ดาวน์โหลดเอกสาร

20/08/57
Chronic Kidney Disease:
Overview
Scope
• Burden of CKD
• How to assess renal function
• Progressive renal dysfunction
– Underlying conditions
– Risk factors/Marker
– Renal fibrosing
• Management
– Life style modification
– Control of underlying conditions
– Stabilize/Reverse Renal fibrosing
Dhavee Sirivongs, M.D.
• CKD clinic: it works? worth ?
Division of Nephrology Department of Medicine Khon Kaen University
August 21, 2014
CKD defined by NKF/KDOQI
Kidney Damage Criteria
• Kidney damage for > 3 months: structural/ functional
abnormalities of the kidney, manifested by:
– Pathological abnormalities or
– Markers of kidney damage, including abnormalities in
blood/urine/imaging tests
GFR Criteria
• GFR < 60 ml/min/1.73 m2 for > 3 months, with or without
kidney damage
Chronic Kidney Disease: Staging
Stage Description
G
1
Kidney damage with
GFR
(ml/min/1.73m2)
3
>90
normal or increase GFR
Kidney damage with
60-89
mild decrease GFR
Moderate decrease GFR 30-59
4
Severe decrease GFR
15-29
5
Kidney failure
<15 or dialysis
2
A 45-59
B 30-44
Am J Kidney Dis,39:S1-246.2002
CKD III-V : Prtevalence (%)
using serum bank from the 3rd National
Prevalence of CKD 3-5 using serum bank
from the 3rd National health survey of
health survey of Thailand 2003-2004
Thailand 2003-2004
Prevalence of CKD (age>15 yr) 4.69 %
–
–
–
CKD III
CKD IV
CKD V
4.47%
0.11 %
0.11 %
%
%
39.56
40
5.15
5
35
30
4
25
3
20
12.84
15
1.7
1.64
15-29
30-44
3.71
3.18
2.94
2
10
5
6
6
1
0
0
45-59
60+
Age
Bangkok
Central
North
Northeast
South
Region
Ong-Aj-Yooth L et al. 2007
Ong-Aj-Yooth L et al. 2007
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Prevalence of CKD 3-5 in Thailand
Risk Factors of CKD: Adjusted Odds Ratios
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
2.99
1.21
1.22
1.08
1.1
Ru
ra
l
To
BM
ta
I
lc
ho
le
st
er
ol
be
te
s
Hy
pe
r te
ns
io
n
Sm
ok
in
g
Di
a
pe
r1
0
Se
x
0.34
Ag
e
Third National Health And Nutrition Examination Survey
Stage
1
2
3
4
5
TOTAL
1.82
1.62
ye
ar
OR
PREVALENCE OF CKD IN USA: (NHANES III)
eGFR
Prevalence
>90 +Up
3.3%
60-89 +Up
3.0%
30-59
4.3%
15-29
0.2%
<15
0.2%
11.0%
Coresh J et al., Am J Kidney Dis, 2003;41:1-12
Thai Prevalence
3.3 %
5.7 %
4.47% 7.6 %
0.11% 1.1 %
0.11%
Ong-Aj-Yooth L et al. 2007
Thai SEEK project 2008
Ong-Aj-Yooth L et al. 2007
CVD events (per 100 pt.yr) increased
with progressive renal dysfunction
Why Prevalence
so different
CKD III >>>>> CKD IV, V
7.6 %
1.1 %
40
36.6
Age-Standardized Rate of Cardiovascular
Events (per 100 person-yr)
35
30
25
21.8
20
15
11.29
10
High mortality:
CKD; Hi-prevalence in elderly
High incidence of CVD
5
2.11
3.65
0
60
>≥60
45-59
45-59
30-44
30-44
15-29
15-29
15
<< 15
Estimated GFR (mL/min/1.73 m2)
N Engl J Med 2004; 351: 1296–305
Longitudinal Follow-up and Outcomes Among
a Population With CKD Study: end point about 5 1/2 years
Endpoints (%)
GFR 60-89
no proteinuria
(n = 14202)
Stage 2
Stage 3
GFR60-89; GFR30-59
proteinuria (n= 11278)
(n = 1741)
Cardiac death prevention
Stage 4
GFR15-29
(n = 777)
Disenrolled from
plan
14.9
16.2
10.3
6.6
Died before RRT
10.2
19.5
24.3
45.7
Received KT
0.01
0.2
0.2
2.3
Initiated dialysis
0.06
0.9
1.1
17.6
To control
- Hypertension
- Anemia
- Dyslipidemia
- Vascular calcification
Keith D, et al. Arch Intern Med. 2004;164:659-63
Nelson RG, Pettitt DJ, Carraher MJ, Baird HR and Knowler WC. Diabetes. 1988;37::1499-504.
Freedman BI and DuBose Jr TD. Arch Inter Med 2007; 167(11):1113 - 5.
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To detect the cases (ASN 2003)
1. BP
2. UA
3. Serum Cr
Screening in general population
is not cost-effectiveness
The modification of diet in renal
disease (MDRD): GFR calculation
MDRD 7
eGFR (mL/min/1.73 m2) =
170 x Cr (mg/dL)-0.999 x age-0.176 x BUN(mg/dL)-0.170 x Alb
(g/dL)+0.318 x (0.762 if female) x (1.18 if black)
MDRD Abbreviation
eGFR (mL/min/1.73m2) = 186.3 x [Cr]-1.154 x Age-0.203
(x 0.742 if female)
How to assess renal function
(GFR) in clinical practice
• CCr/BSA: 24 hour urine collection
• eGFR: Cockcroft & Gault formula
• eGFR: MDRD 7 & abbreviated formula
EPI-CKD
How kidney function deteriorates to ESRD
Normal kidney
Kidney injury
(temporary/permanent)
Kidney dysfunction
DM, Ht, GN, drugs
Proteinuria ?
Kidney damage &
abnormalities detected
CKD III-IV
Causes/Risk
Proteinuria ?
Progressive kidney
deterioration even
no active disease
Ht, smoking,
drugs, Hi-salt,
Hi-protein intake
dyslipidemia
Ht, smoking,
drugs, Hi-salt,
Hi-protein intake
dyslipidemia
CKD V (ESRD)
New formula: Epi-CKD
Objectives of Clinical Evaluation
Establishing that there is CKD
Defining the likely etiology
Determining occurrence/presence of
complications
Assessing prognosis and survival
Clinical Evaluation: Hx & Examination
 Polyuria & Nocturia
 Frothiness of urine
 Oliguria ?
 Symptoms of prostatism
 Features of uremia (Stage V)
 Use of NSAIDs, Hg containing creams/soaps, other
drugs, local herbs
 Past Medical Hx – HT, DM, Body Swelling etc.
 Family Hx – Renal Disease, stone
 Social Hx – Alcohol, Smoking
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Clinical Evaluation – Hx & Examination
Presence of HT
Presence of Edema
Presence of Pallor
Presence of Uremic features
Presence of heart disease
Presence of retinopathy
Investigations
 Blood
 Chemistry




 Hemogram
• Education & Life style modification
• Control of underlying conditions/Risk factors
• Stabilize/Reverse Renal fibrosing
CKD IV
• Treat the complications
• Prepare for dialysis
CKD V
• Pre-dialysis care
• RRT




Plain KUB
U/S KUB
CXR
Echocardiogram
 ECG
 CBC
 Serology
 Clotting profile
 Kidney Biopsy
 Urine
 Urinalysis
 24 hour profile
Management
CKD I-III
 Imaging
BUN, Cr
FBS (HbA1c)
Ca, P
Alb, Chol, lipid profile
Management
CKD I-III
• Education & Life style modification
• Control of underlying conditions/Risk factors
• Stabilize/Reverse Renal fibrosing
CKD IV
• Treat the complications
• Prepare for dialysis
CKD V
• Pre-dialysis care
• RRT
Life style modification
•
•
•
•
•
•
•
•
•
Smoking*
Avoid NSAIDs*
Adequate fluid intake*
Low salt intake
Protein restriction
Exercise
Weight control
Proper stress coping up
(Lipid restriction)
Adequate
Fluid Intake
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20/08/57
How much ?
Water consumption:
drinking water *
1.5 - 2.5 L per day
water in food
0.5 - 0.9 L per day
water (food metabolism) 0.3 - 0.6 L per day
Water disposal:
respiration
0.5 L per day
sweating
0.9 L per day
If drink too little
(more in hot weather)
urine
1.5 L per day >>> Oliguria
>> Constipation
feces
0.1 L per day
ดื่มน้ าชื่นใจ
ไตพลอยแข็งแรง
Recommendation: Ample Fluid Intake
• Drink at least eight 8-ounce servings
of water each day
• Don’t wait until you’re thirsty to
drink water
• Drink water throughout the day
Low Salt Intake
How much sodium is OK ?
• For most healthy people, the recommended
intake of sodium is < 2,400 mg/day
~
one teaspoon of salt (5 gm)
• Salt intake of Thai people ~ 8-10 gm/day
High salt intake may induce progression of
CKD via increased BP and proteinuria
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Salt intake
โซเดียม
(มก.)
โซเดียม
(mEq)
2
786.3
34.18
ปริ มาณที่ต่ามาก ผู้ป่วยมักรับไม่ได้
4
1572.6
68.37
JNC VII แนะนาสาหรับผู้ป่วยความดันโลหิตสูง
(ควรแนะนาให้ กับผู้ป่วย CKD กรณีไม่ มีข้อห้ าม)
5
1965.8
85.47
แนวปฏิบตั ิของยุโรป 2007 แนะนา in case Ht
6
2358.9
102.54
แนะนาให้ คนทั่วไปที่ไม่ มีความดันโลหิตสูง
8
3145.2
136.74
ปริ มาณต่าเล็กน้ อยซึง่ ไม่ค่อยได้ ประโยชน์ในทางคลินิก
10
3931.6
170.94
ปริ มาณเกลือที่คนทัว่ ไปได้ รับในปั จจุบนั
เกลือแกง
(กรัม)
หมายเหตุ
กินจืด ยืดอายุขยั
Protein intake Vs. ESRD /death rate
Cumulative incidence of RF/Daeth
Protein restriction
> 0.75 g/Kg/d
month
Levey AS et al. AJKD 2006
Tips about protein restriction
• Regular Thai food is OK
• Avoidance of occasional protein load
• Control total amount of food in a meal
Control of underlying
conditions/Risk factors
• Treat
– DM (Hba1c < 7%)
– Ht (Target BP: 125/75 – 130/80)
– Stone etc.
• Control dyslipidemia: Statin
• Get rid of proteinuira: ACE-I/ARBs
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Major mechanisms on
controlling proteinuria
• Reduced Intraglomerular pressure
Systemic AII controlled by ACE-I & ARB
• Reduced renal fibrosing (Local AII)
controlled by ARB
• Target proteinuria: < 1 gm/day
with stabilized GFR
Insight on CKD management
•
•
•
•
•
•
•
Successful therapy accounts on
• Patient education
• Life style modification
–
–
–
–
–
Adequate fluid intake
Low salt low protein
Ample amount of water intake
No smoking
Cope-up to stress
• Underlying disease: controlled DM & HT
• Specific drug: ACE-I, ARB
• Regular monitoring
ทางเลือกที่ตอ้ งแจ้งผูป้ ่ วยโรคไตเรื้ อรัง
ล้างไตทางช่องท้อง ฟอกเลือด ปลูกถ่ายไต เสี ยชีวติ
•
•
•
•
•
•
•
CKD is quite common than expected
High cardiovascular mortality
Life style modification is very important
Early detection of CKD and care
Should push effort on CKD I-III
RAS blockage is essential on renoprotection
Regular monitoring
สิ่ งที่ตอ้ งบอกผูป้ ่ วยที่เป็ นโรคไตเรื้ อรัง
จะต้องดูแลตนเอง ดังนี้
กินยาอย่างน้อย 5 ขนาน
จากัดการกินเนื้ อสัตว์
งดอาหารเค็ม ไม่เติมเครื่ องปรุ งรส
ดื่มน้ าตามที่แพทย์แนะนา (บวมต้องจากัดน้ า)
จากัดผลไม้
งดอาหารนม ถัว่ ต่างๆ
อื่นๆ อีกมาก ถ้าต้องบาบัดทดแทนไต
ผูป้ ่ วยต้องการความรู้ในการดูแลตนเอง
เป็ รหน้าที่ของบุคลากรทางการแพทย์ที่จะต้องให้
ความรู้และสนับสนุนผูป้ ่ วยให้ดูแลตนเอง
(Self management)
โรคไตเรื้อรั ง
ไม่ มีทางหาย
7

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