Module 1:

Understanding Chronic Kidney Disease (CKD)

Epidemiology, Identification, and Monitoring;
Medical Nutrition Therapy
This professional development opportunity was created by the National Kidney Disease Education Program
(NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases of the
National Institutes of Health. With the goal of reducing the burden of chronic kidney disease (CKD),
especially among communities most impacted by the disease, NKDEP works in collaboration with a range
of government, nonprofit, and health care organizations to:
•raise awareness among people at risk for CKD about the need for testing;
•educate people with CKD about how to manage their disease;
•provide information, training, and tools to help health care providers better detect and treat CKD; and
•support health system change to facilitate effective CKD detection and management.

To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional materials from
NIDDK, please visit: http://www.niddk.nih.gov.

Slide 2 of 80
 Meet our Presenters
Theresa A. Kuracina, M.S., R.D., C.D.E., L.N.

Ms. Kuracina is the lead author of the Academy of Nutrition and Dietetics’ CKD
Nutrition Management Training Certificate Program and NKDEP’s nutrition
resources for managing patients with CKD.

Ms. Kuracina has more than 25 years of clinical dietetics experience focused on
diabetes and CKD with the Indian Health Service (IHS). Until her retirement in 2017,
she served as a co-coordinator for a diabetes self-management education program at
the IHS Albuquerque Indian Health Center in New Mexico. For more than 9 years,
she has supported NKDEP with expertise regarding medical nutrition therapy for
diabetes and CKD patients, first as a member of the NKDEP’s Coordinating Panel
and more recently as a senior clinical consultant for the Program.

Slide 3 of 80
 Meet our Presenters
Andrew S. Narva, M.D., F.A.C.P.

Dr. Narva is the Director of the National Kidney Disease Education Program
(NKDEP) at the National Institutes of Health. Prior to joining the NKDEP in 2006, he
served as Director of the Kidney Disease Program for the Indian Health Service
(IHS). Dr. Narva continues to serve as the Chief Clinical Consultant for Nephrology
for IHS and to provide care for patients at Zuni Pueblo through a telemedicine clinic.
Dr. Narva is a member of the American Board of Internal Medicine Nephrology
Subspecialty Board. He has served as a member of the Eighth Joint National
Committee (JNC 8) Expert Panel, the National Quality Forum Renal Steering
Committee, the Kidney Disease Outcomes Quality Initiative Work Group on Diabetes
in Chronic Kidney Disease, and the Medical Review Board of End Stage Renal
Disease Network 15.

Slide 4 of 80
 Participants will be able to:
1. Associate kidney function with estimated glomerular filtration rate
(eGFR) and understand significance and limitations of eGFR in
assessing individual patients.

2. Associate kidney damage with urine albumin-to-creatinine ratio

(UACR) and understand significance and limitations of UACR in
assessing individual patients.

3. Use eGFR and UACR when counseling patients.

4. Define the glomerular filtration rate that qualifies Medicare

beneficiaries for medical nutrition therapy referral.

Slide 5 of 80
 Chronic kidney disease basics
• Risk factors for CKD and how nutrition may play a role in
prevention and treatment
• Burden of chronic kidney disease and kidney failure
• Identify and monitor CKD
 Renal anatomy, physiology, and functional assessment
• Medical Nutrition Therapy for CKD

Slide 6 of 80
Risk factors for CKD

• Diabetes
• Hypertension
• Family history of kidney disease
• Cardiovascular disease
• Obesity
• Acute kidney injury

USRDS 2016

Slide 7of 80
Diabetes and hypertension are the leading causes
of kidney failure in the United States

Reference: CDC National Chronic Kidney Disease Fact Sheet, 2017

Slide 8 of 80
 Incidence vs. Prevalence

Incidence =
number of new patients during a given
time/total population at risk

Prevalence =
number of patients with specific disease/total
population at a designated time

Slide 9 of 80
 Incidence (new cases) of obesity
and diabetes is increasing
Obesity 1994 2000 2010

<14% 14-17.9% 18-21.9% 22-25.9% ≥ 26%

Diabetes (diagnosed)

<4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% ≥ 9.0%

Slide 10 of 80
Incidence of end stage renal disease (ESRD)
appears to follow the same trends
Adjusted Incidence Rates of ESRD, 2011–2015

Reference: USRDS Annual Data Report (NIDDK 2017)

Slide 11 of 80
 Weight management may play a role in
CKD prevention and treatment
• In 2009-2012, 65% of women and 73% of men were
overweight or obese.
• About half of all adults have abdominal obesity.
• Rates of diabetes, hypertension and abnormal lipid levels are
higher in adults with abdominal obesity.
• Obesity related glomerulopathy (ORG) is associated with
decline in renal function.
Reference: http://health.gov/dietaryguidelines/2015/guidelines/
D’Agati et al. Nat Rev Neph 2016; 12:453-471.

Slide 12 of 80
 Nutrition care may be an important
component of prevention and treatment
• Healthy eating patterns and physical activity may reduce chronic disease
risk.
• Lifestyle interventions to prevent diabetes or hypertension may prevent or
delay CKD onset.
• Lifestyle modifications are part of initial treatment interventions for
prediabetes, diabetes, hypertension and cardiovascular disease.
• Once CKD is identified, dietary interventions are a key part of
management.
Slide 13 of 80
 Nutrition care is impacted and complicated by CKD
• Risk for hypoglycemia may increase.
• Blood pressure may be harder to control.
• Reduced urinary excretion of waste products may lead to hyperkalemia and metabolic acidosis.
• Anemia may develop.
• Abnormalities in vitamin D, phosphorus and calcium may impact bone strength and lead to
vascular and soft tissue calcification.
• Nutrition care recommendations change when the kidneys fail based on the chosen renal
replacement therapy (RRT).
Slide 14 of 80
Healthy People 2020 includes CKD objectives
that RDNs may impact
Increase proportion of persons with CKD Baseline Target
CKD 2: who know they have impaired renal function 9.4 13.4%

CKD 4.1: who receive recommended medical evaluation with serum 25.7% 28.3%
creatinine, lipids, and microalbuminuria
CKD 4.2: with type 1 or type 2 DM and CKD who receive 23.0% 25.3%
recommended medical evaluation with serum creatinine,
microalbuminuria, HbA1c, lipids, and eye exams
CKD 6.2: over age 50 who currently take statins to lower their 21.6% 25.6%
cholesterol
Reduce proportion of persons with CKD
CKD 6.1: who have uncontrolled blood pressure 22.7% 17.6%
https://www.healthypeople.gov/2020/topics-objectives/topic/chronic-kidney-disease/objectives

Slide 15 of 80
Too few people receive counseling prior to dialysis

Reference: Adapted from USRDS Annual Data Report (NIDDK, 2010)

Slide 16 of 80
The burden of chronic kidney disease
and kidney failure

Slide 17 of 80
 CKD is reduced kidney function
and/or kidney damage
Chronic Kidney Disease
Kidney function

Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for > 3 months with or without kidney damage

AND/OR

Kidney damage

> 3 months, with or without decreased GFR, manifested by

either
•Pathological abnormalities
•Markers of kidney damage, i.e., proteinuria (albuminuria)
- Urine albumin-to-creatinine ratio (UACR) > 30 mg/g Reference: Kidney International Supplements, 2013; 3(1): 5-14

Slide 18 of 80
Kidney failure is defined as eGFR < 15
• The kidneys cannot maintain homeostasis.
• The four options for treating kidney failure include:
Renal replacement therapy (RRT)

1. Hemodialysis
• In-center or home
2. Peritoneal dialysis

3. Kidney transplant

Supportive Management

4. Active medical management without RRT

Slide 19 of 80
 U.S. Renal Data System (USRDS)

• USRDS is a national data system funded by the

National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK).

• USRDS collects, analyzes, and distributes information

about the actual number of people with end-stage renal
disease (ESRD) on dialysis or with a kidney transplant
and the estimated number of people with CKD.

Slide 20 of 80
Thirty million U.S. adults may
have chronic kidney disease

Reference: CDC National Chronic Kidney Disease Fact Sheet, 2017

Slide 21 of 80
The Medicare population with CKD is growing;
more are identified earlier

Reference: USRDS Annual Data Report (NIDDK, 2017)

Slide 22 of 80
Trends in ESRD prevalence by modality, 1980-2015

Reference: USRDS Annual Data Report (NIDDK, 2017)

Slide 23 of 80
Diabetes is the leading cause of ESRD,
followed by hypertension

Reference: USRDS Annual Data Report (NIDDK, 2016)

Slide 24 of 80
African Americans have the highest
incidence rates of ESRD

Reference: USRDS Annual Data Report (NIDDK, 2016)

Slide 25 of 80
ESRD is very costly

Reference: USRDS Annual Data Report (NIDDK, 2017)

Slide 26 of 80
Delaying the need for RRT may be cost-effective

• Medical nutrition therapy may prevent, delay onset and slow

progression of CKD.

• Medical nutrition therapy may help manage CKD complications.

• Delaying the need for dialysis for even a few patients can have a great
impact.

Slide 27 of 80
 Renal anatomy, physiology, and
functional assessment

IDENTIFY AND MONITOR CKD

Slide 28 of 80
 Topics
• Basic anatomy
• Kidney function
• Chronic kidney diseases
• Functional assessment to identify and monitor
 Estimated glomerular filtration rate (eGFR)
 Urine albumin-to-creatinine ratio (UACR)

Slide 29 of 80
Kidneys and collecting system

• Kidneys
• Ureters
• Bladder
• Urethra

Slide 30 of 80
 The Nephron

• Glomerulus
• Proximal tubule
• Loop of Henle
• Distal tubule
• Collecting duct

Slide 31 of 80
Each kidney has about 1 million nephrons;
slow loss may not be noticeable
• Healthy people have a large physiologic reserve.
• Slow, progressive loss of functioning nephrons
may not be noticeable.
• Often, there are no symptoms until more than
three-quarters of kidney function is lost.

Slide 32 of 80
Nephrons maintain homeostatic balance
The functions include:
•Filtration
 Glomeruli generate ultrafiltrate of the
plasma.
•Reabsorption
 Tubules selectively reabsorb substances
from the ultrafiltrate.
•Secretion
 Tubules secrete substances into the urine.

Slide 33 of 80
Ultrafiltration of plasma is the main
function of the glomerulus
• Volume of ultrafiltrate = 135–180 liters(L)/day

• 99% water reabsorbed  1–1.5 L urine excreted

• Filtration of solutes is based on size and charge

 Small solutes cross readily.

 Larger substances are generally restricted.

Slide 34 of 80
The ultrafiltrate is modified by the tubules

• Reabsorption and secretion of substances occurs

within the tubules.
Examples:
• Potassium is reabsorbed from and secreted into the urine by the tubules.

• Sodium and glucose are reabsorbed by the tubules.

• Organic acids are secreted into the urine.

Slide 35 of 80
 The kidneys have many functions
• Regulatory function
 Control composition and volume of blood
 Maintain stable concentrations of inorganic anions such as sodium (Na),
potassium (K), and calcium (Ca)
 Maintain acid-base balance
• Excretory function
 Produce urine
 Remove metabolic wastes
 Including nitrogenous waste

Slide 36 of 80
 The kidneys have many functions
• Endocrine function
 Produce renin for blood pressure control
 Produce erythropoietin which stimulates marrow production of red
blood cells
 Activate 25(OH)D to 1,25 (OH)2D (active vitamin D)

• Metabolic function
 Gluconeogenesis
 Metabolize drugs and endogenous substances (e.g., insulin)

Slide 37 of 80
CKD usually means fewer functioning nephrons

Slide 38 of 80
 Fewer nephrons disrupt the balance
• Urine volume may not change
 Composition of the urine changes

• Reduced waste excretion

 May not be apparent until CKD is advanced

• Altered hormone production

 Anemia (erythropoietin) and mineral & bone disorders (vitamin D) may develop

• Reduced catabolism
 Examples: Insulin, glucagon, drugs

Slide 39 of 80
 Fewer nephrons disrupt the balance
• Reduced renal clearance and accumulation of:
 Advanced glycation end products
 Pro-inflammatory cytokines
 Reactive oxygen species (oxidation)
 Metabolic acids

• Insulin resistance (even in people without diabetes)

 Reduces insulin-mediated glucose uptake in skeletal muscles
 May be associated with inflammation
Slide 40 of 80
 Identify and monitor CKD

FUNCTIONAL ASSESSMENT

Slide 41 of 80
 CKD is reduced kidney function
and/or kidney damage
Chronic Kidney Disease
Kidney function
Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for > 3 months with or without kidney damage
AND/OR

Kidney damage
> 3 months, with or without decreased GFR, manifested by either
• Pathological abnormalities
• Markers of kidney damage, i.e., albuminuria
 Urine albumin-to-creatinine ratio (UACR) > 30 mg/g Reference: Kidney International Supplements, 2013; 3(1): 5-14

Slide 42 of 80
Use eGFR to assess and monitor kidney function

• The eGFR is the estimated glomerular filtration rate.

• The eGFR provides an estimate of how much plasma is

filtered by the kidneys each minute.

Slide 43 of 80
What is the glomerular filtration rate (GFR)?

• GFR is equal to the sum of the filtration rates in all of the

functioning nephrons.

• GFR is not routinely measured in clinical settings.

• Estimation of the GFR (eGFR), using serum creatinine

level, gives a rough measure of the number of functioning
nephrons.

Slide 44 of 80
 What is the GFR?

Cardiac output (CO) = 6 L/min

X 20% of CO goes to kidneys = 1.2 L/min

X Plasma is 50% blood volume = 600 mL/min

X Filtration Fraction of 20% = 120 mL/min

Slide 45 of 80
 eGFR estimates the measured GFR
• eGFR is not the measured GFR.

• eGFR estimates the measured GFR.

• The eGFR is a good estimate of the risk of having decreased

kidney function.

• Like other risk predictors, when it is the solitary indicator, it

should be used cautiously, especially when “diagnosing” disease.
Slide 46 of 80
 Estimating equations for eGFR
• The Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease
Epidemiology (CKD-EPI) equations are most widely used for estimating GFR.
• The variables include serum creatinine (Scr), age, race, and gender.

• MDRD eGFR = 175 x (Scr) -1.154 x (age) -0.203 x (0.742 if female) x (1.212 if African
American)
• CKD-EPI eGFR = 141 × min (Scr /κ,1)a × max (Scr /κ,1) -1.209 × 0.993 age × (1.018 if
female) × (1.180 if African American)
• The estimate is normalized to body surface area.
References: Levey et al. Ann Intern Med. 1999; 130:461–470;
Levey et al. Ann Intern Med. 2009:150:604–612.

Slide 47 of 80
 Serum creatinine alone is not adequate
• Serum creatinine levels reflect muscle mass, age, gender, and race.

• A typical “normal” reference range of 0.6–1.2 mg/dL listed on many lab

reports does not account for muscle mass, age, gender, and race.

• A 28-year-old African American man with serum creatinine of 1.2 has an

eGFR > 60.

• A 78-year-old white woman with serum creatinine of 1.2 has an eGFR of 43.
Slide 48 of 80
 Creatinine-based estimates of kidney
function have limitations
Results may be inaccurate with:
• Rapidly changing creatinine levels
• Example: acute kidney injury

• Extremes in muscle mass, body size, or altered diet patterns

• Medications that interfere with the measurement of serum

creatinine

• Use of creatine supplements

Slide 49 of 80
Decreased kidney function versus kidney disease
• Estimating equations are less reliable at higher GFR.

• Kidney function declines with age.

• While there is an association between decreased eGFR and morbidity,

even in elderly, this association does not mean causality.

• Use diagnostic terms denoting disease with caution, especially in older

people without evidence of kidney damage (e.g. elderly with eGFR 55).
Slide 50 of 80
Kidney function and eGFR decline with age
Reference Table for Population Mean eGFR from NHANES
III Age (years) Mean eGFR (mL/min/1.73 m2)
20–29 116
30–39 107
40–49 99
50–80 93
60–69 85
70+ 75
In healthy kidney donors the number of glomeruli per kidney
decrease 25% by age 60-69 and GFR declines proportionately.
Reference: Coresh et al. Am J of Kidney Dis. 2003;41(1):1–12.
Denic et al. J Am Soc Nephrol. 2017;28(1):313–320.

Slide 51 of 80
 Monitor the eGFR trends

• Stable eGFR levels may mean non-

progressive disease or current therapy
is working.

• A rapid decline in eGFR may indicate

rapid progression of kidney disease.

Slide 52 of 80
 Activity

• Use NKDEP’s CKD-EPI calculator to

determine eGFR for various levels of
creatinine, different genders and races.
 eGFR < 60 = CKD
 eGFR < 15 = kidney failure

• GFR Calculator can be found at:

nkdep.nih.gov/gfr-calculator

Slide 53 of 80
Age, Race, Gender of Patient Serum eGFR
Creatinine
35-year-old African American male 1.2 blank
35-year-old White female 1.2 blank
80-year-old Asian American female 1.2 blank
58-year-old White male 2.4 blank
58-year-old African American female 2.4 blank
80-year-old Hispanic female 2.4 blank

Slide 54 of 80
Age, Race, Gender of Patient Serum eGFR
Creatinine
35-year-old African American male 1.2 ≥ 60
35-year-old White female 1.2 80
80-year-old Asian American female 1.2 43
58-year-old White male 2.4 29
58-year-old African American 2.4 25
female
80-year-old Hispanic female 2.4 18
Slide 55 of 80
 How to explain eGFR results to patients

Normal: ≥ 60 mL/min/1.73 m2

Kidney disease: 15–80 mL/min/1.73 m2

Kidney failure: < 15 mL/min/1.73 m2

Slide 56 of 80
 CKD is reduced kidney function
and/or KIDNEY DAMAGE
Chronic Kidney Disease
Kidney function
Glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for > 3 months with or without kidney damage
AND/OR

Kidney damage
> 3 months, with or without decreased GFR, manifested by either
• Pathological abnormalities
• Markers of kidney damage, i.e., albuminuria
 Urine albumin-to-creatinine ratio (UACR) > 30 mg/g Reference: Kidney International Supplements, 2013; 3(1): 5-14

Slide 57 of 80
Urine albumin is a marker for kidney damage
• Urine albumin measures albumin in the urine.

• An abnormal urine albumin level is a marker for

glomerular disease, including diabetes.
• Urine albumin is a marker for cardiovascular disease
and is a hypothesized marker of generalized
endothelial dysfunction.
• May be associated with increased mortality.

Slide 58 of 80
 Urine albumin results are used for
screening, diagnosing, and treating CKD
• Standard of diabetes care (annual screen)

• Diagnosis
 Forty percent of people are identified with CKD on the basis of urine albumin
alone.

• Prognosis
 Important prognostic marker, especially in diabetes mellitus (DM)

• Tool for patient education and self-management (such as A1C or eGFR)

Slide 59 of 80
 Damaged kidneys allow albumin to
cross the filtration barrier into the urine
• Increased glomerular permeability allows albumin and
other proteins to cross the glomerulus into the urine.

• Higher levels of protein within the tubule may exacerbate

kidney damage.
 Level of protein may exceed the tubules’ ability to reabsorb the
proteins.

Slide 60 of 80
 Risk Factors for Albuminuria

Known risks Possible risks Transient increases

may be due to:
Diabetes High sodium intake Episodic hyperglycemia
Hypertension High protein intake Exercise
Smoking Inflammation Fever
Obesity Urinary tract infection

References: De Jong et al. Kidney International. 2004;66:2109–2118;

Tuttle et al. Diabetes Care; 2014: 37:2864–2883

Slide 61 of 80
Use urine albumin-to-creatinine ratio (UACR) for
urine albumin assessment
• UACR uses a spot urine sample.

• In adults, ratio of urine albumin to creatinine in a spot

specimen correlates closely to albumin excretion in 24
hours.

• UACR < 30 mg/g is generally the cutoff for normal.

Reference: http://nkdep.nih.gov/resources/quick-reference-uacr-gfr.shtml

Slide 62 of 80
UACR quantifies all levels of urine albumin
• UACR is a continuous variable.

• The term microalbuminuria has been used to describe

abnormal urine albumin levels not detected by dipstick
test, 30 mg/g – 300 mg/g.

• The term macroalbuminuria has been used to describe

urine albumin > 300 mg/g.

• Both terms will be replaced by the term urine albumin.

Slide 63 of 80
Explaining urine albumin

Slide 64 of 80
 Medical Nutrition Therapy
• Prescribed by a physician for the purposes of
disease management
• Nutritional diagnosis, therapy and counseling
services provided by a Registered Dietitian
Nutritionist or other nutrition professional (may be
RD eligible)
• In-depth individualized nutrition assessment and
interventions

Slide 65 of 80
 MNT involves numerous steps
• An initial nutrition and lifestyle assessment

• Nutrition counseling

• Information regarding diet management

• Follow-up sessions to monitor progress

• Individual or group sessions

Slide 58 of 80
Medicare Part B Preventive Care Services

Eligibility Frequency

MNT • Diabetes First calendar year No co-pay

Individual or • CKD with eGFR 13- 3 hours Deductible
group 50 waived
• Successful kidney
transplant in past 3 Subsequent year
years. 2 hours

http://qioprogram.org/sites/default/files/editors/141/Medicare%20DSMT%20and%20MNT
%20Requirements%20for%20Reimbursement.pdf

Slide 67 of 80
 MNT telehealth services are covered

• Applies only to Medicare-Fee-For-Service Programs in

rural areas.
• Must use interactive audio and video telecommunication
systems that permits real-time communication.
• For individual and group medical nutrition therapy use
HCPCS code G0270 and CPT codes 97802–97804.

Reference: Medicare Learning Network Telehealth Services. ICN 901705 November 2016

Slide 68 of 80
Coding for MNT including Telehealth
97802 Initial assessment and intervention, individual, face-to-face with patient,
each 15 minutes (NOTE: initial visit only)
97803 Re-assessment and intervention, individual, face-to-face with patient, each
15 minutes
97804 Group (2 or more individuals), each 30 minutes
G0270 Reassessment and subsequent intervention(s) following second referral in
same year for change in diagnosis, medical condition, or treatment
regimen, (including additional hours for renal disease) individual, (face
to face) each 15 minutes
G0271 Reassessment and subsequent intervention(s) following second referral in
same year for change in diagnosis, medical condition, or treatment
regimen (including additional hours for renal disease), group (two or
more), each 30 minutes
• HCPCS = Healthcare Common Procedure Coding System
• CPT = Current Procedural Terminology https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-
services/MPS-QuickReferenceChart-1.html#MNT

Slide 69 of 80
 ICD-10 for CKD
Chronic kidney disease GFR
N18.1 Stage 1 >90
Kidney damage with normal GFR
N18.2 Stage 2 60-89
Kidney damage with mildly low GFR
N18.3 Stage 3 (moderate) 30-80

N18.4 Stage 4 (severe) 15-29

N18.5 Stage 5 (renal failure) <15

N18.6 End stage renal disease requiring dialysis (GFR <15)

R80.9 Proteinuria, unspecified

ICD-10 CM = International Classification of Diseases, Clinical Modification

Slide 70 of 80
Tips for MNT: diabetic kidney disease
• Assess eGFR and UACR, obtain 2nd referral if CKD is identified
(change in medical condition, diagnosis).
• Intensive glucose control to near normal glucose levels early in the
course of diabetes may prevent or delay the onset of CKD.
• A1C < 8% may be appropriate for advanced CKD.
• A1C may measure lower in CKD due to increased erythrocyte
turnover (shorter lifespan).
• Blood pressure control slows CKD progression.
• Review sodium intake.
• Certain blood pressure medications increase risk for hyperkalemia.

Slide 71 of 80
Follow trends in eGFR

Slide 72 of 80
Follow trends in UACR

Note differences in timeframes

Slide 73 of 80
 NKDEP tools to share with other providers
• Explaining Your Kidney Test Results: A Tear-Off pad for clinical use
https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-education-outreach/
explain-kidney-test-results

• Quick Reference on GFR and UACR in Evaluating Patients with Diabetes for Kidney Disease
https://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/a-z/quick-refer
ence-uacr-gfr/Documents/quick-reference-uacr-gfr-508.pdf

• Making Sense of CKD – A concise guide for managing chronic kidney disease in the primary
care setting (Guide)
https://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/a-z/Documents
/ckd-primary-care-guide-508.pdf Slide 74 of 80
 References
Alicic RZ, Rooney MT, Tuttle KR. Diabetic kidney disease: challenges, progress, and possibilities. Clinical Journal
of the American Society of Nephrology. May 2017.doi: https://doi.org/10.2215/CJN.11491116

Bolignano D, Zoccali C. Effects of weight loss on renal function in obese CKD patients: a systematic review.
Nephrology Dialysis Transplantation. 2013;28(Suppl 4):iv82-iv98.

Centers for Disease Control and Prevention. National Chronic Kidney Disease Fact Sheet: general information and
national estimates on chronic kidney disease in the United States, 2017. Atlanta, GA: US Department of Health
and Human Services. Centers for Disease Control and Prevention website.
https://www.cdc.gov/diabetes/pubs/pdf/kidney_factsheet.pdf
Accessed June 21, 2017.

Centers for Disease Control and Prevention. International Classification of Diseases, tenth revision (ICD-10-CM).
Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/icd/icd10cm.htm Accessed August
18, 2017
Slide 75 of 80
 References
Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the
adult US population: Third national health and nutrition examination survey. American Journal of Kidney Diseases.
2003;41(1):1–12.

D’Agati VD, Chagnac A, de Vries APJ, et al. Obesity-related glomerulopathy: clinical and pathological characteristics and
pathogenesis. Nature Reviews Nephrology. 2016; 12:453–471.

De Jong PE, Brenner BM. From secondary to primary prevention or progressive renal disease: the case for screening for
albuminuria.
Kidney International. 2004;66:2109–2118.

Denic A, Lieske JC, Chakkera HA, et al. The substantial loss of nephrons in healthy human kidneys with aging. Journal of the
American Society of Nephrology. 2017;28(1):313–320.

de Zeeuw D, Raz I. Albuminuria: a great risk marker, but an underestimated target in diabetes. Diabetes Care. 2008:31 (suppl 2)
S190–S193.

Slide 76 of 80
 References
GFR calculator. National Kidney Disease Education Program website.
https://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/lab-evaluation/gfr-calculators/Pages/gfr-cal
culators.aspx

Kidney Disease: Improving Global Outcomes (KDIGO): CKD work group. KDIGO 2012 clinical practice guideline for the
evaluation and management of chronic kidney disease. Kidney International Supplements. 2013; 3(1):1–150.
http://kdigo.org/guidelines/ckd-evaluation-and-management/

Levey AS, Bosch JP, Breyer Lewis J, et al. A more accurate method to estimate glomerular filtration from serum creatinine: a new
prediction equation. Annals of Internal Medicine. 1999;130(6):461–470.

Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Annals of Internal Medicine.
2009;150(9):604–612.
Slide 77 of 80
 References
National Kidney Disease Education Program. Explaining your kidney test results: a tear-off pad to clinical use. Revised August
2014. National Kidney Disease Education Program website. https://www.niddk.nih.gov/health-information/health-
communication-programs/nkdep/a-z/explaining-kidney-test-results/pages/explaining-kidney-test-results.aspx

National Kidney Disease Education Program. Quick reference on UACR and GFR in evaluating patients with diabetes for kidney
disease. NIH publication 10-6286. March 2010. National Kidney Disease Education Program website.
https://www.niddk.nih.gov/health-information/health-communication-programs/nkdep/a-z/quick-reference-uacr-
gfr/Documents/quick-reference-uacr-gfr-508.pdf

Tuttle KR, Bakris GL, Bilous RW, et al. Diabetic kidney disease: a report from an ADA consensus conference. Diabetes Care.
2014; 37:2864–2883.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for
Americans 8th edition. http://health.gov/dietaryguidelines/2015/guidelines.

Slide 78 of 80
 References
U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Provider-Supplier
Enrollment web page. https://www.cms.gov/Medicare/Provider-Enrollment-and
Certification/MedicareProviderSupEnroll/index.html

U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Telehealth Services. ICN 901705
November 2016. Medicare Learning Network website. https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf Accessed August 13, 2017.

U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Scientific Report of the
2015 Dietary Guidelines Advisory Committee. https://health.gov/dietaryguidelines/2015-scientific-report/

U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020.
Chronic kidney disease. Healthy people website. https://www.healthypeople.gov/2020/topics-objectives/topic/chronic-
kidney-disease/objectives Accessed July 12, 2017.

Slide 79 of 80
 References
U.S. Renal Data System. USRDS 2010 annual data report. Atlas of chronic kidney disease and end-stage renal disease, National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010. U.S. Renal Data
System website. https://www.usrds.org/atlas10.aspx
Accessed October 31, 2017.

United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016. U.S. Renal
Data System website. https://www.usrds.org/2016/view/Default.aspx
Accessed June 21, 2017.

United States Renal Data System. 2017 USRDS annual data report: Epidemiology of kidney disease in the United States. National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2017. U.S. Renal
Data System website. https://www.usrds.org/2017/view/Default.aspx
Accessed October 31, 2017.
Slide 80 of 80