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1 慢性腎臟病 (CKD) 醫療處置劉宏祥醫師臺灣腎臟護理學會腎臟疾病照護基礎課程研習會

2 慢性腎臟病之發生率與盛行率

3 美國成人慢性腎臟病之分期及其盛行率期別說明腎絲球濾過率盛行率 GFR (ml/min/1.73 m 2 ) 個案數 % 1 腎功能正常持續性蛋白尿 90 5,900, % 2 輕度腎衰竭 60 ~ 89 5,300, % 3 中度腎衰竭 30 ~ 59 7,600, % 4 重度腎衰竭 15 ~ , % 5 末期腎病 < , % 總計 19,572, % K/DOQI, Am J Kidney Dis 2004

4 臺美腎臟病 ( 第 1~5 期 ) 盛行率之比較盛行率 (%) GFR Stage Description (ml/min/1.73m 2 ) 美國臺灣 1 Kidney damage with normal or GFR 2 Kidney damage with mild or GFR 10.9% 11.9% 3 Moderate GFR Severe GFR Kidney failure < 15 or dialysis K/DOQI, Am J Kidney Dis 2004; Wen et al, Lancet 2008

5 美臺腎臟病 ( 第 3~5 期 ) 盛行率之比較 GFR 盛行率 (%) Stage Description (ml/min/1.73m 2 ) 美國臺灣 1 Kidney damage with normal or GFR 2 Kidney damage with mild or GFR 3 Moderate GFR Severe GFR % % Kidney failure < 15 or dialysis K/DOQI, Am J Kidney Dis 2004; Wen et al, Lancet 2008

6 GFR (ml/min/1.73m 2 ) 臺灣人腎臟病 ( 第 3~5 期 ) 之盛行率 < 15 15~29 30~59 60~ % N=6599, an estimate of 1.15 million population aged over 15 to be CKD patients 90 Hwang et al, 2002 TW3H surveillance Case number

7 慢性腎臟病之現況

8 美國成人慢性腎臟病盛行率, 與之比較 CKD Prevalence, % (95 Cl) Prevalence ratio for Estimated No. of Stage NHANES NHANES NHANES US Adults in 2000, to (95% CI) No. in Millions (85% Cl) ( ) 1.78 ( ) 1.05 ( ) 3.6 ( ) ( ) 3.24 ( ) 1.21 ( ) 6.5 ( ) ( ) 7.69 ( ) 1.42 ( ) 15.5 ( ) ( ) 0.35 ( ) 1.70 ( ) 0.7 ( ) 5 NA NA NA NA Total ( ) ( ) 1.30 ( ) 26.3 ( ) Coresh et al, JAMA 2007

9 % 泰國成人慢性腎臟病之盛行率,1985~ Defined by the presence of GFR <60 ml/min/1.73m 2 using the modified MDRD formula A cohort study over a period of 12 years (1985~1997) in 3499 employees of the Electric Generation Authority of Thailand; GFR= X (SCr) X age X (0.742 for women) Domrongkitchaiporn et al, J Am Soc Nephrol 2005

10 美國人腎臟病之盛行率 (I) Age Total Whole population Number Microalbuminuria 5.4% 5.0% 5.1% 9.6% 12.9% 18.9% 28.0% 8.3% Macroalbuminuria 0.3% 0.5% 0.8% 1.1% 1.7% 2.3% 4.7% 1.0% Albuminuria 5.7% 5.5% 5.9% 10.7% 14.6% 21.2% 32.7% 9.2% Diabetic population Number Microalbuminuria 13.1% 22.9% 24.6% 22.9% 32.2% 35.8% 36.1% 28.1% Macroalbuminuria 1.3% 4.6% 7.4% 5.3% 5.4% 6.8% 12.5% 6.1% Albuminuria 14.4% 27.5% 32.0% 28.2 % 37.6% 42.6% 48.6% 34.2% Garg et al, Kidney Int 2002 NHANES III:

11 美國人腎臟病之盛行率 (II) Age Total Non-diabetic hypertensive population Number Microalbuminuria 5.4% 4.7% 6.8% 13.6% 14.9% 20.8% 31.1% 12.8% Macroalbuminuria 0.7% 0.9% 1.7% 1.5% 1.7% 1.8% 4.8% 1.7% Albuminuria 6.2% 5.5% 8.4% 15.2% 16.5% 22.6% % Non-diabetic non-hypertensive population Number Microalbuminuria 5.3% 4.6% 3.5% 4.8% 4.7% 7.5% 14.9% 4.8% Macroalbuminuria 0.2% 0.3% 0.1% 0.2% 0.7% 1.2% 0.5% 0.3% Albuminuria 5.6% 4.9% 3.6% 5.1% 5.4% 8.7% 15.5% 5.1% Garg et al, Kidney Int 2002 NHANES III:

12 全球糖尿病腎病變導致尿毒症比率排行榜,2007 USRDS, ADR, Am J Kidney Dis 2010

13 慢性腎臟病不斷增加的理由

14 左心室肥厚 / 心衰竭冠心症 / 腦血管疾病慢性腎臟病糖尿病高血壓

15 Increasing event rate < < <15 Rates per 100 person years Rates per 100 person years Rates per 100 person years 非透析慢性腎臟病病人腎功能衰退之不利影響住院率心血管疾病發生率死亡率 GFR (ml/min/1.73m 2 ) Decreasing GFR GFR (ml/min/1.73m 2 ) GFR (ml/min/1.73m 2 ) Go et al, N Engl J Med 2004

16 慢性腎臟病對高血壓糖尿病及中風盛行率的影響 % 40 Hypertension DM % 30 Stroke % % 3.9% 1.1% 3.6% 0 CKD - CKD + Data from TW3H Surveillance

17 Survival rate 慢性腎臟病與非慢性腎臟病病人存活率之比較 (n=200,000) Non CKD CKD 0 Months Kuo et al, data from 1% dataset of NHI Taiwan

18 全球末期腎病變發生率排行榜,2008 USRDS, ADR, Am J Kidney Dis 2011

19 全球末期腎病變盛行率排行榜,2008 USRDS, ADR, Am J Kidney Dis 2011

20 如何治療慢性腎臟病

21 慢性腎臟病的治療方法血壓及降低蛋白尿治療高血脂症維持鈣磷平衡及治療次發性副甲狀腺亢進控制血糖矯正貧血避免酸中毒使用低蛋白飲食戒菸早期轉介給腎臟專科醫師

22 台灣人高血壓高血糖及高血脂盛行率 Gender (%) Age (%) Year Female Male N Hypertension Hyperglycemia Hypercholesterolemia Hypertriglyceridemia Data from Nnational Nutritional Health Survey ( ) and DOH (2002)

23 Effect of Long-Term Therapy With Captopril on Proteinuria and Renal Function in Patients With Non-Insulin Dependent Diabetes and With Non- Diabetic Renal Diseases Hung-Hsiang Liou, M.D. ( 劉宏祥醫師 ) Liou et al, Nephron 1995

24 Renoprotective Effect of ACEI, CCB, or In Combination In Patients With Type 2 Diabetic Nephropathy Hung-Hsiang Liou, M.D. ( 劉宏祥醫師 )

25 Long-Term Effect of A HMG-CoA Reductase Inhibitor, Pravastatin, in Primary Glomerulonephritis Patients with Hyperlipidemia: An 18-Month Experience Hung-Hsiang Liou, M.D. ( 劉宏祥醫師 )

26 世界各國腎骨病變治療準則比較表 Target Ca Target phosphorus Target intact PTH (mg/dl) (mg/dl) (pg/ml) Stage 3-4 Stage 5 Stage 3-4 Stage 5 Stage 3-4 Stage 5 CKD CKD CKD CKD CKD CKD Europe (2000) Australia Within N Within N No recom- 2-3 times CARI Lab Ref Lab Ref mendation upper limit (2006) of normal K/DOQI Normal (2003, 2005) KDIGO Within N Within N Within N Toward N Not known 2-9 times (2009) Lab Ref Lab Ref Lab Ref Lab Ref upper limit Data from Am J kidney Dis 2004; Nephrology 2006; Kidney Int 2009 of normal

27 腎骨病變之最新定義

28 Secondary Hyperparathyroidism in Patients With Mild, Moderate and Severe Renal Failure A Cross-Sectional Analysis From 220 Cases Hung-Hsiang Liou, Mei-Chyn Liu, Yao-Ping Lin, Chuan Yao, Tung-Po Huang Section of Nephrology, Department of Medicine, Veterans General Hospital-Taipei & National Yang-Ming University

29 Relationship Between Sr P and FE P According to egfr Gutierrez et al, J Am Soc Nephrol 2005

30 高血磷對次發性副甲狀腺亢進的影響 HYPERPARATHYROIDISM DIRECT INDIRECT 1. Hyperplasia P.T. Glands 2. PTH Synthesis (Postranscriptional) Mechanism 3. PTH Secretion HYPER PHOSPHATEMIA 1. Calcitriol Levels 2. ICa 3. Skeletal Resistance Slatopolsky et al, Am J Kidney Dis 2001

31 高血磷對血液透析病人死亡率的影響 Block et al, J Am Soc Nephrol 2004

32 A Great Link Among Renal Bone Disease Mineral Metabolism Arterial Calcification Cardiovascular Disease

33 高血磷與高血鈣是慢性腎臟病病人心血管疾病的新危險因子 Traditional Risk Factors Older age Male sex Hypertension Higher LDL cholesterol Lower HDL cholesterol Diabetes Smoking Physical inactivity Menopause Family history of CVD LVH Uremia-Related Risk Factors Albuminuria Hyperhomocysteinemia Anemia Abnormal calcium/phosphate metabolism Extracellular fluid volume overload and electrolyte imbalance Oxidative stress Inflammation Malnutrition Thrombogenic factors Sleep disturbances Altered nitric oxide/endothelin balance Sarnak et al, Am J Kidney Dis 2003

34 Effect of Intravenous Calcitriol on Secondary Hyperparathyroidism in Chronic Hemodialysis Patients Hung-Hsiang Liou, M.D. ( 劉宏祥醫師 ) Liou et al, Chin Med J 1994

35 The Comparative Effect of Oral or Intravenous Calcitriol on Secondary Hyperparathyroidism in Chronic Hemodialysis Patients Hung-Hsiang Liou, M.D. ( 劉宏祥醫師 ) Liou et al, Miner Electrolyte Metab 1994

36 Meta-Analysis of Oral Versus Intravenous Calcitriol on PTH Suppression Indridason et al Caravaca et al. Liou et al. ( 劉宏祥醫師 ) Fisher and Harris Summary Effect Size K/DOQI, Am J Kidney Dis 2003, P.O. 0 I.V.

37 維他命 D 對腎臟病的影響

38 Percent of Patients with reduction in dipstick proteinuria 新型維他命 D 可以減少慢性腎臟病病人的尿蛋白 Paricalcitol Placebo p= p= Overall group ACEI/ARB users Agarwal et al, Kidney Int 2005

39 Number (millions) 全球糖尿病盛行率之影響 Increasing Prevalence of Diabetes Complications of Diabetes Worldwide Fourth leading cause of death from disease Leading cause of blindness and amputation in developed countries Risk of developing cardiovascular disease is 2 to 4 times higher Prevalence Adapted from International Diabetes Foundation. 2007

40 英國大型研究,United Kingdom Prospective Diabetes Study, UKPDS 對第二型糖尿病慢性併發症的防治結果英國前瞻性糖尿病大型研究 (United Kingdorn Prospective Diabetes Study, UKPDS) 以 sulfonylurea(chloroprapamide, glyburide) 和 insulin 積極治療第二型糖尿病人, 將 HbA1c 控制在 7% 以下, 經過 10 年發現積極治療有下列結果 : (1) 減少眼底病變發生率 21% (2) 減少白蛋白尿發生率達 32% (3) 減少心肌梗塞發生率達 16%, 但未達統計學上辭意義的差異 (p<0.052)

41 UKPDS 對第二型糖尿病慢性併發症的防治結果 p< p= p= p= p<0.01 Microalbuminuria at 12 yrs Retinopathy Any DM endpoint Microvascular complications Myocardial Infarction Over 10 years, HbA 1c was 7.0% ( ) in the intensive group (n=2,729) compared with 7.9% ( ) in the conventional group (n=1,138). UKPDS Group, Lancet 1998

42 Patients with anemia (%) 貧血在慢性腎臟病病人的盛行率 Anemia defined as Hb <12 g/dl in men, <11 g/dl in women; GFR (ml/min per 1.73 m 2 ) 44.1 Astor et al, Arch Intern Med 2002

43 Patients on dialysis (%) 貧血對慢性腎臟病的不利影響 Baseline Hgb by quartile (Q, g/dl) Q1: Q2: Q3: Q4: *P<0.05 versus Q4 Q1 (n=378)* Q2 (n=377)* Q3 (n=363)* Q4 (n=395) Time (years) Mohanram et al, Kidney Int 2004

44 貧血對慢性腎臟病病人的影響慢性腎臟病病人的貧血會加速腎功能的退化慢性腎臟病病人的貧血往往併發心血管疾病慢性腎臟病貧血的病人接受輸血的機率會增加慢性腎臟病貧血病人的活動量與質會受限認知功能及性功能會受損, 因此生活品質會變差慢性腎臟病病人的貧血會增加住院率致病率以及死亡率

45 貧血對慢性腎臟病病人存活率的影響 Log rank p< Hb> 12 g/dl (0.92) g/dl (0.89) g/dl (0.82) < 10 g/dl (0.76) Survival time (months) Portoles et al, Nephrol Dial Transplant 2007

46 Subjective Global Assessment Dietary interview, dietary recall Biochemistry Nutritional Evaluation in CKD Patients Bio-impedance vectorial analysis Anthropometry Muscle tests

47 % 台灣血液透析病人血中白蛋白的分佈圖 Mean: 3.91 ± 0.45 g/dl Albumin < >=4.5 (g/dl) Taiwan Society of Nephrology, 2001

48 An Analysis of Nutritional Status in 101 Hemodialysis Patients Hung-Hsiang Liou, M.D. Division of Nephrology, Department of Medicine, Hsin-Zen Hospital

49 What Does The Word Malnutrition Mean? 營養不良? 營養不夠?

50 營養不良的定義 True malnutrition Acidosis Toxic metabolites Fatigue Loss of weight & muscle mass Low serum proteins Inflammation Dialysis Diabetes / insulin resistance Mitch et al, J Clin Invest 2002

51 低蛋白飲食在慢性腎臟病病人的使用建議 Group Protein Energy Phosphorus (g/kg per d) (Kcal/Kg per d) (mg/kg per d) Chronic renal failure GFR (ml/min) > 60 Protein restriction not usually recommended 35 No restriction 25 to g/kg per d including 0.35 g/kg per d of HBV to 25 (1) 0.6 g/kg per d including 0.35 g/kg per d of HBV or (2) 0.3 g/kg per d supplemented with EAA or KA 35 9 Nephrotic syndrome GFR (ml/min) < 60 (1) 0.8 g/kg per d (plus 1 g protein/g proteinuria) (2) 0.3 g/kg per d supplemented with EAA or KA 35 9 (plus 1 g protein/g proteinuria) Maroni et al, J Am Soc Nephrol 1998

52 低蛋白飲食在慢性腎臟病病人的治療目標延緩慢性腎臟病症狀及徵候的進行減少慢性腎臟病含氮廢物的累積及代謝異常確認能提供足量的蛋白並避免發生營養不良

53 Keto-/Amino Acid Supplemented Low Protein Diet in Patients With CKD This is a Randomized, Open Label, Active Control, Parallel Assignment, Safety/Efficacy Study to compare the Effects Between Keto-/Amino Acid Supplemented Low Protein Diet and Non-Supplemented Low Protein Diet in Patients With Stage Ⅴ Chronic Kidney Disease Tze-Wah Kao, M.D., Master, Principal Investigator, National Taiwan University Hosp ( 高芷華醫師 )

54 An Attempt to Emphasize The Multifactorial and Complex Nature of Progressive Renal Failure Genetic predisposition Inadequate access to health care Low birth weight Lower economic status High protein diet Lower educational achievements Hyperlipidemia Cardiovascular disease Smoking Analgesic & NSID abuse Drug and alcohol dependence HIV and other viral and bacterial infections Obesity Diabetes Systemic hypertension Endothelin Arachidonic acid metabolites Oxygen free radicals AGEs-related oxidative and carbonyl stress Nitric oxide Renin, Angiotensin & Aldosterone Cytokines, growth factors Progressive Renal Failure Salahudeen et al, Nephrol Dial Transplant 2002

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Microsoft PowerPoint - 醫師.ppt 老年人的腎臟保健與用藥安全嘉義基督教醫院腎臟內科徐約翰 MD, MPH 嘉義市藥師公會 98/4/9 徐生明明天開始洗腎 93-09-09 徐生明腹膜植管 93-09-03 終生得洗腎徐生明哭了 93-09-02 徐生明腎功能只剩百分之十 93-09-01 別讓痛