Chi-Mei Medical Center

簡志強 醫師

2014.10.14

Chronic Kidney Disease

Outline - CKD • Screening for CKD risk factors

• CKD risk reduction

• Complications of CKD

• Prepare for replacement

為什麼要防治腎臟病?

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 %

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

???

腎臟做些什麼事?

Kidneys beyond help!

End-stage kidneys

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.

CKD防治策略

Target on Renal Risk Factors to

Delay Progression

Screen & Identify

High Risk Groups for CKD

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

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

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

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

17

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.

Screening for CKD risk factors

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

CKD Risk Factors-

1. 糖尿病腎病變

deo.ucsf.edu

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

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

CKD Risk Factors-

2.高血壓腎病變

kidney.org.uk

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

CKD Risk Factors:

3. Glomerulonephritis腎絲球腎炎

http://emedicine.medscape.com/article/239927-overview

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

(

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)

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

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

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

Complications of CKD

Edema

Renal anemia

Uremic bleeding

Metabolic acidosis

Electrolyte unbalance

Hyperphosphatemia; CKD-MBD

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

Hyperkalemia

• Hyperkalemia generally develops in patient:

- Oliguria

- High potassium diet

- Increased tissue breakdown

- Use of ACE inhibitor or ARB

Star fruit

Uremic Platelet Dysfunction

Clin J Am Soc Nephrol 8: 665–674, April, 2013

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.

38

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.

Thanks for your attention！