Chronic Kidney Disease

Treatment Guide

Your Guide to Chronic Kidney Disease

A number of diseases, including diabetes and high blood pressure, can prevent your kidneys from functioning at their best. When kidney function steadily worsenschronic kidney disease, or CKDwaste builds up in the blood. You can become anemic and develop weak and brittle bones. CKD also increases the risk of stroke and atrial fibrillation. CKD is managed as long as possible with medications and a special diet. As the disease progresses, however, you may require a kidney transplant or dialysis. Early detection and appropriate treatment are important in slowing the disease process, with the goal of preventing or delaying kidney failure. Cleveland Clinic kidney specialists offer a comprehensive program for patients with all stages of CKD. This guide provides an overview of treatment options for CKD offered at Cleveland Clinic, as well as information you need to become an active participant in your care.

Why choose Cleveland Clinic for CKD care?

Kidney specialists (nephrologists) in Cleveland Clinics Department of Nephrology & Hypertension are experts in the evaluation and management of CKD. The nephrology program is ranked No. 2 in the nation by U.S. News & World Report. Their CKD Clinic uses an innovative team approach, in which the nephrologists are supported by nurse practitioners, physician assistants, nutritionists and educators. The team focuses on educating and involving patients in the daily management of their disease and in decisions about dialysis and kidney transplant options. The goal is to manage the disease so that patients can enjoy a better quality of life. Cleveland Clinics electronic medical record is critically important for monitoring chronic disease status over time and interacting with a number of different Cleveland Clinic specialists, like cardiologists and endocrinologists, involved in the total care of the patient. Despite best efforts, kidney function can decline to a level that requires more than medical and dietary intervention. When kidney transplantation becomes an option, patients can feel comfortable knowing that Cleveland Clinic has one of the most experienced kidney transplant programs in the world. When dialysis is needed, several state-of-the-art forms are offered, including overnight dialysis at home.

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What your kidneys do

Your kidneys play many vital roles in your health. Their primary function is to filter your blood to remove waste and water. Healthy kidneys filter about 200 quarts of blood every day and produce about two quarts of urine. Your kidneys also: Balance your bodys salt, potassium and acid levels Produce hormones that regulate your blood pressure Control calcium metabolism and the production of red blood cells Produce the type of vitamin D you need to build strong bones.

What is CKD?
Over time, diabetes, high blood pressure and other diseases, including autoimmune and congenital diseases, can damage the kidneys. Depending on the disease and the part of the kidney it affects, you may be diagnosed with a form of kidney disease such as diabetic nephropathy, polycystic kidney disease, glomerulonephritis or hypertensive nephrosclerosis. The term CKD applies to all. It indicates that the kidneys ability to filter waste and water from your blood has weakened, is irreversible and has dropped to less than 60 percent of normal function. If you have CKD, you may notice you feel tired and have less energy, urinate more often, have trouble concentrating or sleeping, have little appetite, muscle cramps at night, swollen feet and ankles, puffy eyes, and skin that feels dry and itchy.

How CKD is diagnosed

Two blood tests are performed to diagnose CKD:

It is important to diagnose declining kidney function in its earliest stages, when treatment is most effective at delaying the downward spiral to kidney failure. Cleveland Clinic nephrologists encourage all adults to have a routine urinalysis as a part of their yearly health evaluation. It is particularly important if you have a family history of CKD, diabetes, unsuccessfully treated hypertension, an illness that could affect the kidneys, or take prescription or over-the-counter non-steroidal anti-inflammatory drugs, as these factors increase the risk for developing kidney disease. It is also important to have your kidney function tested if you are planning to undergo coronary artery bypass surgery, since surgery can make abnormal kidney function worse.

Glomerulofiltration rate (GFR), to determine how well your kidneys are filtering blood. Serum creatinine, to understand how well your kidneys are removing waste products. The results of these tests are considered along with your age, race, gender and other factors to determine your kidney function. There are five stages of CKD: Stage 1 = GFR 130-90: Normal to elevated kidney function Stage 2 = GFR 90-60: Kidney damage with mildly decreased kidney function Stage 3 = GFR 60-30: Moderately decreased kidney function Stage 4 = GFR 30-15: Poor kidney function Stage 5 = GFR less than 15: Kidney failure

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The CKD Clinic

Patients with a GFR of less than 45 may benefit from visiting one of our CKD Clinics. Cleveland Clinic CKD Clinics are held at mulitiple locations, including the main campus. At the CKD Clinic, you will undergo thorough kidney function testing ,and a comprehensive cardiovascular risk assessment that includes innovative approaches to blood pressure measurement (BP Tru, central BP assessment) and a cholesterol test. The results will determine the stage of your kidney disease and extent of your cardiovascular risk. The nephrologist will use this information to make an individualized treatment plan. At subsequent visits, a registered dietitian will provide you with nutritional and dietary interven-

Improving CKD care and outcomes

Cleveland Clinic nephrologist Joseph Nally Jr., MD, has been awarded a three-year, $720,000 grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to study and develop approaches for disease management for patients with chronic kidney disease. The grant will fund clinical trials to test two approaches to improving CKD care and outcomes. The first trial will adapt a patient navigator model, where patients are paired with a non-clinical professional who is trained to identify issues and barriers during the care process, such as insurance, transportation to appointments and communication with caregivers. The second trial will test enhancements to the electronic health record designed to assist health care providers in identifying and following patients who show signs of deteriorating kidney function.

tions for CKD, as well as for cardiovascular disease and/or diabetes, if needed. A nurse practitioner will follow your progress. If you are likely to need future dialysis, you will be assessed on a regular basis. It is important that you become an active part of your treatment team. The goal is to help you gain an understanding of the risks of kidney failure, the goals of management and the benefits of your treatment options. It is hard work that requires you keep your medical appointments, take your medications as prescribed, stick to your diet and pay close attention to your blood pressure and blood sugar. By working closely with the CKD team, you may be able to delay the need for transplantation or dialysis. We encourage you to bring a family member or friend with you to your appointments. Bringing a patient advocate with you may help you ask the right questions to get the information you need to be a partner in your disease management.

For information about this study, please call research coordinator Barbara Tucky at 216.444.1044.

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Medical therapy
Most patients with CKD are given an angiotensin-converting en-

Treatment Options
Treatment is designed to delay the progression of the disease to kidney failure. Most patients benefit from the combination of medications and dietary changes. If your kidney function drops below a glomerular filtration rate (GFR) of 20, you will be evaluated for a kidney transplant. If you are not considered a candidate for transplantation, dialysis will be started once your kidney function reaches 10, or possibly earlier.

zyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) to lower the blood pressure in their kidneys. You may also need a diuretic to help your body eliminate extra fluid. If you have glomerulonephritis, you may be given steroids and an immunosuppressant medication such as cyclosporine. Certain patients with CKD require other medications. These may include: a phosphate binder, if your kidneys are unable to eliminate phosphate vitamin D and calcitrol to prevent bone loss erythropoetin to build red blood cells, if you are anemic.

Dietary guidelines
Following a CKD diet is as important as taking medications in maintaining your kidney function. Cleveland Clinic dietitians are experts in balancing the dietary needs of patients with CKD to support kidney function while minimizing the impact of diabetes, high blood pressure or cardiovascular disease. A CKD diet limits sodium to prevent swelling and high blood pressure, and in certain patients, restricts protein intake to prevent elevated urea in the blood. It also balances calcium and phosphorus to prevent bone loss and helps maintain proper potassium levels to prevent a potentially fatal arrhythmia. Because there are many foods you will not be able to eat, nutritional supplements may be added to ensure you get enough calories. If you have diabetes, your primary source of calories will become simple carbohydrates. If appropriate the option of early kidney/pancreas transplantation will be discussed. A CKD diet is not always easy to follow. If you stick to the diet faithfully, keep your blood sugar and blood pressure under control, and take your medications as instructed, you should feel better, retain less fluid and be less itchy. You will also be less likely to lose bone density.

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Donor WIn
Cleveland Clinics Transplant Center offers a unique program of wellness assessment and maintenance designed to ensure the continued good health of our kidney donor patients. Called the Donor Wellness Initiative, or Donor WIn, the program consists of:

A detailed physical examination Sophisticated measurement of

cardiovascular health

Dietary and fitness evaluations

Kidney transplantation
If your kidney function drops to a GFR less than 20, you will be evaluated for a kidney transplant, even before you actually need to start dialysis. A new, healthy kidney can improve your strength, stamina and energy. After transplantation, you should be able to return to a more normal lifestyle. You will be allowed to eat a normal diet and drink fluids normally. Any anemia may resolve, and if you have high blood pressure, you might need fewer blood pressure medications. Because kidney transplantation is so beneficial, Cleveland Clinic nephrologists prefer to transplant patients kidneys before they need dialysis. If you have diabetic nephropathy, you may be able to receive a new pancreas along with a kidney, eliminating the need for insulin or other diabetes medication.

Evaluation of kidney function

For more information about DonorWIn, visit ccf.org/donorwin.

Dialysis
When kidney function drops dramatically, dialysis is required to purge the body of waste and fluid. Several different types of dialysis are available, with the most common forms being hemodialysis and peritoneal dialysis. In hemodialysis, the blood is circulated through a machine that extracts fluid and waste before returning the cleansed blood to the body. Hemodialysis generally requires patients to spend several hours several times a week at a dialysis center.

Patient Evaluations for Kidney Transplant Now Available at South Pointe Hospital
Physicians from Glickman Urological & Kidney Institute ranked urology and nephrology programs are now available in the Medical Office Building at South Pointe Hospital to see kidney disease patients interested in transplantation. Potential transplant candidates include patients suffering from chronic kidney disease (CKD) Stage 4 or 5, or patients currently receiving chronic dialysis treatment.

In peritoneal dialysis, a solution is run directly into the abdomen, where it absorbs waste products. The waste products are then filtered out naturally by the abdominal membrane (peritoneum), and the solution drained out of the body at scheduled intervals. Based on clinical trials suggesting that slow dialysis may be better, Cleveland Clinic nephrologists provide arrangements for some patients to have overnight hemodialysis and peritoneal dialysis at home.
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For more information, please call 216.444.6996.

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CLEVELAND CLINIC | CHRONIC KIDNEY DISEASE | TREATMENT GUIDE

Looking ahead
CKD in children
At Cleveland Clinic Childrens Hospital, children with CKD receive the same outstanding treatment from the full range of medical professionals with expertise and experience treating the disease in pediatric patients, including: Pediatric nephrologists Pediatric physician assistants Pediatric nurse clinicians Pediatric renal (kidney) dietitians Family educators. For the most part, CKD care is similar in children and adults. Initially, the disease and its underlying causes or complications, such as hypertension or diabetes, are managed as long as possible with medications and diet before kidney transplantation or dialysis become options. A key factor of CKD in children, however, is managing delayed growth. Cleveland Clinic pediatric nephrologists offer growth hormone therapy and other treatments for growth failure as part of CKD care.
There is no cure for CKD, and there are many questions about the disease that remain unanswered. For example, although it is known that high blood pressure, high blood lipid levels, high phosphorus levels and uncontrolled diabetes are accelerate kidney function decline, no one knows whether correcting these issues affects the rate of CKD progression. Cleveland Clinic physicians are dedicated to finding answers to these and other issues affecting patients with CKD through clinical studies. A key aid in this effort is the CKD Registry, made possible by data gathered through Cleveland Clinics electronic health records system. The CKD Registry now contains demographic and treatment information on more than 70,000 patients with CKD treated at Cleveland Clinic. The information is vitally important in helping pinpoint which factors cause CKD and regulate its progression, which tests are most useful in diagnosing the disease and monitoring it progression, and which medications are most effective at decreasing complications and retarding the deterioration of kidney function. To date, Cleveland Clinic physicians have used the information in the CKD Registry to identify markers of all-cause and CKD-related mortality and to verify the accuracy of new diagnostic test for CKD. In keeping with the Cleveland Clinics policy on sharing advancements in medicine, a paper detailing how to develop and use a CKD registry has been published. Cleveland Clinic nephrologists also conduct clinical trials (research) of promising medications and procedures for patients with CKD. Projects currently underway include an investigation of the role of stem cells in protecting the kidney during coronary artery bypass surgery, an examination of alternative biomarkers to creatinine for predicting early kidney damage, and a clinical trial of a medication that may decrease the need for dialysis in patients with diabetes. Near term studies will examine the role of kidney nerve denervation for controlling blood pressure in patients with CKD.

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To make an appointment at one of our CKD Clinics, please contact our appointment scheduling office at 216.444.6771. Same day appointments available.

Nephrology Locations

Lake Erie

Willoughby Hills Family Health Center Stephanie Tubbs Jones Health Center Cleveland Clinic Main Campus Beachwood Family Health and Surgery Center

Chronic Kidney Disease Specialists

Director: Joseph V. Nally, Jr., MD Nurse Practitioner: Jennifer Hyland, CNP Physicians: Sevag Demirjian, MD Richard Fatica, MD Michael Ganz, MD Phillip Hall, MD Robert J. Heyka, MD Priya Kalahasti, MD Sheru Kansal, MD Michael Lioudis, MD Joseph V. Nally, Jr., MD Sankar Navaneethan, MD Saul Nurko, MD Emilio Poggio, MD Marc A. Pohl, MD Martin Schreiber, Jr., MD James F. Simon, MD Brian Stephany, MD Jonathan Taliercio, MD George Thomas, MD

Richard E. Jacobs Health Center Avon

Cuyahoga County OHIO

Solon Family Health Center Twinsburg Family Health and Surgery Center

Strongsville Family Health and Surgery Center Brunswick Family Health and Surgery Center

Main Campus 9500 Euclid Ave. Cleveland, OH 44195 Beachwood Family Health and Surgery Center 26900 Cedar Road, Suite 306 Beachwood, OH 44122 Brunswick Family Health and Surgery Center 3574 Center Road Brunswick, OH 44212 Richard E. Jacobs Health Center (in Avon) 33100 Cleveland Clinic Blvd. Avon, OH 44011 Stephanie Tubbs Jones Health Center 13944 Euclid Ave. East Cleveland, OH 44112 Strongsville Family Health and Surgery Center 16761 SouthPark Center Strongsville, OH 44136 Solon Family Health Center 29800 Bainbridge Road Solon, OH 44139 Twinsburg Family Health and Surgery Center 8701 Darrow Road Twinsburg, OH 44087 Willoughby Hills Family Health Center 2570 Som Center Willoughby Hills, OH 44094

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To learn more about these physicians, please visit ccf.org/staff.

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