腎臟疾病的診治進展與臨證經(jīng)驗課件

1、腎臟疾病的診治進展與臨證經(jīng)驗 腎臟疾病的診治進展與臨證經(jīng)驗 腎臟疾病的新分類急性腎臟損傷（Acute Kidney Injuries, AKI）慢性腎臟?。–hronic Kidney Disease, CKD）腎臟疾病的新分類急性腎臟損傷（Acute Kidney InAKI的診斷標準 腎功能在48小時內(nèi)突然降低至少兩次Scr升高絕對值0.3mg/dl（26.5umol/L）Scr較前升高50% 持續(xù)6小時以上尿量0.5ml/kg/h符合下列條件之一：單獨應用尿量的改變作為診斷標準時，需要除外尿路梗阻或其他可導致尿量減少的原因。AKIN Organizing Committee 2005 2

2、005年9月阿姆斯特丹AKI的國際研討會AKI的診斷標準 腎功能在48小時內(nèi)突然降低符合下列條件之AKI的RIFLE分級反映預后AKI的RIFLE分級反映預后AKI合作研討會標準IIIIIIIncreased creatinine x0.5or 0.3mg/dlUO 0.3ml/kg/hx 24 hr or Anuria x 12 hrsUO 0.5ml/kg/hx 12 hrUO 0 .5ml/kg/hx 6 hrIncreased creatinine x2Increase creatinine x3or creatinine 4mg/dlHighSensitivityHighSpecif

3、icity (Acute rise 0.5 mg/dl) 2005年9月阿姆斯特丹AKI的國際研討會AKI合作研討會標準IIIIIIIncreased crea反映預后AKI的改良RIFLE分級 J Himmelfarb. Kidney International (2007) 71, 971976.反映預后AKI的改良RIFLE分級 J HimAKI的RIFLE分期與預后2005年bell等回顧性分析207名CRRT治療的AKI患者首次采用RIFLE分期評價AKI的預后Bell. Nephrol Dial Transplant (2005) 20: 354360RIFL+EAKI的RIFLE

4、分期與預后2005年bell等回顧性分析2尿量能否界定CRRT的介入時機A Randomized Controlled study28例冠脈搭橋術后AKI患者Early group 尿量30ml/h 持續(xù)3h , 14 cases Late group 尿量20ml/h 持續(xù)2h, 14 cases86%14%Early groupLate group Souichi. Hemodialysis International. 2004; 8: 320-325尿量能否界定CRRT的介入時機A Randomized CRIFLE分期與CRRT介入時機 Chih-Chung Shiao. Criti

5、cal Care. 2009, 13:R17125%27%13%RIFLE分期與CRRT介入時機 Chronic kidney disease（CKD）Chronic kidney disease (CKD) is a worldwide public health problem with an increasing incidence and prevalence, poor outcomes, and high cost. Outcomes of CKD include not only kidney failure but also complications of decreased

6、 kidney function and cardiovascular disease.Levey AS, et al. Ann Intern Med. 2003; 139: 137-147. Chronic kidney disease（CKD）ChrNKF. Am J Kidney Dis. 2002; 39: S1-246. NKF. Am J Kidney Dis. 2002; 39Kidney damage Kidney damage is defined as pathologic abnormalities or markers of damage, including abno

7、rmalities in blood or urine tests or imaging studies. Persistent proteinuria is the principal marker of kidney damage.An albumin creatinine ratio greater than 30 mg/g in two of three spot urine specimens is usually considered abnormal. Levey AS, et al. Kidney Int. 2005; 67: 2089-2100. Kidney damage

8、Kidney damage isNKF. Am J Kidney Dis. 2002; 39: S1-246. NKF. Am J Kidney Dis. 2002; 39GFR can be estimated from calibrated serum creatinine and estimating equations, such as the Modification of Diet in Renal Disease (MDRD) Study equation or the Cockcroft-Gault formula. The MDRD formula is recommende

9、d by European and American guidelines for estimating GFR，which has not been fully validated in different populations and at different stages of CKD NKF. Am J Kidney Dis. 2002; 39: S1-246. GFRGFR can be estimated from caliApplication of GFR-estimating equations in Chinese patients with CKDTo evaluate

10、 whether the MDRD equations could be applied accurately to Chinese patients with CKD, GFR estimated by using MDRD equation 7 (7GFR), the abbreviated MDRD equation (aGFR), and the Cockcroft-Gault equation (cGFR) were compared in patients with different stages of CKD.Dual plasma sampling of technetium

11、 Tc 99m-labeled diethylene triamine pentaacetic acid plasma clearance was used as the reference standard GFR (sGFR) for comparison of 7GFRs, aGFRs, and cGFRs at different stages of CKD. The study enrolled 261 patients with CKD, including 146 men and 115 women. All patients were older than 18 years .

12、Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Application of GFR-estimating Comparison of 7GFR with sGFR showed that 7GFR correlated significantly with sGFR, but the regression line was significantly different from the identical lineMDRD Equation 7Abbreviated MDRD EquationC-G Equationb (95% CI)2

13、7.03(22.0032.05)27.73(22.6132.86)21.87(17.5126.24)m (95% CI)0.63(0.570.69)0.64(0.570.70)0.56(0.500.61)r0.780.770.78r20.600.590.61Mean SD (mL/min/1.73 m2)69.7634.1570.7934.7959.6330.15Comparison of Equation-Estimated GFRs With 99mTc-DTPA Plasma ClearanceZuo L, et al. Am J Kidney Dis. 2005; 45(3):463-

14、72.Comparison of 7GFR with sGFR sPerformance of GFR-Estimating Equations: Bias, Precision, and Accuracy MDRD Equation 7Abbreviated MDRD EquationC-G Equationb (95% CI)18.09(11.3924.79)18.07(11.2624.87)15.62(9.6021.64)m (95% CI)0.24(0.320.15)0.22(0.300.13)0.37(0.460.29)r0.320.290.48r20.100.080.23Bias1

15、,182.941,107.742,096.52Precision (mL/min/1.73 m2)98.7791.2391.23Accuracy within 15%36.4034.1030.65Accuracy within 30%60.1558.2457.09Accuracy within 50%74.3374.3380.08The regression line showed that MDRD equation 7 overestimated GFR at low levels and underestimated GFR at near-normal levelsZuo L, et

16、al. Am J Kidney Dis. 2005; 45(3):463-72.Performance of GFR-Estimating Performance of the Abbreviated MDRD Equation in Different Stages of CKD 99mTc-DTPA Plasma Clearance (mL/min/1.73 m2)90aGFR (mL/min/1.73 m2)26.8422.8035.6414.7659.4618.0482.0422.8199.8028.73Median of difference (mL/min/1.73 m2)11.3

17、5*12.00*12.45*5.7514.30*Accuracy within 15%10.3416.6729.0348.2842.48Accuracy within 30%13.7933.3350.0081.0373.17Accuracy within 50%24.1440.0072.5893.1092.68NOTE. Values expressed as mean SD or median of difference (25%, 75% percentile).*P 0.05 comparing estimated GFR with sGFR.P 0.001 comparing accu

18、racies of an equation with those in CKD stages 4 to 5.Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.Performance of the Abbreviated99mTc-DTPA Plasma Clearance (mL/min/1.73 m2)90cGFR (mL/min/1.73 m2)23.9714.9731.0310.1847.2514.0267.6721.2986.3826.26Median of difference (mL/min/1.73 m2)9.97*8.25*1.

19、437.83*29.35*Accuracy within 15%13.7916.6748.3946.5517.07Accuracy within 30%17.2433.3377.4272.4153.66Accuracy within 50%20.6960.0094.8394.8391.46NOTE. Values expressed as mean SD or median of difference (25%, 75% percentile).*P 0.05 comparing estimated GFR with sGFR.P 0.001 comparing accuracies of a

20、n equation with those in CKD stages 4 to 5.P 0.001 comparing accuracies of the C-G equation with those of the MDRD equations.Performance of the C-G Equation in Different Stages of CKD Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.99mTc-DTPA Plasma Clearance (mMDRD equations based on data from Ch

21、inese CKD patientsThe MDRD equation 7 to estimate GFR (7GFR, ml/min per 1.73m2) = 170 Pcr-0.999 age-0.176 BUN-0.170 albumin0.318 0.762 ( if female) 1.211 ( if Chinese) Abbreviated MDRD equation to estimate GFR (aGFR, ml/min per 1.73m2) = 186 Pcr-1.154 age-0.203 0.742 ( if female) 1.233 ( if Chinese)

22、Where Pcr is in mg/dl, BUN is in mg/dl, albumin is in g/dl, and age is in years. Ma et al. J Am Soc Nephrol 2006; 17: 2937MDRD equations based on data Prevalence of chronic kidney disease and decreased kidney function in the adult US population:The prevalence of CKD in the US adult population was 11

23、%CKDSubjects (million)PrevalenceStage(Ccr90ml/min)Stage(Ccr：6089ml/min)Stage(Ccr：3059ml/min)19.2011%5.903.3%5.303.0%Third National Health and Nutrition Examination Survey Stage(Ccr：1529ml/min)Stage(Ccr15ml/min)Total Subjects7.604.3%0.400.2%0.300.2%Coresh J, et al. Am J Kidney Dis. 2003; 41: 1-12. Pr

24、evalence of chronic kidney dChadban SJ, et al. J Am Soc Nephrol. 2003;14(7 Suppl 2):S131-8. Prevalence of kidney damage in Austrinian adults: AusDiab kidney studyApproximately 16.4% have at least one indicator of kidney damage9.7%Renal ImpairmentProteinumia1.1%Hematuria3.7%0.1%0.3%0.6%0.8%11,247 Aus

25、tralians aged 25 yr or over GFR 60 ml/min/1.73m2 （11.2%）Chadban SJ, et al. J Am Soc NeChen J, et al. Kidney Int. 2005; 68(6):2837-45 The overall prevalence of CKD with GFR 60 mL/min/1.73m2 was 2.53%.Prevalence of decreased kidney functionin 15,540 Chinese adults aged 35 to 74 yearsChen J, et al. Kid

26、ney Int. 200Age years Percent (SE)Estimated population (SE)Total2.53 (0.16)11,966,653 (756,537)35440.71 (0.12)1,295,194 (228,878)45541.69 (0.25)2,429,871 (354,784)55643.91 (0.44)3,369,606 (383,422)65748.14 (0.83)4,871,981 (513,043)Chen J, et al. Kidney Int. 2005; 68(6):2837-45. Overall, the age-stan

27、dardized prevalences of GFR 60 to 89, 30 to 59, and 30 mL/min/1.73m2 were 39.4%, 2.4%, and 0.14%, respectively. Age-standardized and age-specific prevalence of decreased kidney function with GFR 60 mL/min/1.73m2 estimated using the simplified MDRD study equation in Chinese adults aged 35 to 74 years

28、Age years Percent (SE)EstimateCommunity-based screening for chronic kidney disease among population older than 40 years in Beijing, China Subjects: 2353 residents older than 40 years.Results: Approximately 11.3% of subjects had at least one indicator of kidney damage.(1).Albuminuria(albumin/creatini

29、ne30mg/g), 6.2%; (2).GFR60ml/min/1.73m2, 5.2%;(3).Hematuria, 0.8%;(4).Non-infective pyuria, 0.09%.Zhang L, et al. Nephrol Dial Transplant. 2007; 22: 1093 Community-based screening for Analysis based on 13,519 renal biopsies in China Cases of renal biopsies performed each yearLi LS, Liu ZH. Kidney In

30、t. 2004; 66(3): 920-3. Analysis based on 13,519 renal*P 0.01; *P 0.001, compared with 1985. Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3. The changing frequency of primary and secondary glomerulonephritis from 1979 to 1999*P 0.01; *P 3mg/dl, N = 607)No. of cases%Primary glomerulaChinese maintenance

31、 dialysis According to the registration of dialysis and transplantation in China in 1999, 41775 patients underwent maintenance dialysis; among them, 89.5% was hemodialysis (HD) and 10.5% was peritoneal dialysis (PD). The first cause of CRF in HD patients was glomerulonephritis (50%), and then diabet

32、ic nephropathy (13.5%), hypertensive nephrosclerosis (8.9%). Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78. Chinese maintenance dialysis AAnnual average incidence of ESRD Prevalence of ESRD Europe 135 new patients per million of population 700 patients per million

33、of population USA 336 new patients per million of population 1403 patients per million of population Annual incidence ofHD PDPrevalence of HD PDShanghai135 20 patientsper million of population180 34 patientsper million of populationThese data showed that the annual incidence rate of dialysis in Shan

34、ghai, China was coincident with the annual average incidence of ESRD in Europe. However, prevalence of dialysis has marked difference between Europe and Shanghai. The financial problem may be the most important cause of the difference formation. Meguid El, et al. Lancet. 2005; 365: 331-340. Shanghai

35、 dialysis and transplantation registration group. Chin J Nephrol. 2001; 17: 83-85. Comparisons of incidence and prevalence of ESRD in developed countries and ChinaAnnual average incidence of ES1658 childhood with CRF in ChinaThe criterion of CRF was creatinine clearance (Ccr) 115 umol/LUP 1.0g/24hGl

36、omerulosclerosis 2 Crescent formationInterstitial injury 2 Risk factors predicting renal Multivarite analysis of influercing factors for hypertension in 540 patients with IgAN Zhuang Y, Chen X, et al. Chin J Intern Med. 2000; 39: 371-375. CharacteristicsOROR 95%CIP valueAge Familial history of HTPro

37、teinuria Serum creatinine Body weightRenal arteriolar lesion1.0486.7321.0181.2681.0292.1931.022-1.0741.662-27.2641.011-1.0251.107-1.4471.006-1.0521.637-2.9380.00010.00750.00010.00040.00920.0001The prevalence of hypertension in IgAN was 39.6% (214/540) at the time of renal biopsy.Multivarite analysis

38、 of influeCharacteristics of tubulointerstitial lesions (TIL) in 609 patients with IgAN Degree and percent of TIL:mild TIL 47.1%, moderate TIL 21.7%, severe TIL 16.6%, Non-TIL 14.6%. Related factors with severity of TIL :hypertension, the level of proteinuria, the scores of vascular lesion,total glo

39、merular lesion, hypercellularity,glomerulosclerosis Zhang Y, Chen X, et al. Chin J Intern Med. 2001; 40: 613-617. Characteristics of tubulointerPrevention of CKD Primary prevention of CKD will rely on controlling the obesity and associated type 2 diabetes as well as hypertension. such as weight redu

40、ction, exercise, and dietary manipulations. Secondary prevention of progression of CKD needs pharmacological approaches. Molich M, et al. J Am Soc Nephrol. 2003; 14: S103107.Appel LJ. J Am Soc Nephrol. 2003; 14: S99102. Moser M. J Clin Hypertens. 2004; 6: S413. Prevention of CKD Primary prevManageme

41、nt of CKDCurrent management options for CKD are based on the control of known risk factors such as hypertension, proteinuria, hyperlipidaemia, and smoking. Control of hypertension is the single most effective intervention. Antihypertensive approaches with inhibitors of ACE or angiotensin-2-receptor

42、blockers have been widely advocated. Control of proteinuria and the inhibition of the rennin-angiotensin system are important factors in slowing the progression of diabetic and non-diabetic CKD. Remuzzi G, et al. Ann Intern Med. 2002; 136: 604615.Gaede P, et al. N Engl J Med. 2003; 348: 383393. Mana

43、gement of CKDCurrent manag我們所面對新的挑戰(zhàn)CVD is an epidemicDiabetes is an epidemicCKD is an epidemicCVD and DM are leading causes of CKDCKD is a risk factor for CVDDialysis is costlyDialysis is life saving我們所面對新的挑戰(zhàn)CVD is an epidemicDi中西醫(yī)治療CKD的現(xiàn)狀分析腎臟病的演變 腎臟病的表現(xiàn) 腎臟病的治療 治療的局限性 早期CKD1期 中期CKD2-3期 中晚期CKD4期 尿毒癥 單純血尿輕度蛋白尿合并高血壓大量蛋白尿 透析腎移植降壓藥糖皮質激素免疫抑制劑西醫(yī)無特殊治療療效有限藥副作用大腎功能不全尿毒癥前期晚期 CKD5期 西醫(yī)無特殊治療低蛋白飲食必需氨基酸 尋找并去除危險因素 治標不治本 器官來源不足醫(yī)療費用高中醫(yī)治療優(yōu)勢 針對血尿蛋白尿治療降低蛋白尿減少副作用延緩腎臟疾病進展推遲進入透析時間,減少醫(yī)療費用中西醫(yī)治療CKD的現(xiàn)狀分析腎臟病的演變 腎臟病的表現(xiàn) 腎臟CKD中醫(yī)治療十法滋養(yǎng)肝腎法 癥屬肝腎陰虛者，或辨證屬氣陰兩虛以陰虛為主者，方選杞菊地黃湯、歸芍地黃湯、一貫煎合二至丸、桑麻丸等加減。稍有乏力者可加太子參；有