Smoking has significant adverse effects on renal function and increases the risks of chronic kidney disease, end stage renal disease, cardiovascular disease, and mortality. It accelerates the progression of kidney damage in patients with diabetes, hypertension, and other renal diseases. Smoking cessation is an important intervention for renal patients but is difficult to achieve due to the addictive nature of tobacco use. Physicians need to prioritize addressing smoking as a modifiable risk factor.

2. By

7. Tobacco : Deadly in any form

14. Until recently the potential impact of smoking on renal
function and renal diseases have remained largely
unnoticed.
In the past few years the knowledge about the renal
risks of smoking has been expanded rapidly& smoking
emerges as an important modifiable renal risk factor.

15. Effect of Smoking on Renal Function in
Subjects of the General Population with
Apparently Normal Kidneys

16.  Smoking increases the risk of albuminuria/proteinuria in
the general population in a dose-dependent manner .
 Smoking is a risk factor for renal function impairment ,
has a negative impact on renal function, independent
of the pre-existing renal disease , particularly in men
and in the elderly..

17.  Microalbuminuria is the earliest manifestation of kidney
damage in diabetes mellitus and hypertension.
 It has also been found in cigarette smokers, and more
prominently in smokers with diabetes mellitus or
hypertension.

18. Adverse Renal effects of smoking
in patients with primary hypertension

19. Smoking was the strongest predictor for albuminuria in
patients with primary hypertension.
In patients with primary hypertension the prevalence
of microalbuminuria was almost double in smokers
compared to non-smokers.

20. Smoking was by far the most powerful predictor of renal
functional deterioration in hypertensive patients and
the only one which is remediable.
Albuminuria (and even more proteinuria) is an independent
predictor of cardiovascular mortality in patients with
primary hypertension.

21. GFR declined faster in patients with “severe” as compared
with those with “mild” hypertension, and GFR declined
faster in smokers versus nonsmokers .
Smokers with high blood pressure can increase their risk of
reaching end stage renal disease (ESRD), the final stage of
kidney disease .

22. Smoking should be considered as a renal risk factor
in hypertensive patients.
Smoking seems to remain a renal risk factor despite
lowering of blood pressure to the target level using
currently recommended therapy, at least in
patients with type 2 diabetes.

23. Adverse Renal effects of smoking
in patients Diabetes mellitus

24. Smokers are at greater risk to develop type 2 diabetes
in a dose-dependent.
The increased risk may be related to the fact that
smoking aggravates insulin resistance in healthy
smokers.

25. Smokers have a higher risk to develop diabetic nephropathy
than non-smokers in type 1 and type 2 diabetes mellitus.
The prevalence of diabetic nephropathy was significantly
higher among "heavy" smokers than among "non-heavy"
smokers .

26. o Studies have shown the kidney disease risk in diabetics is
about two to three times higher than for those who don’t
smoke.
o In diabetic smokers, there is a 2.8 times greater risk of
microalbuminuria that’s an early sign of diabetic
renal involvement.

27. Smoking promotes the progression of all stages of diabetic
nephropathy to a similar extent, both in type 1 and type 2
diabetes:
 Increases the risk for development of microalbuminuria
 Accelerates progression from the stage of microalbuminuria
to macroalbuminuria
 Accelerates progression from early stages of diabetic
nephropathy to ESRD

35. Association of Smoking with CKD or ESRD
Recent epidemiologic studies demonstrate that cigarette
smoking increases the risk for progressive chronic kidney
disease (CKD ), which may lead to end-stage renal disease
(ESRD) , in a dose-dependent manner especially in elderly
individuals.
Current smoking (>20 cigarettes per day) was the strongest
independent predictor of a pathologic loss of renal function .

37. Smoking increases the risk of
renal failure in general population.

43. Relationship Between CKD and CVD
CKD = chronic kidney disease; CVD = cardiovascular disease; CV = cardiovascular.
1. Menon V et al. Am J Kidney Dis. 2005;45:223–232.
CVD
CKD
Traditional
CV risk factors
Non-traditional
CV risk factors
CKD is a risk factor for CVD, and CVD may be a risk factor for the progression of CKD

45. Patients with CKD should be regarded a “highest risk”
group for cardiovascular disease, irrespective of levels
of traditional cardiovascular disease risk factors .
The older individual with CKD is at the highest risk of
cardiovascular disease .

46. Once in end-stage renal failure (ESRF), the failure to stop
smoking adversely affects the prognosis of patients on
renal replacement therapy and patients with a kidney
transplant, mainly by increasing the risk of cadio-
vascular complications.

48. Major Cause of Death in CKD

52. Diabetes Amplifies the CKD and CVD Paradigm

53. CKD-CVD-Diabetes Link: CKD is a Disease Multiplier

54. Diabetes and High Blood Pressure are Like Twins

55. ESRD, end stage renal disease
USRDS ADR, 2007
Diabetes and hypertension are leading causes of kidney failure
Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race.

57. Diabetes
The Most Common Cause of ESRD
Primary Diagnosis for Patients Who Start Dialysis
Diabetes
50.1%
Hypertension
27%
Glomerulonephritis
13%
Other
10%
United States Renal Data System. Annual data report. 2000.
No. of patients
Projection
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.ofdialysispatients
(thousands)
©2006. American College of Physicians. All Rights Reserved.

59. Diabetes or hypertension are the two leading causes of
chronic kidney disease.
Smokers with diabetes or hypertension face an accelerated
rate of kidney damage compared to non-smokers with
chronic kidney disease, resulting in a much quicker
progress towards ESRD .

66. Global Burden of Hypertension 2025 Projection
 26.4% of world adult
population had hypertension
 Total of 972 million adults
 Highest prevalence is in
established market
economies (eg, North
America, Europe)
 29.2% of world adult population
will have hypertension
 Total of 1.56 billion adults
20 % in developed nations,
80% in developing nations)
 Highest prevalence will be in
developing continents (eg, Asia,
Africa) will account for 75% of
world’s hypertensive patients
Year 2000 Year 2025
Kearney PM et al. Lancet. 2005;365:217-223.
66

67. 41%
38%
36%
41%
45%
35%
HTN GLOBAL
PREVALENCE
39%
HTN PREVALENCE 2014

68. Hypertension: A Growing Problem
Prevalence (%)
United States7
Egypt9
Japan8
Italy7
Sweden7
England7
Spain7
Finland7
Germany7
0 10 20 30 40 50
Taiwan9
Canada7
South Korea9
*Defined as systolic/diastolic blood pressure 140/90, (160/95 for Taiwan) or receiving treatment.
†South Korea is defined as men, aged 30 to 59.
7. Wolf-Maier et al. JAMA. 2003;289:2363-2369; 8. Data on file. Pfizer Inc, New York, NY;
9. WHO Collaborating Centre on Surveillance of Cardiovascular Disease Web site. Available at: www.cvdinfobase.ca. Accessed February 22, 2005.

74. Rate of Kidney Diseases in Egypt is 36.4* with About
5.19% Deaths
*Per 100,000
http://www.worldlifeexpectancy.com/cause-
of-death/kidney-disease/by-country/
accessed 2012 Oct.

77.  Bangladesh
 Brazil
 China
 Egypt
 India
 Indonesia
 Mexico
 Pakistan
Reducing the level of exposure of individuals and
populations to tobacco use
Technical assistance package to implement
the WHO FCTC demand reduction measures
 Monitoring (surveillance and evaluation)
 Protect (second hand smoke)
 Offer help
 Warn against dangers
 Enforce legislation against tobacco
promotion
 Raise taxes
 Philippines
 Russia
 Thailand
 Turkey
 Ukraine
 Vietnam
 Uruguay

80. Smoking and atherosclerotic renal
artery stenosis/ischemic nephropathy

81. Smoking promotes, plays a prominent role in the genesis
of atherosclerotic renal artery stenosis & ischaemic
nephropathy.
Prevalence of atherosclerotic renal artery stenosis is
increasing in the ageing population
Ischemic nephropathy is a significant cause of ESRF in
patients over 65 years of age.

82. Adverse Renal effects of smoking in
patients on Renal replacement therapy

86. In hemodialysis patients, most deaths are related to
cardiovascular and infection-related conditions.
Cardiovascular mortality rates are 10- to 20-fold higher,
and mortality rates from sepsis are up to 30-fold higher,
compared with those in the general population.

87. Cardiovascular disease is the main cause of death in end-
stage renal failure treated by hemodialysis .
Smoking is a major, modifiable cardiovascular risk factor in
patients starting dialysis therapy, CAD and PAD are
particularly common in dialysis patients.

88. Infection remains the second highest cause of death in
long-term hemodialysis patient .
Current smoking may be a major modifiable risk factor
for infection-related hospitalization and mortality

89. The high proportion of active smokers in the hemodialysis
population is concerning because of the risk-multiplying
effects of smoking that we have identified.
Smoking and dialysis: A dreadful scenario for the CVS
Address smoking cessation as part of routine dialysis
rounds.

90. Adverse Renal effects of smoking in
patients with a Renal transplast

92.  Smoking is a risk factor for progressive loss of renal graft
 The donors’ history of smoking was an independent risk
factor for shortened graft survival
 Cigarette smoking at the time of transplantation is an
independent risk factor for cerebrovascular&peripheral
vascular disease in transplanted patients


93. The effect of smoking on renal allograft function may
depend on the renal disease that has led to ESRF.
In patients who had reached ESRF as a result of lupus
nephritis, the risk of renal transplant loss was
substantially increased in smokers

94. Smokers had significantly worse kidney graft survival as
compared with nonsmokers , Therefore, every attempt
should be made to encourage kidney transplant
candidates to stop smoking
It Is recommend to consider smoking cessation as an
important measure in long-term care of renal transplant
recipients

95. Smoking is a risk factor that amplifies the risk for fatal
and nonfatal CVD events in kidney transplant recipients
The annual risk for a fatal or nonfatal CVD event is 3.5 to
5.0% in kidney transplant recipients (50-fold higher than
in the general population).

96. Compared to never-or ex-smokers, the diabetic renal transplant
recipient had a significantly increased risk of early death if he
smoked during the predialysis phase or after having received
his graft.

97. Another important issue is de novo congestive heart failure
in renal transplant patients.
It has a poor prognosis and has been shown to be
associated with smoking .

98. Finally, smoking increases the risk for osteoporosis in
corticosteroid-treated transplant patients (and patients
with chronic glomerulonephritis) and favours the
development of post-transplant erythrocytosis .

116. Should you stop at the red traffic ??
116
What will you do?

117. PREDICT AND
PREVENT117

121. Motivation of patients to quit smoking should be immediately
implemented, because it is certainly the most cost-effective
and beneficial strategy against the whole spectrum of CKD,
ESRD, and CVD morbidity and mortality in renal patients.
Weaning smokers from their habit is a difficult task & most
physicians do not invest sufficient time to address this
problem .