Chronic Kidney Disease - Chi...
Transcript of Chronic Kidney Disease - Chi...
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Chi-Mei Medical Center
簡志強 醫師
2014.10.14
Chronic Kidney Disease
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Outline - CKD • Screening for CKD risk factors
• CKD risk reduction
• Complications of CKD
• Prepare for replacement
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為什麼要防治腎臟病?
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全部病例數(年終) 52,537
血液透析 HD 48,072腹膜透析 PD 4,465
Prevalence rate: 2,288 per million population
Incidence rate: 416 per million population
TSN Renal Registry
1990 ~ 2007
PD腹膜透析8.5 %
2007台灣接受透析治療之末期腎臟病人數與模式
HD血液透析91.5 %
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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
???
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腎臟做些什麼事?
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Kidneys beyond help!
End-stage kidneys
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Prevalence and Stage of CKD
Stage DescriptionGFR
(ml/min/1.73 m2)
Prevalence*
N
(1000s)%
1Kidney Damage with
Normal or GFR 90 5,900 3.3
2Kidney Damage with
Mild GFR60-89 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.
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CKD防治策略
Target on Renal Risk Factors to
Delay Progression
Screen & Identify
High Risk Groups for CKD
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Conceptual model for stages in the
initiation and progression of CKD and
therapeutic interventions
American Journal of Kidney Diseases, Vol 43, No 5, Suppl 1, 2004: S16-S41
疾病發生 疾病進展
治療介入
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CKD 各分期的治療策略
Stage DescriptionGFR
(ml/min/1.73 m2)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
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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
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Risk factors for CKD:
Perpetuating factors 持續惡化因素Nephrotoxins
↓ Nephron numberProteinuria
SBP >130 mmHg
High dietary protein intakeObesity
Anemia
DyslipidemiaSmoking
Cardiovascular disease
Taal, Kidney Int 2006;70:1694
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Key Considerations for Patients with CKD?
Susceptibility Risk Factors
Progression Factors
Complications
• Diabetes
• Hypertension
• Older age
• Family history of CKD
• Racial or ethnic minority
• Other: kidney-mass
reduction, known kidney
disease
• Proteinuria
• Higher BP
• Poor glycemic
control
• Smoking
• Hyperlipidemia
• Drug use
• 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.
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Screening for CKD risk factors
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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,毒藥物傷害
感染、毒藥害
5. 多囊性腎病 遺傳
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CKD Risk Factors-
1. 糖尿病腎病變
deo.ucsf.edu
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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
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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
糖尿病
無微量白蛋白尿
微量白蛋白尿
蛋白尿
末期腎
衰竭X X X
Lewis et al, 1993 (ACEI)T1D
IDNT, 2001 (ARB)T2D
RENAAL, 2001 (ARB)T2D
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
Ravid et al, 1998 (ACEI)T2D
BENEDICT, 2004 (ACEI) T2D
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CKD Risk Factors-
2.高血壓腎病變
kidney.org.uk
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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
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CKD Risk Factors:
3. Glomerulonephritis腎絲球腎炎
http://emedicine.medscape.com/article/239927-overview
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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
Isolated proteinuria
(
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henryoshoremoh.blogspot.com http://geneticpeople.com/?p=554
CKD Risk Factors-
4.遺傳性腎臟病-多囊性腎Autosomal dominant polycystic kidney
disease (ADPKD)
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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
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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
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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
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Complications of CKD
Edema
Renal anemia
Uremic bleeding
Metabolic acidosis
Electrolyte unbalance
Hyperphosphatemia; CKD-MBD
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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
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Hyperkalemia
• Hyperkalemia generally develops in patient:
- Oliguria
- High potassium diet
- Increased tissue breakdown
- Use of ACE inhibitor or ARB
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Star fruit
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Uremic Platelet Dysfunction
Clin J Am Soc Nephrol 8: 665–674, April, 2013
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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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Key Considerations for Patients with CKD?
Susceptibility Risk Factors
Progression Factors
Complications
• Diabetes
• Hypertension
• Older age
• Family history of CKD
• Racial or ethnic minority
• Other: kidney-mass
reduction, known kidney
disease
• Proteinuria
• Higher BP
• Poor glycemic
control
• Smoking
• Hyperlipidemia
• Drug use
• 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.
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Thanks for your attention!