent arteriole SNGFR = L P S ( ∆ P - ∆Π )
Why does proteinuria predict progression? A. Reflects intra-glomerular hypertension which is deleterious B. Filtered protein itself is nephrotoxic (contains complement cascade proteins, transferrin etc.)
Zandi-Nejad KI 2004
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies) 4. Resources and approach
Asians > white ESRD incidence US Renal Data System 2016 Annual Data Report
International comparison
US Renal Data System 2016 Annual Data Report
Baseline characteristics White Asian Black (n=221,686) (n=17,793) (n=59,689) Age (yr) 39 ± 14 36 ± 12 * 35 ± 12 * Female 53% 54% * 58% * BP (mmHg) 129/ 76 123/75 * 131/78 * DM 1.9% 1.9% 2.7% * BMI (kg/m 2 ) 24 ± 4 22 ± 3 * 26 ± 5 * 0.95 ± 0.24 0.89 ± 0.23 * 0.97 ± 0.25 * Cr (mg/dl) * p< 0.05
White Asian Black Proteinuria 96.2% 96.8% 94.8% Negative 2.1% 1.5% 2.9% Trace 1.6% 1.4% 2.0% 1-2 + 0.2% 0.2% 0.3% 3-4+ Education High school or less 34% 26% 41% 23% 23% 24% Some college College graduate 21% 24% 9% * p< 0.05 for Asians vs. white and for black vs. white
Multivariable hazard ratios (95% CI) Asian Black (v. white) 1.7 (1.3-2.2) 5.3 (4.8-5.9) Unadjusted +adjusting for age, sex, education 1.6 (1.3-2.1) 5.1 (4.6-5.8) 1.7 (1.3-2.2) 3.7 (3.3-4.2) +DM, MI, Cr, BP, proteinuria, hematuria +Smoking, chol, BMI 2.1 (1.6-2.7) 3.3 (2.9-3.7)
• Several other studies have also shown that Asians have more rapid rates of renal function loss/kidney failure (compared with whites) Hall CJASN 2010 Among the urban poor in San Francisco Barbour NDT 2010 Canadian patients referred to nephrology Derosa AJKD 2013 Kaiser S. California enrollees Barbour KI 2013 Canadian IgA nephropathy patients • No study has shown less rapid rates of loss Peralta JASN 2011 NIH cohort study (MESA) participants Conley AJKD 2012 Citizens of Alberta, Canada • Generally lower rates of mortality
What could be some reasons for higher risks of kidney failure? • Higher incidence of glomerulonephritis? • Use of herbal medications?
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies) 4. Resources and approach
“In the early 1970s, mandatory kidney disease screening was started with urinalysis in the Japanese health examination program for all workers and school-age children. In 1983, nationwide urinalysis screening in adults aged >40 yr was mandated in the community-based health examination program. Because glomerulonephritis was an endemic disease and the leading cause of end-stage renal disease in Japan until 1997, the urinalysis in the annual health examination program aimed for early detection of glomerulonephritis and early referral of patients to physicians.”
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies) 4. Resources and approach
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies) 4. Resources and approach
Kidneys Weakness Forgetfulness Fatigue Dizziness Male Female Sore in Nocturnal manifestation of Erectile back and emission weak kidneys dysfunction knees Ringing in (wet dream) the ears http://baike.baidu.com/view/14324.htm (accessed August 12, 2014)
http://zh.m.wikipedia.org/wiki/ 五臟 (accessed August 12, 2014)
Hippocrates, Galen and humorism “The Human body contains blood, phlegm, yellow bile and black bile. These are the things that make up its constitution and cause its pains and health. Health is primarily that state in which these constituent substances are in the correct proportion to each other, both in strength and quantity, and are well mixed.” --On the nature of man (Hippocrates) http://en.wikipedia.org/wiki/Humorism (accessed August 12, 2014)
The kidneys maintain stable internal milieu for the body
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies) 4. Resources and approach
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies) 4. Resources and approach
Bottomline • At a fundamental level, approach to chronic kidney disease in Asians in no different from approaching chronic kidney disease in non-Asians • Raise awareness, appropriate work-up and management (culturally sensitive)
http://nkdep.nih.gov/resources/NKDEP_Explaining_kid ney_test_results_Vietnamese_508.pdf
http://nkdep.nih.gov/resources/NKDEP_Explaining_kid ney_test_results_Chinese_508.pdf
Approach to (Asian) patients with CKD • Treatment targeted to underlying etiology (e.g. glomerulonephritis) • General treatment to retard CKD progression (e.g. blood pressure and proteinuria reduction) • Manage CVD risk factors (e.g. lipid) • Treat complications of CKD (e.g. anemia, acidosis) • Prepare for renal replacement therapy (transplant evaluation, peritoneal dialysis, pre- emptive fistula)
Outline Basic concepts in chronic kidney disease (CKD) Unique aspects of CKD in Asians 1. Epidemiology 2. Risk factors (e.g. glomerulonephritis, herbal medications) 3. Lessons from clinical practice (e.g. Eastern vs. Western view of “the kidney”; use of traditional remedies 4. Resources and approach
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