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1、 MANAGEMENTOFTHEPATIENTWITHCHRONICKIDNEYDISEASE MedicineHousestaffConference2 13 2009MargaretAKiserMDPhD Outline ChronicKidneyDiseaseDefinitionsEpidemiologyScreeningforCKDTreatingComplicationsofAdvancedCKDHypertensionControlofvolumeAlterationsinbonemetabolismAnemiaNutritionHyperkalemiaSuggestedK DOQ
2、IactionplanbasedondiseaseseverityWhentoreferandwhySlowingProgressionofCKDEvidencesupportingantihypertensiveuseCardiovascularRiskModificationGettingthewordout WhatisChronicKidneyDisease DefiningCKD Kidneydamagefor 3monthsasdefinedbystructuralorfunctionalabnormalitiesofthekidney withorwithoutdecreased
3、GFR manifestbyeither Pathologicalabnormalities orMarkersofkidneydamage includingabnormalitiesinthecompositionofthebloodorurine orabnormalitiesinimagingtestingGlomerularFiltrationRate GFR 60ml min 1 73m2for 3months withorwithoutstructuralkidneydamage EstimatesofU S ChronicKidneyDiseasePopulationin200
4、0 19 000 000 ChronicKidneyDisease 372 000 Dialysis 80 000 Transplant StagesofCKD ProposedNKF K DOQIGuidelines NKFClinicalNephrologyMeetings2001 Orlando Fla 6RRT PrevalenceofCKD 1Kidneydamage 90 10 2595 82MildGFR 60 89 5 300 7 1003 43ModerateGFR 30 59 7 5533 34SevereGFR 15 293630 25Kidneyfailure 15or
5、dialysis3000 112 4 13 4 GFRPrevalenceinUSPop StageDescription mL min 1 73m2 N 1 000s Populationof177millionadultsageover20 withpresenceofproteinuriaorhematuria structuralchanges donotneedproteinuriaorhematuria justGFR 60 AGEANDRACE Further AfricanAmericansdevelopESRDatayoungerage55 8vs62 2yoAlthough
6、only12 6 oftheUSpopulation AfricanAmericansconstitute50 oftheESRDpopulation PointprevalenceofESRD USRDS2007AnnualReportAJKD51 Suppl1 Jan2008 FamilialInfluences InheritedNephropathiesFamilyhistoryisastrongriskfactorfordiabeticnephropathyInallethnicgroupsstudiedtodatediabeticsiblingsofptswithESRD2 2DM
7、wereatmarkedlyincreasedriskofdevelopingESRD ParticularlycommoninAfricanAmericanswithanincreasedincidencerateof4 25foldgreaterthanCaucasians AJKD2008 51 1 29 37 EtiologyofChronicKidneyDisease USRDS2001 Identifyingpatientsatrisk NationalKidneyFoundationRecommendations KDOQI Individualsatincreasedriskf
8、orCKDshouldbetestedatthetimeofhealthevaluationstodetermineiftheyhaveCKD Thisshouldincludepatientswith DMHTNAutoimmunediseasesChronicsystemicinfectionsRecoveryfromacuterenalfailureAge 60yrsFamilyhistoryofkidneydiseaseExposuretodrugsorproceduresassociatedwithanacutedeclineinkidneyfunctionKidneydonorsa
9、ndtransplantrecipients AJKD 39 2002 pS214 RelationshipofSerumCreatininetoGFR EstimationofGFR GFRcanbeassessedbytherenalclearanceofasubstanceClearanceofsubstanceX Cx UxVx SxRecallGFR Sx UxVx amountfiltered amountexcreted Cx UxV SxCx GFRTwoimportantassumptions MarkerneithersecretedorabsorbedSteadystat
10、eExamplesofmarkers inulin iothalamate iohexol serumcreatinine cystatin C CalculationofGFR MethodsofcalculationCockcroft GaultformulaMDRDformula modifiedMDRD TheCockcroft Gaultcalculation GFRml min 1 73m2 140 age xLeanBWKg72xScreatininemg x0 85forFemales MDRDGFRFormula 170 x SCr 0 999x Age 0 176x 0 7
11、62iffemale x 1 180ifblack x Alb 0 318ModifiedMDRDFormula186 338x SCr 1 154x Age 0 203x 1 212ifblack x 0 742iffemale MDRDGFR FromLeveyetal 1999AnnInternMed130 461 470 Acalculatormaybefoundatwww hdcn org 84F22M66M66FWt kg 45 5104 577 271 8Screat1 21 21 21 2 eGFR 26 9 142 7 66 1 52 3 CalculatedwithCock
12、croft Gault UrineProtein CreatinineRatio BasedontheassumptionthatinthepresenceofstableGFR urinecreatinineandproteinexcretionconstantGinsbergetalfirstdemonstratedastrongcorrelationbetweensingleUrineP Cand24hurinein46ambulatorypatientsatasinglecenter r 0 97ImportantcaveatsLeanbodymassTimingofurinecoll
13、ection Relationshipofspotand24urineprotein GroupA Lowcreatinineexcretion slope 1 11GroupB IntermediateCrexcretion slope 0 97GroupC HighCrexcretion slope 0 77 Fig1Correlationbetweenlnspotmorningurineprotein creatinineratioandlog24hoururinaryproteinin177non diabeticpatientswithchronicnephropathiesandp
14、ersistentclinicalproteinuria PhysiologicChangesinChronicKidneyDisease IncreasedsinglenephronGFRAfferentarteriolarvasodilationIntraglomerularhypertensionLossofglomerularpermselectivityInabiltytoappropriatelydiluteorconcentratetheurineinthefaceofvolumechallenge AnatomicandHistologicFeaturesDuetoGlomer
15、ularHypertension GlomerularhypertrophyFocalsegmentalglomerulosclerosiswithhyalinosisInterstitialfibrosisVascularsclerosisEpithelialfootprocessfusion PathogenesisofSecondaryGlomerulosclerosis NephronMass GlomerularVolumeandGlomerularHypertension EpithelialCellDensityandFootProcessFusion GlomerularScl
16、erosisandHyalinosis PrimaryInsult Proteinuria HypertensioninCKD RecommendationsforAnti hypertensivesinPatientswithChronicKidneyDiseaseTreatmentisindicatedatanystageofthediseaseUsedrugsthatlowerglomerularcapillarypressure ACEinhibitors ARB verapamilanddiltiazem Goalistokeepthebloodpressure 130 80mmHg 120SBPinDM EffectsofVariousAnti hypertensivesonGlomerularCapillaryPressure AfferentArteriole EfferentArteriole DihydropyridinesNifedipineFelodipineAmlodipine Vasodilate Pressure ARBVerapamilDiltiazem
