CKD - PDF Free Download

Chronic Kidney Disease Chi-Mei Medical Center 簡志強醫師 2014.10.14

Outline - CKD Screening for CKD risk factors CKD risk reduction Complications of CKD Prepare for replacement

為什麼要防治腎臟病?

2007 台灣接受透析治療之末期腎臟病人數與模式全部病例數 ( 年終 ) 52,537 血液透析 HD 48,072 腹膜透析 PD 4,465 PD 腹膜透析 8.5 % Prevalence rate: 2,288 per million population Incidence rate: 416 per million population HD 血液透析 91.5 % TSN Renal Registry 1990 ~ 2007

台灣慢性腎臟病的危險因子老年慢性腎絲球炎糖尿病高血壓高血脂肥胖代謝症候群藥物 : 中草藥西藥透析腎臟病患家屬抽菸檳榔慢性感染重金屬???

腎臟做些什麼事?

Kidneys beyond help! End-stage kidneys

Prevalence and Stage of CKD Stage 1 2 Description Kidney Damage with Normal or GFR Kidney Damage with Mild GFR GFR (ml/min/1.73 m 2 ) Prevalence* N (1000s) % 90 5,900 3.3 60-89 5,300 3.0 3 Moderate GFR 30-59 7,600 4.3 4 Severe GFR 15-29 400 0.2 5 ESRD < 15 or Dialysis 300 0.1 *Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two measurements.

CKD 防治策略 Screen & Identify High Risk Groups for CKD Target on Renal Risk Factors to Delay Progression

Conceptual model for stages in the initiation and progression of CKD and therapeutic interventions 治療介入疾病發生疾病進展 American Journal of Kidney Diseases, Vol 43, No 5, Suppl 1, 2004: S16-S41

CKD 各分期的治療策略 Stage Description GFR (ml/min/1.73 m 2 ) Action 1 Kidney Damage with Normal or GFR >90 診斷及治療治療合併症延緩腎功能惡化減少心血管疾病危機 2 Mild GFR 60-89 預估腎功能衰退情形 3 Moderate GFR 30-59 評估及治療併發症 4 Severe GFR 15-29 準備腎臟替代療法 5 Kidney Failure <15 or Dialysis 尿毒症出現時開始替代療法

Risk factors for CKD: Initiating factors 啟動誘發因子 Older age Family history of CKD Gender Diabetes mellitus Metabolic syndrome Hyperfiltration state Obesity High protein intake Anemia High normal urinary albumin excretion Dyslipidemia Nephrotoxins NSAIDS Antibiotics/anti-virals Radiological contrast Primary renal disease Urological disorders Obstruction Recurrent urinary infections Cardiovascular disease Taal, Kidney Int 2006;70:1694

Risk factors for CKD: Perpetuating factors 持續惡化因素 Nephrotoxins Nephron number Proteinuria SBP >130 mmhg High dietary protein intake Obesity Anemia Dyslipidemia Smoking Cardiovascular disease Taal, Kidney Int 2006;70:1694

Key Considerations for Patients with CKD? Susceptibility Risk Factors Diabetes Hypertension Older age Family history of CKD Racial or ethnic minority Other: kidney-mass reduction, known kidney disease Progression Factors Proteinuria Higher BP Poor glycemic control Smoking Hyperlipidemia Drug use Complications CVD Anemia Altered bone & mineral metabolism Levey et al. Ann Intern Med. 2003;139:137-147. USRDS. 1999 Annual Data Report. Available at: www.usrds.org. 17

Screening for CKD risk factors

台灣尿毒症五大常見病因 : 病因機制 1. 糖尿病代謝異常 2. 腎絲球腎炎免疫異常 3. 高血壓血管傷害 4. 尿路阻塞結石感染毒藥害感染, 毒藥物傷害 5. 多囊性腎病遺傳

CKD Risk Factors- 1. 糖尿病腎病變 deo.ucsf.edu

糖尿病腎病變致病惡化因素血糖控制不佳高血壓控制不佳蛋白尿 : CKD 診斷指標及惡化加重因素微量白蛋白尿 (Microalbuminuria): Urine albumin/creatine ratio (ACR) 30-299 mg/mg 巨量蛋白尿 (Macroalbuminuria):Urine albumin/creatine ratio (ACR) 300 mg/mg 抽煙年輕時發病具糖尿病高血壓家族史

糖尿病腎病變治療策略阻斷血管張力素劑 (ACEI or ARB) 控制血壓預防及改善蛋白尿無微量白蛋白尿糖尿病微量白蛋白尿 X X X Ravid et al, 1998 (ACEI) T2D BENEDICT, 2004 (ACEI) T2D 蛋白尿 EUCLID, 1997 (ACEI) T1D Mathiesen et al, 1999 (ACEI) T1D Ravid et al, 1996 (ACEI) T2D MicroHOPE, 2000 (ACEI) T2D IRMA2, 2001 (ARB) T2D MARVAL, 2002 (ARB) T2D DETAIL, 2004 (ARB) T2D 衰竭末期腎 Lewis et al, 1993 (ACEI) T1D IDNT, 2001 (ARB) T2D RENAAL, 2001 (ARB) T2D

CKD Risk Factors- 2. 高血壓腎病變 kidney.org.uk

高血壓引起之腎臟血管傷害 (1) 本態性或原發性高血壓 Essential hypertension ( 腎小動脈硬化, arteriolar nephrosclerosis) 好發於長期高血壓 10-20 年以上老年人, 輕微蛋白尿和腎功能異常, 合併動脈硬化性缺血性腎病 (2) 惡性高血壓 Malignant hypertension 好發於 20-30 幾歲年青人, 血壓突然飆高至舒張壓 >130 mmhg, 合併 papilledema, 神經病變, 心衰竭, 溶血性貧血, 腎衰竭治療主要是控制血壓, 以免演變成末期腎病

CKD Risk Factors: 3. Glomerulonephritis 腎絲球腎炎 http://emedicine.medscape.com/article/239927-overview

Major Renal Syndrome: Glomerulonephritis 腎絲球腎炎 Renal syndrome Clinical Renal pathology Nephrotic syndrome: Proteinuria 3.5 g/day Minimal change, Membranous nephropathy, Focal glomerulosclerosis Asymptomatic urinary abnormalities Acute nephritic syndrome Rapidly progressive renal failure Isolated proteinuria (<2.0 g/day) or hematuria Abrupt onset of renal insufficiency with hematuria Heavy proteinuria, Rapid decline in renal function Immunoglobulin A nephropathy (IgA N) Poststreptococcal glomerulonephritis (PSGN) Rapidly progressive glomerulonephritis (RPGN)

CKD Risk Factors- 4. 遺傳性腎臟病 - 多囊性腎 Autosomal dominant polycystic kidney disease (ADPKD) henryoshoremoh.blogspot.com http://geneticpeople.com/?p=554

CKD Risk Factors 5. 腎小管間質性腎炎如感染毒藥物結石阻塞等 Nortier J, Nephrology Dialysis Transplantation 2007;22;1512

急性腎小管間質性腎炎急性腎傷害藥物 : 抗生素 NSAID 顯影劑感染 : 細菌病毒 Leptospira Mycobacterium Mycoplasma 等勾端螺旋體間質性腎炎 Leptospiral interstitial nephritis (Yang et al, 1997) 原發性 : anti-tubule basement membrane disease

毒藥物傷害慢性腎小管間質性腎炎毒藥物止痛藥中草藥腎病變鋰鹽代謝物尿酸腎病變重金屬鉛腎病變

Complications of CKD Edema Renal anemia Uremic bleeding Metabolic acidosis Electrolyte unbalance Hyperphosphatemia; CKD-MBD

Volume overload Patients with CKD and volume overload generally respond to the combination of dietary sodium restriction and diuretic therapy, usually with a loop diuretic given daily. Side effects

Hyperkalemia Hyperkalemia generally develops in patient: - Oliguria - High potassium diet - Increased tissue breakdown - Use of ACE inhibitor or ARB

Star fruit

Uremic Platelet Dysfunction Clin J Am Soc Nephrol 8: 665 674, April, 2013

Cryoprecipitate Factor VIII, vwf and fibrinogen Indication: (1) Uremic patients at high risk of bleeding (2) Uremic patients with active bleeding Advantage: fast onset (approximately 1 h) Disadvantages: risk of post-transfusion hepatitis, HIV, fever, and allergic reaction.

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