慢性肾脏病患者疾病管理课件.ppt
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1、,.,2,MANAGEMENT OF THE PATIENT WITH CHRONIC KIDNEY DISEASE,Medicine Housestaff Conference 2/13/2009 Margaret A Kiser MD PhD,.,3,Outline,Chronic Kidney DiseaseDefinitions EpidemiologyScreening for CKDTreating Complications of Advanced CKDHypertensionControl of volumeAlterations in bone metabolismAnem
2、iaNutritionHyperkalemiaSuggested K-DOQI action plan based on disease severityWhen to refer and whySlowing Progression of CKDEvidence supporting antihypertensive useCardiovascular Risk ModificationGetting the word out,.,4,What is Chronic Kidney Disease?,.,5,Defining CKD,Kidney damage for 3 months as
3、defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either:Pathological abnormalities; orMarkers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging testingGlomerular Filtration Rate (
4、GFR) 60 ml/min/1.73 m2 for 3 months, with or without structural kidney damage,.,6,Estimates of U.S. Chronic Kidney Disease Population in 2000,19,000,000,Chronic KidneyDisease,372,000,Dialysis,80,000,Transplant,.,7,Stages of CKD,Proposed NKF-K/DOQI Guidelines. NKF Clinical Nephrology Meetings 2001; O
5、rlando, Fla.,6 RRT,.,8,Prevalence of CKD,1Kidney damage 90*10,259 5.82Mild GFR 60 89*5,300 7,100 3 43Moderate GFR 30 59*7,553 3.34Severe GFR 15 29363 0.25Kidney failure 15 or dialysis300 0.112.4 13.4,GFRPrevalence in US Pop.* StageDescription(mL/min/1.73 m2) N (1,000s)%,*Population of 177 million ad
6、ults age over 20* with presence of proteinuria or hematuria +/- structural changes* do not need proteinuria or hematuria, just GFR 60,.,9,AGE AND RACE,Further, African Americans develop ESRD at a younger age 55.8 vs 62.2 yoAlthough only 12.6% of the US population, African Americans constitute 50% of
7、 the ESRD population,Point prevalence of ESRD,USRDS 2007 Annual Report AJKD 51, Suppl 1, Jan 2008,.,10,Familial Influences,Inherited NephropathiesFamily history is a strong risk factor for diabetic nephropathyIn all ethnic groups studied to date diabetic siblings of pts with ESRD 2/2 DM were at mark
8、edly increased risk of developing ESRD.Particularly common in African Americans with an increased incidence rate of 4-25 fold greater than Caucasians,AJKD 2008, 51 (1), 29-37,.,11,Etiology of Chronic Kidney Disease,USRDS 2001,.,12,Identifying patients at risk:National Kidney Foundation Recommendatio
9、ns (KDOQI),Individuals at increased risk for CKD should be tested at the time of health evaluations to determine if they have CKD. This should include patients with:-DM HTN Autoimmune diseases Chronic systemic infectionsRecovery from acute renal failureAge 60yrsFamily history of kidney disease Expos
10、ure to drugs or procedures associated with an acute decline in kidney functionKidney donors and transplant recipients,(AJKD, 39, 2002, pS214),.,13,Relationship of Serum Creatinine to GFR,.,14,Estimation of GFR,GFR can be assessed by the renal clearance of a substanceClearance of substance X (Cx) = U
11、xVx/SxRecall GFR * Sx = UxVx (amount filtered = amount excreted) Cx = UxV/Sx Cx = GFRTwo important assumptions:Marker neither secreted or absorbedSteady stateExamples of markers: inulin, iothalamate, iohexol, serum creatinine, cystatin-C,.,15,Calculation of GFR,Methods of calculationCockcroft-Gault
12、formulaMDRD formula/modified MDRD,.,16,The Cockcroft-Gault calculation,GFR ml/min/1.73m2 = (140-age) x Lean BW Kg 72 x S creatinine mg% ( x 0.85 for Females ),.,17,MDRD GFR Formula*170 x SCr-0.999 x Age-0.176 x 0.762 if female x 1.180 if black x Alb+0.318Modified MDRD Formula186.338 x SCr-1.154 x Ag
13、e-0.203 x 1.212 if black x 0.742 if female,MDRD GFR,*From Levey et al, 1999Ann Intern Med 130: 461-470,(A calculator may be found at www.hdcn.org),.,18,84 F 22 M 66 M 66 F Wt (kg) 45.5 104.5 77.2 71.8 Screat 1.2 1.2 1.2 1.2,eGFR,26.9,142.7,66.1,52.3,(Calculated with Cockcroft-Gault),.,19,Urine Prote
14、in / Creatinine Ratio,Based on the assumption that in the presence of stable GFR, urine creatinine and protein excretion constantGinsberg et al first demonstrated a strong correlation between single Urine P/C and 24 h urine in 46 ambulatory patients at a single center, r=0.97Important caveatsLean bo
15、dy massTiming of urine collection,Relationship of spot and 24 urine protein,Group A: Low creatinine excretion, slope=1.11Group B: Intermediate Cr excretion, slope=0.97Group C: High Cr excretion, slope = 0.77,.,20,Fig 1 Correlation between ln spot morning urine protein:creatinine ratio and log 24 hou
16、r urinary protein in 177 non-diabetic patients with chronic nephropathies and persistent clinical proteinuria,.,21,Physiologic Changes in ChronicKidney Disease,Increased single nephron GFRAfferent arteriolar vasodilationIntraglomerular hypertensionLoss of glomerular permselectivityInabilty to approp
17、riately dilute or concentrate the urine in the face of volume challenge,.,22,Anatomic and Histologic Features Due to Glomerular Hypertension,Glomerular hypertrophyFocal segmental glomerulosclerosis with hyalinosisInterstitial fibrosisVascular sclerosisEpithelial foot process fusion,.,23,Pathogenesis
18、 of Secondary Glomerulosclerosis,Nephron Mass,Glomerular Volume andGlomerular Hypertension,Epithelial Cell Density andFoot Process Fusion,Glomerular Sclerosisand Hyalinosis,Primary Insult,Proteinuria,.,24,Hypertension in CKD,.,25,Recommendations for Anti-hypertensives in Patients with Chronic Kidney
19、 DiseaseTreatment is indicated at any stage of the diseaseUse drugs that lower glomerular capillary pressure (ACE inhibitors, ARB, verapamil and diltiazem) Goal is to keep the blood pressure 130/80 mmHg ( 120 SBP in DM),.,26,Effects of Various Anti-hypertensives on Glomerular Capillary Pressure,Affe
20、rentArteriole,Efferent Arteriole,DihydropyridinesNifedipineFelodipineAmlodipine,Vasodilate,Pressure,ARBVerapamilDiltiazem,Vasodilate,Pressure,Vasoconstrict,ACE-I,.,27,Number of Medications to Achieve Goal BP in 5 Trials of DM/Renal Disease,Bakris. J Clin Hypertens 1999;1:141.,.,28,A Hierarchy of Age
21、nts,ACE-IARB,-BlockersThiazide Diuretics,Vasodilators- BlockersCentral Agents,CCBs,More Preferred,Less Preferred,.,29,Volume Management-Diuretics,% Filtered Na+Site of Action Diuretic ExcretedNa+-K+-2Cl- carrierFurosemide in Loop of Henle Bumetanide 20 %TorsemideEthacrynic acidNa+-Cl- carrier Thiazi
22、des 3-5 % in the distal tubule MetolazoneNa+ channel in theAmiloride 1-2 % cortical collectingTriamterene ductSpironolactone (indirect),.,30,Natriuretic Response to Furosemide at Different Levels of Renal Function,GFR 150 ml/min,GFR 15 ml/min,1250 mEq,125 mEq,250 mEq,25 mEq,.,31,Diuretic Tolerance,T
23、ype I: Short-termDecrease in the response to a diuretic after the first doseTeleologically- appropriate response to volume depletionType II: Long-termHypertrophy of distal nephron segments allowing greater sodium resorption,.,32,Algorithm for Diuretic Use,Renal Insufficiency CrCl 50,Loop DiureticDet
24、ermine Effective Dose: 5-10X Usual DoseAdminister as Frequently as Necessary,Thiazide According to CrCl 50ml/min50-100mg/ 50-100mg/ 25-50mg/ day day day,ADD,Add Distal Diuretic Drug,From Brater DG N Eng J Med 1998;339:387,.,33,Alterations in Bone and Mineral Metabolism,.,34,PTH,Pi,Ca2+,Renal Mass,25
25、(OH)D3,1,25(OH)2D3,1-alpha-hydroxylase,1-alpha-hydroxylase,+,Acidosis,+,Hyperparathyroid Related Bone Disease,ImpairedAbsorption,Osteitis FibrosaCystica,.,35,Reduced Renal Mass,GFR, 65,40,25,Increased PTH Secretion,Decreased 1,25-D,Hyperphosphatemia,Hypocalcemia,.,36,Calcium and Phosphorus Balance:N
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