ckd thai guideline 2009
TRANSCRIPT
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ISBN 974-300-791-0
1 2552 5,000
2 50 3 47 10310 0-2716-6901
()
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(Chronic Kidney Disease, CKD)
(End Stage Renal Disease,
ESRD)
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III
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IV
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7 .. 2552 8 9
11 12
13 14
1: 15 2: 17 3: 20 4: 21
5: 22 6: 24 7: 25
V
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8: 28 9: 29 10: 30 11: 34
12: 35
13: 36 14: 37 15: 38 16: 39 17: 40
1 43 2 44
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3 (eGFR) 45 MDRD 4 (eGFR) 46
MDRD
IV
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7
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a (cost effective)
+
c
b
Strength of Recommendation
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Quality of Evidence1
1.1 (systematic review)- (randomize-controlled clinical trial) 1
1.2 -(a well-designed randomize-controlled clinical
trial) 1
2 2.1
(non-randomized controlled clinicaltrial)
2.2 (well-designed non-randomized controlled
clinical trial) 2.3
(cohort) (case-control analytical studies) /
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2.4 (multiple time series) .. 2480
3 3.1 (descriptive studies) 3.2
(fair-designed controlled clinical trial)
4 4.1
(consensus)
4.2 (case series)
2 (anecdotal report)
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1. (screening and consultationor referral)
2. (slowing the progression of kidney
disease)
3. (evaluationand treating CKD complications)
4. (cardiovascu-lar risk reduction)
5. (preparation for renalreplacement therapy)
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1. 3 (glomerular filtration rate, GFR)
1.1 2 3 1.1.1
1.1.1.1 microalbuminuria
1.1.1.2 proteinuria 500 mg 500 mg/g creatinine
1.1.2 (hematuria)1.2 1.3
2. GFR 60 mL/min/1.73m2 3
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1 GFR 902 GFR 60 - 893 GFR 30 - 594 GFR 15 - 295 < 15 (
)
GFR (mL/min/1.73m2)
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: 2.2 ( 18)
micro proteinuria
albuminuria
total 24 < 300 mg - > 300 mgprotein
- (dipstick) < 200 mg/g - > 200 mg/g
creatinine creatinine protein/
creatinine ratio
albumin 24 < 30 mg 30-300 mg > 300 mg -
(microalbuminuria
dipstick)
< 30 mg/g 30-300 > 300 mg/g creatinine mg/g creatinine
albumin/ creatininecreatinine ratio
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1
1.1 ( a 1)
1.2 ( a 2)
1.3 (autoimmune diseases)
( + 3)
1.4 (systemic infection) ( + 3)
1.5 (cardiovascular disease) ( + 3)
1.6 ( + 3)
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1.7 ( + 4)
1.8 60 ( + 4)
1.9 ( + 4)
1.10 ( + 4)
1.11 ( + 4)
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2
1 2.1 estimated GFR (eGFR) 1 (serum creatinine, SCr) Modification of Diet in Renal Disease (MDRD)
Equation[1] ( a 2)
eGFR (mL/min/1.73m2) =
186.3 x SCr (jaffe) 1.154 x Age 0.203 x (0.742 )
MDRD equation eGFR Crockcoft-Gault equation ( c 4)
[2] 1.73m2
CCr (ml/min) =(140Age) x Body weight
x (0.85 )72 x SCr
[1] racial-factor eGFR racial-factor 1.016
MDRD
[2] Body surface area (Mosteller formula) = Body weight (kg) x Hight (cm)3,600
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2.2 (Dipstick)
2.2.1 2.2.1.1 1+
( a3)
2.2.1.2 urinary albumin/creatinine ratio
(UACR) (spotmorning urine) 30-300 mg/g
microalbuminuria ( a2)
2.2.1.3 UACR microalbuminuria dipstick
microalbuminuria
( +4)
2.2.2 2.2.2.1 2+
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2.2.2.2 1+ urinary protein/creatinine ratio(UPCR) 500 mg/g
( a3)
2.3 microscopic examination
5/HPF ( a 4)
2.4 2.1 - 2.3 3 ( a 4)
2.5 (plain KUB) / (ultrasonography of KUB) ( c 4)
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3
eGFR ( a 4)
3.1 1 2 12
( 6 )
3.2 3 6 ( 12
)
3.3 4 3 ( 6 )
3.4 5 3
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4
4.1 4.1.1 eGFR 30-59 mL/min/1.73m2
7 mL/min/1.73m2 ( a 4)
4.2 4.2.1 eGFR 30-59 mL/min/1.73m2
7 mL/min/1.73m2 ( a 4)
4.2.2 eGFR 30 mL/min/1.73m2
( a 4)
4.2.3 1,000 mg spot urine protein/creatinine ratio 1,000mg/g creatinine
( c 4)
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5
5.1 130/80 mmHg ( a 1)
5.2 angiotensin
converting enzyme inhibitor (ACEI) angiotensin recep-tor blocker (ARB)
( a 1)
5.3 ACEI ARB ( a 1)
5.4 ACEI ARB (SCr) (serum K) [3]
SCr 30% 4 serum K5.5 mmol/L
( a 3)
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5.5 2
( a 2)
[3] , GFR ACEI ARB
(.) 120 110 - 119 < 110GFR (mL/min/1.73m2) 60 30 - 59 < 30
GFR (%) < 15 15 - 30 > 30 (mmol/L) 4.5 4.6 - 5.0 > 5
4-12 2-4 < 2 BP 6-12 3-6 1-3
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7
7.1
7.1.1 (Preprandial capillary plasmaglucose) 90-130 mg/dL (5.0-7.2 mmol/L)
( + 2)
7.1.2 (Peak postprandial capil-lary plasma glucose) 180 mg/dL (
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7.2.2 7.2.2.1 biguanide (metformin) :
serum creatinine 1.5 mg/dL 1.4 mg/dL ( 4)
7.2.2.2 sulfonylurea chlorpropamide :
( 2)
glybenclamide : eGFR 30 mL/min/1.73m2
( 4)
glipizide gliclazide : eGFR 10 mL/
min/1.73m2
( + 3)
7.2.2.3 alpha-glucosidase inhibitors :
acarbose miglitol eGFR 30 mL/min/1.73m2
( 4)
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7.2.2.4 metiglinide (repaglinide) : ( +4)
nateglinide eGFR 30 mL/min/
1.73m2
( 4)
7.2.2.5 thiazolidinedione : ( +2)
Rosiglitazone ( 2)
7.2.3 ( a 2)
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8
8.1 LDL cholesterol 100 mg/dL ( a 3)
70 mg/dL
( c 3)
8.2 statin ( a 2)
8.3 statin ( + 2)
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( a 1)
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10.1
10.1.1 eGFR 30 mL/min/1.73m2 ( 4-5) 0.6 / [4]
( + 2)
10.1.2 eGFR 30 mL/min/1.73m2 ( 1-3) 0.6-0.8 / ( + 2)
10.1.3 (highbiological value protein)
60 ( a 2)
10.2 10.2.1 60 35 /
/ ( a 3)
[4] () = () 100 = () 110
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10.2.2 60 30-35 / / ( a 3)
10.3 ACEI [5]
( a 3)
[5]
(100-200 / 1 ) (250-350 / 1 )
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10.4 100
(2,300 ) ( a 3)
10.5 (body mass index, BMI)
( a 4)
10.6 (serum albumin) 3-6 3.5 g/dL ( a 1)
10.7 (Dietary protein intake) 3-6 normalized protein catabolic rate
(nPNA) [6]
[6] UNA = UUN (g N/day) + NUN (g N/day)
NUN = 0.031 g N x body weight in Kg
PNA = UNA x 6.25
[UNA = urea nitrogen appearance, UUN = 24-hour urinary urea nitrogen (g N/day),
N = nitrogen, NUN = non urea nitrogen (g N/day), PNA = protein equivalent of total
nitrogen appearance (g protein/day)]
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nPNA dietary recall food record ( + 4)
10.8 24 3-6 ( c 3)
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11
11.1 serum calcium (Ca) phosphate (P)
( a 2)
11.1.1 corrected serum Ca 9.0-10.2 mg/dL
11.1.2 serum P 2.7-4.6 mg/dL11.1.3 serum Ca x P 55 (mg/dL)2
11.2 serum P (phosphate binder) ( a 2)
11.3 ( + 2)
11.4 5 (Hyperparathyroidism) (intact parathyroid hormone, iPTH) iPTH 150-300 pg/mL ( + 1)
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12.1 Hemoglobin (Hb) 10.0 g/dL
erythropoiesis stimulating agent (ESA)
( + 2/3)
12.2 ESA Hb 10.0 g/dL serum ferritin 100 ng/mL Transferrin saturation (TSAT) 20% ESA 3 ( a 2)
serum fer-ritin 500 ng/mL
( a 2)
12.3 ESA Hb 10.0g/dL
( a 3)
13.0 g/dL ( a 1)
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13
- ( 22 mmol/L) ( a 3)
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non steroidal anti-inflammatory drugs (NSAIDs) COX2 inhibitors aminoglycosides radiocontrast agents ( b 4)
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15
15.1
(hepatitis B vaccine)
2 3 (0, 1, 6 )
deltoid 1 (anti
HBs
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16.1 (very high risk) ( a 1)
16.2 ( a 3)
16.2.1 (Chest x-ray)16.2.2 (EKG)
16.3 ( a 3)
16.4 ( a 3)
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17
17.1 4 (eGFR < 30 mL/min/
1.73m2)
( + 4)
17.2 4 ( a 4)
17.3 (vascular access) 4 arterio-venous
fistula ( + 3)
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42 ()
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2 12 2552
1 1-4
.. . . . . . ..
3 7-9
. . .. .. ..
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5 12-14
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.. .. .. . .
2 5-6 .. . ... . . .. .
4 10-11
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6 15-17
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3 (eGFR) MDRD( mL/min/1.73m2)
() (mg/dL) 20 30 40 50 60 70 80
0.8 >90 >90 >90 >90 >90 >90 >90
0.9 >90 >90 >90 > 90 >90 89 86
1.0 >90 >90 88 84 81 79 76
1.1 >90 84 79 75 73 70 68
1.2 82 76 71 68 66 64 62
1.3 75 69 65 62 60 58 56
1.4 69 63 60 57 55 53 52
1.5 63 58 55 53 51 49 48
1.6 59 54 51 49 47 46 44
1.7 55 51 48 46 44 43 41
1.8 51 47 45 43 41 40 391.9 48 44 42 40 39 37 36
2.0 46 42 40 38 36 35 34
2.1 43 40 37 36 34 33 32
2.2 41 38 35 34 33 32 31
2.3 39 36 34 32 31 30 29
2.4 37 34 32 31 29 29 28
2.5 35 32 31 29 28 27 27
2.6 34 31 29 28 27 26 25
2.7 32 30 28 27 26 25 24
2.8 31 28 27 26 25 24 23
2.9 30 27 26 25 24 23 22
3.0 28 26 25 24 23 22 22
3.1 27 25 24 23 22 21 21
3.2 26 24 23 22 21 21 203.3 26 24 22 21 20 20 19
3.4 25 23 21 20 20 19 19
3.5 24 22 21 20 19 18 18
3.6 23 21 20 19 18 18 17
3.7 22 21 19 19 18 17 17
3.8 22 20 19 18 17 17 16
3.9 21 19 18 17 17 16 16
4.0 20 19 18 17 16 16 15
4.1 20 18 17 16 16 15 15
4.2 19 18 17 16 15 15 15
4.3 19 17 16 16 15 15 14
4.4 18 17 16 15 15 14 14
4.5 18 16 16 15 14 14 13
4.6 17 16 15 14 14 13 13
4.7 17 16 15 14 14 13 13
4.8 17 15 14 14 13 13 13
4.9 16 15 14 13 13 13 12
5.0 16 15 14 13 13 12 12
5.1 15 14 13 13 12 12 12
5.2 15 14 13 13 12 12 11
5.3 15 14 13 12 12 11 11
5.4 14 13 12 12 11 11 11
5.5 14 13 12 12 11 11 11
5.6 14 13 12 12 11 11 10
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