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1、CKD及其一体化管理,1,Annul Increase of RRT in China,2,我国大陆与香港/台湾/日本的透析病人数比较,3,北京,全国,3,2007年、2008年北京市城区和郊区血透治疗患者比较,透析分布失衡,4,慢性肾脏病(CKD)?,5,慢性肾脏病(CKD) 的定义,肾损害（肾脏结构或功能异常3个月，伴有或不伴有肾小球滤过率（GFR）的下降，表现为下列异常之一： 有病理学检查异常； 有肾损害的指标，如血、尿检查异常； GFR60ml/min/1.73m2 3个月，有或无肾损害。,Am J Kidney Dis. 2002 Kidney Int. 2005,6,慢性肾脏病(C
2、KD)及其诊断,分期 描述GFR (ml/min/1.73m2) 1 肾损伤GFR正常或 90 2 肾损伤GFR轻度 6089 3 GFR中度 3059 4 GFR严重 1529 5 肾衰竭 15或 透析（ 5D）,7,慢性肾功能衰竭 (CRF) 慢性肾功能不全 (CRI) 终末期前肾损害 (pre-ESRD),CKD及分期,KDOQI AJKD 2002,39:S1-S226,二次国际讨论会修改、确认 (KDIGO 2004；2006),KI 2005,67：2089 KI 2007,72：247,各种疾病引起,并已被录入国际疾病分类代码（ICD）第9版， 从而成为正式疾病分类名词,8,CK
3、D定义及分期的影响,医学研究:,- 促进了肾脏病的临床科研,- 搭建全球肾脏病医疗和学术交流平台,- 统一了既往对肾脏病混乱的命名,- 促进肾脏病流行病学研究（筛查和随访）,9,Definition and classification of chronic kidney disease. KDIGO 2005,Prevalence of CKD in big cities of China From cross-sectional studies,1. Am J Kidney Dis 2008; 51:373-384 2. Nephrol Dial Transplant . 2009 24:
4、 1205-1212 3. Nephrol Dial Transplant 2009;24:1202-1210 4 .Kidney Int 2005; 68:2837-2845 5.China J Nephrol 2008,24:9,10,Prevalence of CKD in rural area of China from regional studies,Definition and classification of chronic kidney disease. KDIGO 2005,1. Chinese Journal of Nephrology 2007; 23:152-157
5、 2. Chinese Journal of Nephrology 2008;24:609-613 3. Chinese Journal of Nephrology to be published,11,与罹患慢性肾脏病相关的因素,肾功能下降的危险因素：年龄，服用肾毒性药物，脂代谢紊乱，高血压 白蛋白尿的危险因素：女性，糖尿病，高血压，脂代谢紊乱，慢性感染，,12,Special interested factors have been screened: Chronic respiratory tract infection (-) Hepatitis B virus infection (
6、-) Nephrotoxic medications,* Concomitant diseases include HBP or DM or CHD.,13,CKD横断面研究,回答：CKD在某一人群中的患病率(prevalence) 及其相关危险因素 影响环节： 研究对象的选取 取样方法、应答率 检测指标及方法 肌酐测定 变异程度 室间系统误差 eGFR公式 * 尿蛋白 重复测试 * 对获得数据进行清理的认真程度,14,Incidence of CKD Longitudinal study in a community-based population,1504 individuals( el
7、der than 40 years) who were identified as non CKD in 2004, After follow-up for 4 years:,CKD Stages No. % 1, 13 8.6 2, 53 35.4 3, 84 56,15,CKD 在中国及全球 都是常见病、知晓率很低。 CKD是预后严重的慢性病。,16,肾衰竭与恶性肿瘤死亡率比较(2000, 美国),(thousands),SEER, 2003,17,Progression of CKD,Longitudinal study of 1437cases for 4 years Decreasi
8、ng of eGFR 20%,The incidence RRT will continue to increase in China in the following decades, partly due to the progression of CKD.,18,NDT 待发表,肾功能进行性损伤的影响因素 1 563例队列人群4年追踪,19,心血管病的年死亡率,AJKD 39: Supp 1, S44, 2002,ESRD病人中心血管疾病的危险性 是同年对照人群的10倍 NDT 2005,20,石景山社区资料,CKD二期(eGFR 6089ml/min) 心脑血管疾病发病率 OR1.31
9、5* CKD三期(eGFR 3059ml/min) 心脑血管疾病发病率 OR2.398*,* 纠正传统因素后,JASN 2006,17:2617,21,CKD各期颈内动脉中层厚度,IMT (mm)eGFR90 eGFR 60-89 eGFR90 and Ualb-, b P0.05 compared with eGFR90 and Ualb+, c P90 and Ualb-, d P90 and Ualb+, Abbreviations: IMT, intima-media thickness; eGFR, estimated glomerular filtration rate; Ualb
10、, albuminuria; - absent; +present; Note: To convert eGFR in ml/min/1.73m2 to mL/s/1.73m2, multiply by 0.01667,Am J Kidney Dis 2007, 49:786-792.,22,开始透析病人： 心衰1/3 心绞痛1/4 心梗10% USRDS 1999,125例透析前病人 65.5%出现心血管合并症 需要紧急透析的病人 72%为急性左心衰,杨莉，等。中国实用内科杂志 2004,23,Number of patients with CMBs according to CKD sta
11、ges,P = 0.0041 ( 2 test).,T2*-weighted MRI of brain was performed with a 1.5-T MRI system 162 CKD patients (CKD stages 15, excluding CKD stage 5(D) 24 normal subjects.,N DT 2010 25(5):1554-1559,24,Model 1,Model 2,Model 3,Online ISSN 1460-2385 - Print ISSN 0931-0509 Copyright 2010 European Renal Asso
12、ciation - European Dialysis and Transplant Assoc Oxford Journals Oxford University Press Site Map Privacy Policy Frequently Asked Questions Other Oxford University Press sites:,Odds ratio for the presence of CMBs adjusted by variables,25,Association of CKD and Cancer Risk in Older People,3654 reside
13、nts aged 49 to 97 yr, during a mean follow-up of 10.1 yr 711 (19.5%) cancers occurred in 3654 participants. Men with at least stage 3 CKD had a significantly increased risk for cancer (test of interaction for gender P = 0.004). The excess risk began at an estimated GFR (eGFR) of 55 ml/min per 1.73 m
14、2 (adjusted hazard ratio HR 1.39; 95% confidence interval CI 1.00 to 1.92),Journal of the American Society of Nephrology April 30, 2009,26,27,Association of CKD and Cancer Risk in Older People,3654 residents aged 49 to 97 yr, during a mean follow-up of 10.1 yr 711 (19.5%) cancers occurred in 3654 pa
15、rticipants. Men with at least stage 3 CKD had a significantly increased risk for cancer (test of interaction for gender P = 0.004). The excess risk began at an estimated GFR (eGFR) of 55 ml/min per 1.73 m2 (adjusted hazard ratio HR 1.39; 95% confidence interval CI 1.00 to 1.92) And increased linearly as GFR declined. for every 10-ml/min decrement in eGFR, the risk for cancer increased by 29% (adjusted HR 1.29; 95% CI 1.10 to 1.53), with the greatest risk at an eGFR 40 ml/min per 1.73 m2 (adjusted HR 3.01; 95% CI 1.72 to 5.27). The risk for lung and urinary tra
