《慢性肾脏病患者疾病管理PPT课件.ppt》由会员分享，可在线阅读，更多相关《慢性肾脏病患者疾病管理PPT课件.ppt（67页珍藏版）》请在金锄头文库上搜索。
1、 MANAGEMENT OF THE PATIENT WITH CHRONIC KIDNEY DISEASE Medicine Housestaff Conference 2 13 2009 Margaret A Kiser MD PhD Outline nChronic Kidney Disease nDefinitions nEpidemiology nScreening for CKD nTreating Complications of Advanced CKD nHypertension nControl of volume nAlterations in bone metaboli
2、sm nAnemia nNutrition nHyperkalemia nSuggested K DOQI action plan based on disease severity nWhen to refer and why nSlowing Progression of CKD nEvidence supporting antihypertensive use nCardiovascular Risk Modification nGetting the word out What is Chronic Kidney Disease Defining CKD nKidney damage
3、for 3 months as defined by structural or functional abnormalities of the kidney with or without decreased GFR manifest by either nPathological abnormalities or nMarkers of kidney damage including abnormalities in the composition of the blood or urine or abnormalities in imaging testing nGlomerular F
4、iltration Rate GFR 60 ml min 1 73 m2 for 3 months with or without structural kidney damage Estimates of U S Chronic Kidney Disease Estimates of U S Chronic Kidney Disease Population in 2000Population in 2000 19 000 000 Chronic Kidney Disease 372 000 Dialysis 80 000 Transplant Stages of CKDStages of
5、CKD Proposed NKF K DOQI Guidelines NKF Clinical Nephrology Meetings 2001 Orlando Fla 50403020 90 90 10 25910 259 5 8 5 8 2 2 Mild Mild GFR GFR 60 8960 89 5 300 7 100 5 300 7 100 3 43 4 3 3 Moderate GFR Moderate GFR 30 5930 59 7 5537 553 3 3 3 3 4 4 Severe GFR Severe GFR 15 2915 29363363 0 2 0 2 5 5
6、Kidney failureKidney failure 15 or dialysis 15 or dialysis300300 0 1 0 1 12 4 13 412 4 13 4 GFRPrevalence in US Pop StageDescription mL min 1 73 m2 N 1 000s Population of 177 million adults age over 20 with presence of proteinuria or hematuria structural changes do not need proteinuria or hematuria
7、just GFR 60yrs nFamily history of kidney disease n Exposure to drugs or procedures associated with an acute decline in kidney function nKidney donors and transplant recipients AJKD 39 2002 pS214 Relationship of Serum Creatinine to GFR Estimation of GFR nGFR can be assessed by the renal clearance of
8、a substance Clearance of substance X Cx UxVx Sx Recall GFR Sx UxVx amount filtered amount excreted Cx UxV Sx Cx GFR nTwo important assumptions nMarker neither secreted or absorbed nSteady state nExamples of markers inulin iothalamate iohexol serum creatinine cystatin C Calculation of GFR nMethods of
9、 calculation nCockcroft Gault formula nMDRD formula modified MDRD 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 nMDRD GFR Formula 170 x SCr 0 999 x Age 0 176 x 0 762 if female x 1 180 if black x Alb 0 318 nModified MDRD Formula 186 338
10、 x SCr 1 154 x Age 0 203 x 1 212 if black x 0 742 if female MDRD GFR From Levey et al 1999 Ann Intern Med 130 461 470 A calculator may be found at www hdcn org 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 9142 7 66 152 3 Calculated with Cockcroft Gault Urine Protein
11、Creatinine Ratio nBased on the assumption that in the presence of stable GFR urine creatinine and protein excretion constant nGinsberg 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 97 nImportant caveats nLean bo
12、dy mass nTiming of urine collection Relationship of spot and 24 urine protein Group A Low creatinine excretion slope 1 11 Group B Intermediate Cr excretion slope 0 97 Group C High Cr excretion slope 0 77 Fig 1 Correlation between ln spot morning urine protein creatinine ratio and log 24 hour urinary
13、 protein in 177 non diabetic patients with chronic nephropathies and persistent clinical proteinuria Physiologic Changes in ChronicPhysiologic Changes in Chronic Kidney DiseaseKidney Disease n n Increased single nephron GFRIncreased single nephron GFR n n Afferent arteriolar vasodilationAfferent art
14、eriolar vasodilation n n Intraglomerular hypertensionIntraglomerular hypertension n n Loss of glomerular permselectivityLoss of glomerular permselectivity n n Inabilty to appropriately dilute or concentrate Inabilty to appropriately dilute or concentrate the urine in the face of volume challengethe
15、urine in the face of volume challenge Anatomic and Histologic Features Due to Anatomic and Histologic Features Due to Glomerular HypertensionGlomerular Hypertension n n Glomerular hypertrophyGlomerular hypertrophy n n Focal segmental glomerulosclerosis with Focal segmental glomerulosclerosis with hy
16、alinosishyalinosis n n Interstitial fibrosisInterstitial fibrosis n n Vascular sclerosisVascular sclerosis n n Epithelial foot process fusion Epithelial foot process fusion Pathogenesis of Secondary Pathogenesis of Secondary GlomerulosclerosisGlomerulosclerosis Nephron Mass Glomerular Volume and Glomerular Hypertension Epithelial Cell Density and Foot Process Fusion Glomerular Sclerosis and Hyalinosis Primary Insult Proteinuria Hypertension in CKD n n Recommendations for Anti hypertensives Recom
