106907 高雄市醫師公會
慢性腎臟病診斷與治療上的迷思 黃尚志 高雄醫學大學 醫學系 腎臟照護學系 教授 高醫附設醫院 副院長 內科部主任 台灣腎臟醫學會 CKD防治委員會主委
大綱 台灣末期腎臟病ESRD/慢性腎臟病CKD的重要性 CKD的診斷條件與診斷上應注意的問題 CKD的治療原則與治療上應注意的問題 結語
楔子:政府為什麼要投入某種疾病防治? 國民生命與健康遭受嚴重威脅 急慢性傳染病 慢性病:退化性與代謝性 惡性腫瘤 精神與身心疾病 職業環境疾病
醫療資源與社會經濟遭受嚴重耗損 老衰 器官衰竭維生療法 惡性腫瘤治療 3
Geographic variations in the incidence rate of treated ESRD (per million population/year), by country, 2014
4
USRDS 2016 Annual Data Report, Vol 2, ESRD, Ch 13
Incidence of ESRD
% of diabetic patients
High ESRD incidence and high percentage of diabetic patients in Asian countries
5
USRD, 2016 annual report
Prevalence of ESRD High ESRD incidence and prevalence in Asian countries Differences between developed and developing countries in ESRD treatment acceptance USRD, 2016 annual report
Prevalence of ESRD and Economic Welfare
台灣末期腎病狀況
2014台灣透析現況 I
Tw RDS, 2016 (衛福部國家衛生研究院資料庫)
2014台灣透析現況 II
9
台灣慢性腎臟病流行病學的代表性資料
All-cause mortality attributable to chronic kidney disease: A prospective cohort study based on 462,293 adults in Taiwan Wen CP et al, Lancet 2008
年紀愈大盛行率愈高
約兩百萬人
台灣CKD 第1期至第5期 CKD各期盛行率 三高調查, 溫等人 第1期: 1.3%,
1.0%
第2期: 1.5%,
3.8%
第3期: 7.9%,
6.8%
第4期:
0.4%,
0.2%
第5期: 0.2%,
0.1%
全部:
11.9%
9.8%
世界各國的 報告,CKD 的盛行率約 佔全體人口 之10-14%
健保年度預算與透析支出
%
NHI
ESRD patients
• 透析人口約全人口之0.25% 卻花費6-7% 的醫療總預算 (約350億台幣) • 透析與移植皆屬重大傷病,非但免費又免部分負擔
•無法負擔無限度之透析費用成長 • 必須有政策與行動以降低透析人 數及醫療支出 2016, Tw RDS ADR
透析總額每年 成長率 Year
Dialysis budget Growth rate, %
2003
10.0
2004
8.0
2005
7.8
2006
6.68
2007
2.886
2008
2.886
2009
2.886
2010
2.0
2011
0
2012
0+1%
2013
1+1%
2014
3.7%
2015
3.7%
2016
3.8%
2017
4.0%
台灣慢性腎臟病防治體系的建立與發展
2002 計劃書
台灣CKD防治計畫的推展 腎臟醫學會於衛生署慢性病委 員會(2001)會議提議 國民健康局於2002年開始投 入先導計畫 腎臟醫學會成立CKD防治委員 會(2003) 國民健康局與腎臟醫學會腎臟 保健推廣機構計畫(2003) 健保局Pre-ESRD整體照護計畫 (2007) 健康局、生策會慢性腎臟病防 治科技研究計畫(2008) 健保局初期慢性腎臟病醫療給 付改善方案計畫(2011)
2003~2016
台灣腎臟病防治計畫佈陣圖
台灣CKD 整體照護研究有效性證據 降低病患死亡率 較佳的生活品質 較少的醫療費用 較好的照護品質 較慢的惡化速度
Better Quality, Less Cost Pre-ESRD 計畫全國資料呢?
Nephrology 2010;15:108-115 NDT 2009;24:3426-3433 Nephrology. 2014;19:699-707 NDT 2013.28:671-682 Am J Medicine. 2015;128:68-76
Pre-ESRD 計畫之效益 改善各期pre-ESRD病人 的血壓良好率,對第 五期病人其血比容良 好率也獲得改善。 每年 eGFR ml/min/1.73m2/yr改變 蛋白尿 (-2.93), stage3b (-1.19), stage4 (-1.67), stage5 (-0.86)
降低心臟、中風、周邊 血管併發症的發生 降低透析與死亡的發生 較頻繁的檢驗,並有較 佳的透析準備 降低死亡風險並節省醫 療費用 提升病患遵從性
全民健康保險末期腎臟病前期(Pre-ESRD)之病 人照護與衛教計畫執行成效評估 黃尚志等 M0HW103-NH-1001
增加 DM, Early CKD, and PreESRD program等論質計酬 整合 性照護計畫之涵蓋率
國家衛生研究院
58%
Pre-
55% 51% 50%
41.1% 39% 33.9%
35.1%
38.5%Early
CKD
36.5%
31.2% 29.3%
30% 26.3%
27.6% 29.4%
24.7% 23.2%
26.4%
15.1% 10% 95 2007 96 2006
97 2008
2016, Tw RDS ADR
98 2009
99 100 2010 2011
101 2012
DM
38.5%
102 2014 103 2013
104 2015
101年至105年慢性腎臟病防治及照護品質五年提升計畫 四大目標 降低洗腎之發生率: 新增透析重大傷病領證人數年成長-2%。10年目標為台灣透 析發生率於世界排名前5名之外。 修訂:年齡標準化透析發 生率年成長 -2% 提升腎臟之移植率: 以98年移植率0.50%推估,100年至104年移植人數分別為312 人、319人、326人、333人、及339人。 提升腎臟病患5年之存活率: 透析病患五年存活率高於歐盟3%。20-44歲五年存活率為 88.16%,45-64歲五年存活率為62.1%。 提升腹膜透析之執行率: 以99年Q1腹膜透析人數5,473人推估,三年內腹膜透析人數 占率達15%。100年、101年、102年之腹膜透析人數及占率 分別為7,031人(11%)、8,724人(13%)、10,570人(15%)。 修 訂:55歲以下非糖尿病患者年成長率 1%
Aim 1: Decrease the dialysis incidence rate
2000~2016 Dialysis Incidence Rate in Taiwan 12
Standardared incidence rate: 2007-2016)-0.5% 2012-2016)-0.5% 2014-2016)+0.2%
Crude Incidence rate 2007-2016)+2.2% 2012-2016)+1.4% 2014-2016)+1.6% 408
366
No. x 1000
338 314
6
310
324
311
373
414
439
431
458
455
476 476
450
392
345
330 311
309
307
318
315
323
325
321
330
314
316
317
305
312
307
3
300
150
0
0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 發生數 Numbers
註: 1.透析標準需滿足門診透析連續3個月以上。 2.2016年數據乃推估而來,資料僅供參考。 3.年齡標準化發生率是以WHO 2000年的標準人口為準。
粗發生率 Crude incidence rate
年齡標準化發生率 Standardized incidence rate
2016, Tw RDS ADR
Incidence (per million population)
9
445
600
11
11
Age-specific Dialysis Incidence Rate p.m,p, 3,000
2012-2015: +1.7%/year 2,808
2,675
2,720
2,784
2,693
2,000 1,749 1,734
1,457
1,660
1,688
2012-2015: -1.2%/year 1,592 1,633
1,000 558
502
503
474
491
498
2012-2015: -0.7%/year 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 <40
Aim 1.
40-64
65-74
75+
Decrease dialysis Incidence Rate (Annual growth of agestandardized dialysis incidence rate -2%) Not achieved : 2016 vs. 2015, 2015 vs. 2014ďź&#x161;-1.3%, +2.0%
2016, Tw RDS ADR
2016, Tw RDS ADR
2000~2015 Domestic Kidney Transplantation Rate 360
20 323 302
(276) (281)
(293) 279
254
270 12.0
13.1
)
12.2
11.9
10.9
10 8.5
)
6.7
12.9
11.9
10.4
6.1
15
6.3
90
5
0
0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
資料來源---健保資料庫,(xx): 年度目標數 註: 2016年數據乃推估而來,資料僅供參考。
Aim 2.
移植率 每(百萬人口
移植人數 人(
13.2 12.1
8.9
286 13.8
13.4
180
(299)
(287)
移植率 Transplantation
移植數 Transplant
numbers
rate
Increase the numbers of renal transplantation (annual growth rate 3%) Not achieved: 2016, 2015: Numbers and rates fluctuated not constant
Aim 3. Improve dialysis 5-year survival rate (3% higher than EDTA Registry)
Survival rate for chronic dialysis patients in Taiwan, 2000~2004 1y
2y
3y
5y
10y
HD PD Tx All
%
5y survival rate 2000-2009
ALL
M
F
0-19
20-39
40-64
65-74
75+
Chronic dialysis: undertaking dialysis for at least 3 months
2016, Tw RDS ADR
Dialysis 5-year survival rate (International comparison)
USA Aim 3.
EU
TW
Tw
TW
JP
Improve dialysis 5-year survival rate (3% higher than EDTA Registry) Achieved
2016, Tw RDS ADR
Aim 4. Increase peritoneal dialysis penetration rate (annual growth rate 1% for age less than 55 years and non-diabetes group)
No. and % of Incident PD patients of age <55 and Non-DM 800
40.0 34.8
33.4
34.9 33.7
538
532
人數
400 15.1
361
285
499 444
442 414
401
30.1
523
21.8 19.6
30.0 30.4
492
391
31.0
30.8
600 24.8
31.8
410
426
443 409
377
20.0
(
All incident PD
使 用 腹 膜 透 析 百 分 比 )
%
200
10.0
0
0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 人數
25 註: 2016年數據乃推估而來,資料僅供參考。
佔率
2016, Tw RDS ADR
No. and % of Prevalent PD patients of age <55 and Non-DM 3,000
2,000
30
18.3
19.9
19.0 18.0
18.0
17.8
18.0
20.4
20.8
21.4
21.5
21.1
21.0
21.0
20.8
20.9
18.5
20
人數
佔 率 ( )
%
1,000
10
0
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 人數 佔率
Aim 4. 26
Increase peritoneal dialysis penetration rate (annual growth rate 1% for age less than 55 years and non-diabetes group) Not achieved,: 2016 vs. 2015:20.9%, vs. 20.8% ( +0.1%))(2015 vs. 2014: 20.8%, vs. 21.0% ( -0.2%)) 2016, Tw RDS ADR
本篇對台灣健康政策/疾病預防/疾病治療政策的影響?
大綱 台灣末期腎臟病ESRD/慢性腎臟病CKD的重要性 CKD的診斷條件與診斷上應注意的問題 CKD的治療原則與治療上應注意的問題 AKI急性腎損傷的衝擊 腎臟病防治的未來展望 結語
成人/老年健檢的結果與後續行動 68歲女性,某診所健檢1060321,1060904
用血清肌酸酐(creatinine) 推測腎功能 傳統的定義標準: 正常血清肌酸酐 男性 <1.5 mg/dl 女性 <1.3 mg/dl
GFR與S.Cr並非呈直線關係,而 是曲線,造成臨床誤判 S.Cr由 0.5mg/dl上升至 1.5mg/dl 時,GFR可由100降至50 ml/min 雖已喪失50%腎功能,但不論 病患或醫療人員皆不 知道 老人、女性Scr小於1.3 mg/dl, 但GFR已相當低 每位醫師對Scr的感受性不同判 讀可能產生差異 ESRD
血清肌酸酐值無法正確反映出GFR
n = 53,000
CKD ?
New definition and classification of CKD, 2002, US-NKF Change Scr to estimated GFR and use eGFR equation CKD is defined as kidney damage or eGFR less than 60 ml/min/1.73m2 for more than 3 months Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine and images.
只有eGFR沒有蛋白尿時,不能診斷為CKD,否則 變成全部檢查對象皆是CKD。如同全民皆是CKD
何謂腎絲球濾過率?(狹義的腎功能) Glomerular Filtration Rate, GFR 單位時間內(分鐘)腎動脈內血漿 由腎絲球過濾出之過濾液總量 (每分鐘毫升) 125 ml/min (約180 L/day)
何謂廓清率? Clearance 單位時間內(分鐘)某一物質在流經腎臟 被完全清除時之過濾液總量 (每分鐘毫 升) Inulin clearance菊糖廓清率 肌酸酐廓清率Creatinine Clearance, CCr) Ccr (ml/min)=
Urine creatinine(mg/dl) x Urine volume(ml) Serum creatinine(mg/dl) x Time(min) 正常值: 男性 120 ml/min, 女性 100 ml/min
Measuring GFR Inulin 菊糖
不被再 吸收; 也不被 分泌 尿液
33
完全由 過濾排出
Levey AS et al. Am J Kidney Dis. 2014 May;63(5):820-34
腎功能GFR檢查的種類 以物質廓清率代表GFR 菊糖廓清率(Inulin Clearance) Gold standard method 肌酸酐廓清率(Creatinine Clearance) 尿素氮廓清率(Urea Clearance) 同位素測定法(Isotope method) I125 Iodothalamate clearance Tc99m EDTA plasma clearance Tc99m DTPA image method
以血中尿素氮(BUN)、肌酸酐 (Cr) 、Cystatin C濃度推測GFR 以計算公式推測GFR
「懶惰」的臨床工作者 方便的方法 正確的要求 測定的穩定 長期的比較 便宜的價格 快速的方式 …………………
血清肌酸酐濃度 正常值約0.5~1.5 mg/dl GFR下降時Cr排不出去血 清Cr昇高 食用大量肉類或個人肌肉 量的多寡會影響血清中肌 酸酐的濃度 年紀大肌肉量少Cr應下降 長期肌肉病變血清肌酸酐 下降,但肌肉損壞的初期 血清肌酸酐會昇高 懷孕時GFR上升血清肌酸 酐濃度下降
血清尿素氮濃度 (BUN) 正常值約5~20 mg/dl BUN受許多因素的影響 蛋白質攝取增加時,BUN會 增高 腸道出血時,血液在腸道受 細菌分解,產生NH3經腸肝 循環再代謝成urea,故BUN 上升。 異化作用增加,如感染、服 用Steroid、Tetracycline時皆 會使BUN上升 血液有效循環量減少時例 如,服用利尿劑、心衰竭、 肝硬化、腎病症候群
肌酸酐的來源與代謝 C4N3H7O: MW 113
Cr
肌肉的代謝物 肌肉量多寡影響血清濃度 運動員 vs. 肌肉萎縮者 腎臟排泄 經腎絲球濾過—GFR測量 Proximal tubule S2分泌 高估GFR 藥物由S2分泌與之競爭 Cimetindine的影響 尿中每日肌酸酐排出總量大約為 男性:20-25 mg/kg;女性:1520 mg/kg 測定Ccr必須收集一段時間之尿量
血清肌酸酐的檢驗與分析方法 Alkaline Picrate methods (鹼性苦味肌酐比色法) 測定肌酸酐的方法用Jaffé reaction,使用試劑為 picric acid,經反應後測 其吸光度而換算出濃度。血中存在有些物質為干擾其讀出值,導致測 定值較實際值略微偏高,這些物質稱為non-creatinine chromogens。
Enzymatic methods (酵素反應法) HPLC Procedures (高流速液相層析法) Mass Spectrometry-Based Procedures (質譜分析法) (標準作法) Gas chromatography-Isotope-dilution mass spectrometry (GC-IDMS) Liquid chromatography (LC)-IDMS (<0.2% bias compared to GC-IDMS)
腎絲球過濾率GFR 估算公式 (140-Age)
Bw
Cockcroft-Gault Ccr =
x 0.85 (if female) 72
Cr
Original MDRD-Simplified-GFR (4-variable equation) eGFR = 186 Scr -1.154 x Age -0.203 x 0.742 (if female) x 1.212 (if black) IDMS Traceable MDRD-Simplified-GFR (4-variable equation) eGFR (mL/min/1.73 m2) = 175 x Scr -1.154 x Age -0.203 x 0.742 (if female)
x 1.210 (if African American) Taiwanese GFR equation: ~MDRD x 0.9 (未使用) CKD Epidemiology Collaboration (CKD-EPI)公式 Female Cr ≦ 0.7 eGFR = 144 × (Cr/0.7)-0.329 × (0.993)age Cr > 0.7 eGFR = 144 × (Cr/0.7)-1.209 × (0.993)age Male Cr ≦ 0.9 eGFR = 141 × (Cr/0.9)-0.411 × (0.993)age Cr > 0.9 eGFR = 141 × (Cr/0.9)-1.209 × (0.993)age
何者最適當?
Comparison of Risk Prediction Using the CKD-EPI Equation and the MDRD Study Equation for Estimated Glomerular Filtration Rate (45 cohorts)
39
Taiwanese MDRD equation is better than the MDRD, CKD-EPI, Japanese, Asian, Thai, Taiwanese CKD-EPI, and Taiwanese fourlevel CKD-EPI equations for Taiwanese adults Chen LI et al. PLoS One. 2014 Jun 13;9(6):e99645
TwMDRD=1.309×MDRD0.912
40
TwCKD-Epi=1.262×CKD-EPI0.914
Twfour-level CKD-EPI= 1.205×four-level CKD-EPI0.914
eGFR公式何者較適當? 國外普遍改為CKD-EPI公式 對高GFR(>60)之預估較MDRD公式正確 但是對低GFR (<60)則MDRD較佳
台灣所研發之公式之一會讓eGFR更低,因此若CKD 的定義與分期標準不改,我們的CKD盛行率會更高 MDRD 4-variable公式已推行有年,且建立觀念,要 改會再費一番周章 建議寫論文時用CKD-EPI公式 使用MDRD 4-variable公式於臨床與公衛,無礙事實 判斷與防治工作負擔
門診eGFR計算軟體
y=ax+b a=slope of GFR decline 1y slope=-0.3456 4y slope=-3.4967
手機APP eGFR計算軟體 從APP Store打入 GFR就可搜尋一些 免費GFR計算軟體
如何檢驗出腎臟實質傷害或功能障礙? 傳統組合-基層院所 以尿液常規檢查測蛋白尿、血尿等 血清肌酸酐值—以公式計算eGFR 新的建議組合-醫院、CKD健康促進機構 傳統組合加上以下 將血清肌酸酐值轉化成腎絲球濾過率 (ml/min/1.73m2) 測量 Urine albumin to creatinine ratio (UACR) Microalbuminuria: UACR > 30 mg/gm 測量 Urine total protein to creatinine ratio (UPCR), (如果 已是明顯蛋白尿時) UPCR > 200 mg/gm
Microalbuminuria: an important and sensitive marker of early kidney dysfunction • Albumin is one of the smallest plasma proteins and accounts for ~60% of total plasma protein1 Clinical significance of albuminuria
• Albumin is the first to appear in the urine during kidney dysfunction2 • MAU occurs in the earliest stages of kidney disease and reflects vascular damage3 • MAU can indicate dysfunction, even during early chronic kidney disease (CKD), while eGFR may remain within the normal range2 1. Gekle M. News Physiol Sci. 1998;13:5-11. 2. Levey AS. Ann Intern Med. 2003;139:137-47. 3. Cerasola G, et al. J Hypertens. 2010 Sep 16.
Albuminuria indicates vascular damage at different stages of renal impairment leading to end-organ damage Cardiovascular event
Odds ratio (age and sex adjusted)
* 6
* 4
* 2
Odds ratio (age and sex adjusted)
Renal event
6
4
*
2
0
*
*
0 <15
15-30
30-150 150-300
>300
<15
UAE (mg/24hr)
N n
*
4,132 143
796 42
574 49
15-30
30-150 150-300
>300
UAE (mg/24hr)
51 9
57 13
*P < 0.05 versus patients with a urinary albumin excretion (UAE) 15 mg/day. N = Number of patients with follow-up data available. n = Number of patients with an event. Gansevoort RT, et al. J Am Soc Nephrol. 2009;20(3):465-8.
N n
6,013 252
1,279 121
1,023 150
121 20
134 25
Albuminuria & Proteinuria - A index of renal injury and CKD progression Albuminuria Gold standard 24 hours urine collection (urine albumin, x urine amount)
Clinical practice Morning spot urine, urine albumin and creatinine ratio (ACR) >17 mg/gm in adult males and 25 mg/gm in adult females usually signifies chronic renal damage Microalbuminuria refers to the excretion of amounts of albumin too small to detect by urinary dipstick 24hr (ug/min)
24hr (mg/day)
Spot (ug/mg, mg/g Cr)
Normo
<20
<30
<30
Micro
20-200
30-300
30-300
Marcro
>200
>300
>300
Albuminuria & Proteinuria - A index of renal injury and CKD progression Proteinuria (Overt, Macro-) Use of urine dipstick for proteinuria is convenient, but it needs to be rechecked and confirmed and quantified by Upcr or Uacr. Gold standard 24 hours urine collection (urine total protein x urine amount)
Clinical practice Morning spot urine, urine total protein and creatinine ratio (PCR) > 150 (200) mg/g creatinine usually signifies chronic renal damage If patient already has macroalbuminuria, it is not necessary to check ACR. Check PCR is cheaper.
Urine total protein (mg/dl)/urine Cr (mg/dl) x 1000 = UPCR (mg/g creatinine)
診
eGFR, Albuminuria, Cause
沒有考量蛋白尿時,不能用CKD,只能說eGFR 否則變成全部研究對象皆是CKD。如同全民皆是 CKD。 (Sex vs. Gender)
Impact of CKD criteria on clinical practice “Epidemiology” CKD equation improves systematic error, especially in prevalence of stage 3a general population, and younger subjects. “Patient” in clinic Care based on persistent (≥3m) of low eGFR, Delanaye P et al. Nephrol Dial Transplant. 2013 Jun;28(6):1396-403 proteinuria
Can it be over-diagnosed? (my view point) Aging of kidney with declined eGFR should not be considered as CKD. (Glassock) 50
GFR measured by Cinulin: 95 ml/min, Ccr 85ml/min AKI caused by renal stone obstructing ureter, Use of NSAID, and contrast media A male, born in 1957,BW around 85 Kg Muscular type at youth BMI 29 recently
Is he a case of CKD?
2001/05/31~2016/09/01
The dilemma of CKD diagnosis and its influence + Proteinuria Stage 1, 2
3A
3B
4
5
Tool of GFR measurement-eGFR equation? Underlying causes of Renal diseases
60?
45?
30
15 10? 5? eGFR
The underlying cause of renal disease? The tool of eGFR measurement—which eGFR equation? The need of renal injury marker—Proteinuria, etc The cut point of eGFR for CKD stage 3—Normal or 3A/3B? The true value of eGFR at advanced CKD stage 5—eGFR at dialysis initiation
Dialysis initiation in Taiwan Serum Cr and at initiation of Hemodialysis in Taiwan, (2001-2004, n=25,767)
compared to US (1999-2004).
Tw: n=23,551 BUN: 107 (83.2-135.0)mg/dl Scr: 10.1 (8.2-13.1) mg/dl eGFR: 4.7 (3.6-6.1) Salb: 3.2 (2.8-3.7) g/dl Hct: 24.2 (20.6-27.5) % Median (25th-75th) Hwang SJ et al. NDT, 25:2616-24, 2010
Change of eGFR vs. Change of UPCR eGFR eGFR UPCR + UPCR -
eGFR +
UPCR +
!
eGFR +
UPCR -
ï¼&#x;
eGFR的變化 vs. UPCR的變化 UPCR上升eGFR下降 UPCR 最壞的結果 病情惡化
? eGFR與UPCR皆下降 贏了面子輸了裡子 蛋白尿因GFR下降而 下降 eGFR
! eGFR與UPCR皆上升 腎病症候群 糖尿病超高過濾 高蛋白尿,低血清肌 酸酐
UPCR下降eGFR上升 最佳的結果 病情改善
UPCR上升eGFR下降 最壞的結果 病情惡化 (DM Nephropathy)
Change of UPCR Feb-2009~Feb-2010
Change of eGFR -5.7891/yr Dec-2006~Dec-2010
超高UPCR eGFR快速下降 最壞的結果 快速病情惡化 (DM Nephropathy+DVT)
Change of UPCR Jun-2010~Dec-2010
Change of eGFR -38.0183/yr Nov-2008~Dec-2010
eGFR與UPCR皆下降 贏了面子輸了裡子 蛋白尿因GFR下降而 下降 (DM nephropathy+CHF)
Change of eGFR -7.9903/yr Dec-2003~Dec-2010
Change of UPCR Dec-2003~Dec-2010
Change of UPCR eGFR與UPCR皆下降 贏了面子輸了裡子 蛋白尿因GFR下降而 下降 (DM nephropathy+ESRD)
Change of eGFR -3.9585/yr Jan-2010~Dec-2010
Jan-2010~Dec-2010
UPCR下降eGFR上升 最佳的結果 病情改善 (查無此人) (DM Nephropathy?)
Change of UPCR Feb-2007~Feb-2010
Change of eGFR -0.6234/yr Feb-2007~Dec-2010
Summary-CKD diagnosis concept eGFR equations could influence more on diagnosis and staging of CKD population but less on clinical judgment
Stage of CKD and eGFR cut-off point Necessary change or Unnecessary change? eGFR less than 60, and proteinuria significantly predict adverse events
61
以eGFR下降的斜率評估腎衰竭的進行速度 Slow progression: 900222—991231 Slope: -1.72/ml/min/1.73m2/year Mesangial proliferative GN
Rapid progression: 970101—991231 Slope: -37.96/ml/min/1.73m2/year DM nephropathy + Deep vein thrombosis
eGFR
Upcr: 800-1000 mg/g
Upcr: 10000-15000 mg/g
Date
糖尿病併嚴重蛋白尿病患之eGFR下降十分快速
eGFR slope changes
All: Dec-2004~Dec-2010 -4.6298/yr PI: Dec-2004~Apr-2008 -6.8073/yr PII: Apr -2008~Dec-2010 -1.4116/yr
Period I
Period II
UPCR
PII
Dec-2004~Dec-2010 PI: Dec-2004~Apr-2008 -6.8073/yr
PI PII: Apr -2008~Dec-2010 -1.4116/yr
2001-03-18 2014-03-27
A 55 years old male of CGN maintains a stable eGFR around 10-8 ml/min from Mar. 2001 to Mach 2014 without obvious uremic S/S and no RRT preparation was done.
20010301-20140401
Why not start preparation? No obvious S/S, still working well
2001-04-27 2005-01-18
2010-02 PD Cath. Insertion with subcutaneous bury 2014-02 Initiation of PD
A 55 years old male of CGN+TIN maintains a stable eGFR around 8-4 ml/min from Jan. 2005 to Nov. 2009. PD catheter was inserted and buried in subcutaneous at eGFR of 5, but no initiation of PD until eGFR reached 2.3 with uremic S/S after 4 years of insertion. He is doing well now.
Why not start PD? Job not allowed
2005-01-19
A 64 years old female of CGN?CIN? maintains a stable eGFR around 10-6 ml/min from Jan. 2005 to Jan. 2014, Tx with EPO+Keto analogue until appearance of uremic S/S, and PD catheter insertion with subcutaneous bury was done. Now she is still on conservation treatment only. Why not start PD? No obvious S/S
2014-01 PD cath. Insertion Buried in Subcut.
2001-02-16
Rt Nephrectomy due to Urothelial cancer 2006-07-07
Created AVF and subsequent TACE for HCC Near 3 years ago.
A 70 years old female of DM+CIN+Hepatitis B+LC+HCC maintains a stable eGFR around 5 ml/min from 2007 to 2010. AVF was created for fear of TACE induced eGFR shut down, but it has been near 3 years without HD initiation. Her condition is stable and followed every one to two months with EPO Tx.
Why not start HD? No obvious S/S, Donâ&#x20AC;&#x2122;t want to
Drug influences Scr and eGFR 950117 95-06-26
96-04-11
95-12-27 96-03-21
Medications: 95-01-06~95-12-27 ACEI 95-11-10~95-11-17 NSAID 95-12-18~96-04-30 Cimetidine
A 45 y/o female case of chronic interstitial nephritis with stable renal function for years
甚麼時候/為什麼要轉介病人到腎臟科? AKI or abrupt sustained fall in GFR; GFR < 30 ml/min/1.73 m2 (GFR categories G4-G5)∗; a consistent finding of significant albuminuria (ACR ≥ 300 mg/g [≥ 30 mg/mmol] or AER ≥ 300 mg/24 hours, approximately equivalent to PCR ≥ 500 mg/g [≥50 mg/mmol] or KDIGO 2012 Clinical Practice Guideline PER ≥ 500 mg/24 hours) 轉給腎臟科的好處
Kidney Int Suppl. 3(1):1-150, 2013
減緩腎功能的惡化速度 預防併發症(貧血、電解質異常等) 較好的預後(生存率高、較少住院)
較完整的進入透析前的準備 選擇適當的透析模式 69
做好廔管/導管 Smart NA et al. Am J Med 124(11): 1,073-1,080, 2011; Cochrane Database Syst Rev. 18;6, 2014
CKD自然病程與治療策略 CKD病患治療的目的 阻緩腎功能惡化 處理併發症 防止死亡
併發症
心血管疾病
正常
高風險
CKD危險 因子篩檢
減少CKD 危險因子, 篩檢CKD
傷害
GFR 下降
腎衰竭
診斷與治療, 評估惡化速度 治療合併症, 治療併發症, 阻緩腎病惡化 準備替代療法
死亡
進行腎臟 替代療法
Levey AS et al, Kidney Int 2007
六大CKD照護主軸 慢性腎臟病流行病學、診斷及 惡化因子 慢性腎臟病預防與治療(非藥 物類) 慢性腎臟病預防與治療(藥物 類) 慢性腎臟病合併症之處理 特殊族群之處理 慢性腎臟病轉介與照護 71
增加 DM, Early CKD, and Pre-ESRD program等論質計酬 整合性 照護計畫之涵蓋率—基層醫的角色 58%
Pre-ESRD
55% 51% 50%
41.1% 39% 33.9%
35.1%
38.5% 36.5%
31.2% 29.3%
30% 26.3%
27.6% 29.4%
24.7% 23.2%
26.4%
15.1% 10% 2006 952007
96 2009 2008
2016, Tw RDS ADR
97 2010 2011 982012
99 2014 2013
100 2015
101
DM
38.5%
102
103
104
Early CKD
2017-2021總體目標:
76
腎臟健康促進面-全面預防、積極篩檢 促進腎臟健康,減少腎臟傷害因子,發掘潛在腎臟 病患,積極治療腎臟疾病,減少各種急性與慢性腎 臟疾病之發生率 腎臟病醫療照護面-優質醫療、完整照護 提供優質醫療照護,提升各時期慢性腎臟病(CKD) 醫療照護成果與病人生活品質,穩定與阻緩腎功能 惡化,防止急性腎功能惡化(AKI),防治各種慢性腎 臟病併發症,提升病患生活品質 末期腎臟疾病面-獨立自主、回歸社會 下降或維持非老化因素引起的末期腎臟疾病(ESRD) 發生率與盛行率,穩定透析人數的成長,促進增加 腎臟移植成長,推廣腎臟安寧照護
Conclusion eGFR, Albuminuria, Cause of renal disease should be evaluated in patients with chronic diseases for diagnosis and staging of CKD and define the risk of CKD related complications. The choice of adequate eGFR equation depends on the different situation of each country. To reach a universal consensus on CKD diagnosis based is still undergoing.
Thank you for your attention