肾脏疾病的诊治进展与临证经验ppt课件

1、肾脏疾病的诊治进展与临证阅历肾脏疾病的诊治进展与临证阅历 China-Japan Friendship Hospital, , ChinaLi Ping 肾脏疾病的新分类肾脏疾病的新分类急性肾脏损伤急性肾脏损伤Acute Kidney Injuries, AKI慢性肾脏病慢性肾脏病Chronic Kidney Disease, CKDAKI的诊断规范 肾功能在肾功能在48小时内忽然降低小时内忽然降低至少两次至少两次Scr升高绝对值升高绝对值0.3mg/dl26.5umol/LScr较前升高较前升高50% 继续继续6小时以上尿量小时以上尿量0.5ml/kg/h符合以下条件之一：单独运用尿量的改动

2、作为诊断规范时，需求除外尿路梗阻或其他可导致尿量减少的缘由。AKIN Organizing Committee 2005AKI的RIFLE分级反映预后AKI协作研讨会规范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/dlHighSensitivityHighSpecificit

3、y (Acute rise 0.5 mg/dl)反映预后AKI的改良RIFLE分级 J Himmelfarb. Kidney International (2007) 71, 971976.AKI的RIFLE分期与预后20052005年年bellbell等回想性分析等回想性分析207207名名CRRTCRRT治疗的治疗的AKIAKI患者患者初次采用初次采用RIFLERIFLE分期评价分期评价AKIAKI的预后的预后Bell. Nephrol Dial Transplant (2005) 20: 354360RIFL+E尿量能否界定CRRT的介入时机A Randomized Controlled

4、 study28例冠脉搭桥术后例冠脉搭桥术后AKI患者患者Early group 尿量尿量30ml/h 继续继续3h , 14 cases Late group 尿量尿量20ml/h 继续继续2h, 14 cases86%14%Early groupLate group Souichi. Hemodialysis International. 2004; 8: 320-325RIFLE分期与CRRT介入时机 Chih-Chung Shiao. Critical Care. 2021, 13:R17125%27%13%Chronic kidney diseaseCKD Chronic kidne

5、y 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 kidney function and cardiovascular disease.Levey AS, et al. Ann Intern Med. 2003; : -147

6、. NKF. Am J Kidney Dis. 2002; 39: S1-246. Kidney damage Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Persistent proteinuria is the principal marker of kidney damage.An albumin creatinine ratio greater t

7、han 30 mg/g in two of three spot urine specimens is usually considered abnormal. Levey AS, et al. Kidney Int. 2005; 67: 2089-2100. NKF. Am J Kidney Dis. 2002; 39: S1-246. GFR can be estimated from calibrated serum creatinine and estimating equations, such as the Modification of Diet in Renal Disease

8、 (MDRD) Study equation or the Cockcroft-Gault formula. The MDRD formula is recommended by European and American guidelines for estimating GFR，which has not been fully validated in different populations and at different stages of CKD GFRApplication of GFR-estimating equations in Chinese patients with

9、 CKDTo evaluate 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 samplin

10、g of technetium 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

11、than 18 years .Comparison of 7GFR with sGFR showed that 7GFR correlated significantly with sGFR, but the r e g r e s s i o n l i n e w a s significantly different from the identical lineMDRD Equation 7Abbreviated MDRD EquationC-G Equationb (95% CI)27.03(22.0032.05)27.73(22.6132.86)21.87(17.5126.24)m

12、 (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 ClearancePerformance of GFR-Estimating Equations: Bias, Precision, and Accuracy MDRD Equation 7Abbreviated

13、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)r0.320.290.48r20.100.080.23Bias1,182.941,107.742,096.52Precision (mL/min/1.73 m2)98.7791.2391.23Accuracy within 15%36.4034.1030.65Accuracy within 30%60.1558.2457.0

14、9Accuracy within 50%74.3374.3380.08The regression line showed that MDRD equation 7 overestimated G F R a t l o w l e v e l s a n d underestimated GFR at near-normal levelsPerformance of the Abbreviated MDRD Equation in Different Stages of CKD 99mTc-DTPA Plasma Clearance (mL/min/1.73 m2)90aGFR (mL/mi

15、n/1.73 m2)26.8422.8035.6414.7659.4618.0482.0422.8199.8028.73Median of difference (mL/min/1.73 m2)11.35*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

16、 of difference (25%, 75% percentile).99mTc-DTPA Plasma Clearance (mL/min/1.73 m2) 90 cGFR (mL/min/1.73 m2)23.9714.9731.0310.1847.2514.0267.6721.2986.3826.26 Median of difference (mL/min/1.73 m2)9.97*8.25*1.437.83*29.35* Accuracy within 15%13.7916.6748.3946.5517.07 Accuracy within 30%17.2433.3377.427

17、2.4153.66 Accuracy within 50%20.6960.0094.8394.8391.46 NOTE. 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 an equation with those in CKD stages 4 to 5.P 0.001 comparing accuracies of the C-G equati

18、on with those of the MDRD equations.Performance of the C-G Equation in Different Stages of CKD MDRD equations based on data from Chinese CKD patients The 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)

19、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)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: 2937Prevalence of chronic kidney disease and decre

20、ased kidney function in the adult US population:The prevalence of CKD in the US adult population was 11%19.2011%Third National Health and Nutrition Examination Survey Prevalence of kidney damage in Austrinian adults: AusDiab kidney studyApproximately 16.4% have at least Approximately 16.4% have at l

21、east one indicator of kidney damageone indicator of kidney damage9.7%9.7%Renal ImpairmentRenal ImpairmentProteinumiaProteinumia1.1%1.1%HematuriaHematuria3.7%3.7%0.1%0.1%0.3%0.3%0.6%0.6%0.8%0.8%11,247 Australians aged 25 yr or over GFR 60 ml/min/1.73m2 11.2%The overall prevalence of CKD with GFR 60 m

22、L/min/1.73m2 was 2.53%.Prevalence of decreased kidney functionin 15,540 Chinese adults aged 35 to 74 yearsAge 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

23、(0.83)4,871,981 (513,043)Chen J, et al. Kidney Int. 2005; 68(6):2837-45. Overall, the age-standardized 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

24、.73m2 estimated using the simplified MDRD study equation in Chinese adults aged 35 to 74 yearsCommunity-based screening for chronic kidney disease among population older than 40 years in , China Subjects: 2353 residents older than 40 years. Results: Approximately 11.3% of subjects had at least one i

25、ndicator of kidney damage.(1).Albuminuria(albumin/creatinine30mg/g), 6.2%; (2).GFR60ml/min/1.73m2, 5.2%;(3).Hematuria, 0.8%;(4).Non-infective pyuria, 0.09%.Analysis based on 13,519 renal biopsies in China Cases of renal biopsies performed each year*P 0.01; *P 3mg/dl, N = 607)Chinese maintenance dial

26、ysis uAccording 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). u The first cause of CRF in HD patients was glomerulonephritis (50%), and then diabetic

27、 nephropathy (13.5%), hypertensive nephrosclerosis (8.9%). Annual average incidence of ESRD Prevalence of ESRD Europe 135 new patients per million of population 700 patients per million of population USA 336 new patients per million of population 1403 patients per million of population Annual incide

28、nce 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 Shanghai, China was coincident with the annual average incidence of ESRD in Europe. However, prevalence of dialysis ha

29、s 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 dialysis and transplantation registration group. Chin J Nephrol. 2001; 17: 83-85. Comparisons of incidence and pr

30、evalence of ESRD in developed countries and China1658 childhood with CRF in ChinauThe criterion of CRF was creatinine clearance (Ccr) 115 umol/LUP 1.0g/24hGlomerulosclerosis 2 Crescent formationInterstitial injury 2 Multivarite analysis of influercing factors for hypertension in 540 patients with Ig

31、AN The prevalence of hypertension in IgAN was 39.6% (214/540) at the time of renal biopsy.Characteristics 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

32、 : hypertension, the level of proteinuria, the scores of vascular lesion, total glomerular lesion, hypercellularity, glomerulosclerosis Prevention of CKD Primary prevention of CKD will rely on controlling the obesity and associated type 2 diabetes as well as hypertension. such as weight reduction, e

33、xercise, 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. Management of CKD Current management options f

34、or 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 blockers have been widely advocated.

35、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; : 604615.Gaede P, et al. N Engl J Med. 2003; 348: 383393. 我们所面对新的挑战我们所面对新的挑战CVD is an epidemicDiabetes

36、 is an epidemicCKD is an epidemicCVD and DM are leading causes of CKDCKD is a risk factor for CVDDialysis is costlyDialysis is life saving中中医治疗中中医治疗CKDCKD的现状分析的现状分析肾脏病的演化肾脏病的演化 肾脏病的表现肾脏病的表现 肾脏病的治疗肾脏病的治疗 治疗的局限性治疗的局限性 早期早期CKD1CKD1期期 中期中期CKD2-3CKD2-3期期 中晚期中晚期CKD4CKD4期期 尿毒症尿毒症 单纯血尿单纯血尿轻度蛋白尿轻度蛋白尿合并高血压合并高

37、血压大量蛋白尿大量蛋白尿 透析透析肾移植肾移植降压药降压药糖皮质激素糖皮质激素免疫抑制剂免疫抑制剂中医中医无特殊治疗无特殊治疗疗效有限疗效有限药副作用大药副作用大肾功能不全肾功能不全尿毒症前期尿毒症前期晚期晚期 CKD5CKD5期期 中医中医无特殊治疗无特殊治疗低蛋白饮食低蛋白饮食必需氨基酸必需氨基酸 寻觅并去除寻觅并去除危险要素危险要素 治本不治本治本不治本 器官来源缺乏器官来源缺乏医疗费用高医疗费用高中医治疗优势中医治疗优势 针对血尿针对血尿蛋白尿治疗蛋白尿治疗降低蛋白尿降低蛋白尿减少副作用减少副作用延缓肾脏延缓肾脏疾病进展疾病进展推迟进入透析推迟进入透析时间时间, ,减少医减少医疗费用疗

38、费用CKD中医治疗十法中医治疗十法 滋养肝肾法滋养肝肾法 症属肝肾阴虚者，或辨证属气阴两虚症属肝肾阴虚者，或辨证属气阴两虚以阴虚为主者，方选杞菊地黄汤、归以阴虚为主者，方选杞菊地黄汤、归芍地黄汤、一向煎合二至丸、桑麻丸芍地黄汤、一向煎合二至丸、桑麻丸等加减。稍有乏力者可加太子参；有等加减。稍有乏力者可加太子参；有心悸怔忡者，可合用生脉饮；失眠者心悸怔忡者，可合用生脉饮；失眠者加柏子仁或酸枣仁；口燥咽干甚者加加柏子仁或酸枣仁；口燥咽干甚者加麦冬、五味子等；兼尿频、尿急、尿麦冬、五味子等；兼尿频、尿急、尿热、尿痛者，可用知柏地黄汤加滑石、热、尿痛者，可用知柏地黄汤加滑石、车前子等。车前子等。健脾益

39、肾法健脾益肾法 适用证属脾肾气虚者，方选七味白术散、参苓白适用证属脾肾气虚者，方选七味白术散、参苓白术散加菟丝子、补骨脂；兼自汗者可合用玉屏风术散加菟丝子、补骨脂；兼自汗者可合用玉屏风散；兼腰膝冷痛者加狗脊、川牛膝；兼下肢水肿散；兼腰膝冷痛者加狗脊、川牛膝；兼下肢水肿者，可合用防已地黄汤或防已茯苓汤；兼有纳少者，可合用防已地黄汤或防已茯苓汤；兼有纳少腹胀者可加砂仁、寇仁；兼心悸气促者，可合用腹胀者可加砂仁、寇仁；兼心悸气促者，可合用苓桂术甘汤等、葶苈大枣泻肺汤等。苓桂术甘汤等、葶苈大枣泻肺汤等。 益气养阴法益气养阴法 方选参芪地黄汤为主，兼下肢肿加车前子、冬葵方选参芪地黄汤为主，兼下肢肿加车前子、冬葵子、冬瓜皮、抽葫芦、防己；兼湿热者加白花蛇子、冬瓜皮、抽葫芦、防己；兼湿热者加白花蛇舌草、石苇、；兼瘀血者加丹参、泽兰、红花；舌草、石苇、；兼瘀血者加丹参、泽兰、红花；兼气滞者加广木香、槟榔、陈皮、大腹皮；气虚兼气滞者加广木香、槟榔、陈皮、大腹皮；气虚明显参与红参另煎兑服；阴虚明显加黄芪、石斛；明显参与红参另煎兑服；阴虚明显加黄芪、石斛；兼阳虚加仙茅、仙灵脾等；兼浊毒者参与生大黄，兼阳虚加仙茅、仙灵脾等；兼浊毒者参与生大黄，或加用大黄灌肠；有痈疽者加金银花、蒲公英、或加用大黄灌肠；有痈疽者加金银花、蒲公英、野菊花、天葵子、败酱草等；尿中有酮体加黄芩、野菊花、天葵子、