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만성콩팥병   경희대 병원 신장내과 정경환 만성콩팥병   경희대 병원 신장내과 정경환

만성콩팥병 경희대 병원 신장내과 정경환 - PowerPoint Presentation

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만성콩팥병 경희대 병원 신장내과 정경환 - PPT Presentation

2002 증례 1 40 세 남성이 건강검진상 신장이상으로 왔다 환자는 수년전 부터 소변 검사상 혈뇨와 단백뇨가 있었다고 한다 혈압은 13080mmHg ID: 675323

kdigo ckd evaluation gfr ckd kdigo gfr evaluation kidney guideline 150 int 2013 management abnormalities risk suggest recommend phosphate

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Slide1

만성콩팥병

경희대 병원 신장내과 정경환Slide2

2002Slide3

증례 1

40

세 남성이 건강검진상 신장이상으로 왔다

. 환자는 수년전 부터 소변 검사상 혈뇨와 단백뇨가 있었다고 한다

. 혈압은 130/80mmHg, 몸무게는 72kg이었고 검사결과 다음과 같다.

혈액

: BUN/Cr 28/2.0 mg/dl

소변

: ACR 500mg/g, RBC many/HPFSlide4

환자의 만성콩팥병 병기

?

1) 1기 2) 2

기 3) 3기 4) 4기 5) 5기 Slide5

증례 요약

CKD is defined as abnormalities of

kidney structure or function

,

present for ≥3 months, with implications for health

Cockcroft-Gault equation 

              (140 - age)  x  lean body weight [kg]

CCr (mL/min)    =    -------------------------------------------- (

여성

,

X 0.85)

                                          Cr [mg/dL]  x  72

NKF KDOQI CKD guideline 2002, Am

J Kidney Dis 2002; 39:S1Slide6

Definition of CKD

CKD

is defined as abnormalities of

kidney structure or function, present

for ≥3 months, with implications for health

KDIGO

Guideline for the Evaluation and Management of CKD

Kidney

Int

2013;

3 : 1-150Slide7

NKF KDOQI CKD Classification

Am J Kidney Dis 2002; 39:S1

30

90

60

15Slide8

KDIGO staging of CKD

1.2.1: We recommend that CKD is classified

based on

cause, GFR category and albuminuria category

(CGA) (1B)1.2.2: Assign cause of CKD based on presence or absence

of systemic disease and the location

within

the

kidney of observed or presumed

pathologic,

anatomic findings

. (Not graded)Slide9

KDIGO revised classification based upon glomerular filtration rate and albuminuria

GFR stages

GFR

(mL/min/1.73 m

2)TermsG1

>90

Normal or high

G2

60 to 89

Mildly decreased

G3a

45 to 59

Mildly to moderately decreased

G3b

30 to 44Moderately to severely decreasedG415 to 29Severely decreasedG5<15Kidney failure (add D if treated by dialysis)Albuminuria stagesAER(mg/day)TermsA1<30Normal to mildly increased (may be subdivided for risk prediction)A230 to 300Moderately increased

A3

>300

Severely increased (may be subdivided into nephrotic

and

non-nephrotic for differential diagnosis,

management

, and risk prediction)Slide10

Staging of CKD

Kidney

Int

2013; 3 : 1-150Slide11

Rationale for GFR categories

New

Engl

J Med 2004; 351:1296Slide12

Evaluation of CKD: GFR1.4.3.1: We recommend using

serum creatinine and a

GFR

estimating equation for initial assessment. (1A)

1.4.3.2: We suggest using additional tests (such as cystatin C or a clearance measurement) for confirmatory testing in specific circumstances

when

eGFR

based on

serum creatinine

is less accurate. (2B)

1.4.3.3: We recommend that clinicians (1B):

use a GFR estimating equation to derive GFR from serum creatinine (eGFRcreat) rather than relying on the serum creatinine concentration alone • understand clinical settings in which eGFRcreat is less accurate KDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150Slide13

Creatinine Based eGFR

Cockcroft-Gault equation 

              (140 - age)  x  lean body weight [kg]

CCr

(mL/min)    =    -------------------------------------------- (여성, X 0.85)                                           Cr [mg/dL

]  x  72 Slide14

CKD-EPI and MDRD study equations

Ann Intern Med 2009; 150: 604Slide15

Evaluation of CKD: albuminuria

1.4.4.1: We suggest using the following measurements

for initial testing

of proteinuria (early morning urine sample is preferred

) (2B);1) urine albumin-to-creatinine ratio (ACR);2) urine protein-to-creatinine ratio (PCR);3) reagent strip urinalysis for total protein with automated reading;4) reagent strip urinalysis for total protein

with manual reading

1.4.4.3:

Confirm

reagent strip positive

albuminuria and

proteinuria by

quantitative

laboratory measurement and express as a ratio to creatinine wherever possible. Confirm ACR ≥ 30 mg/g (≥ 3 mg/mmol) on a random untimed urine with a subsequent early morning urine sample If a more accurate estimate, measure albumin excretion rate or total protein excretion rate in a timed urine sample KDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150Slide16
Slide17

Etiology

신대체

요법 현황

2015,

신장학회Slide18

증례 2

50

세 남자가 신기능 이상으로 왔다

. 혈압은

160/90 mmHg 였고, 검사 결과 다음과 같다.

혈액

:

Hb

10.0 g/dl, Creatinine 2.5 mg/dl

Na/K 139/6.0

mEq

/L, HCO

3

-

13 mEq/L Ca/P 10/6.0 mg/dl 소변 : ACR 500 mg/g Slide19

환자의 치료로 맞는 것은?

1)

혈압은 120/70 mmHg 로 유지한다

2) Hb 은 13g/dl이상으로 유지한다 3)

경구용

Bicarbonate

를 투여한다

4)

알루미늄 인

결합제를

투여한다

5) 단백질 2g/kg/day, 염분 8 g/day로 식이조절한다Slide20

증례 요약

Treatment

Goal of CKDBP: CKD+단백뇨

130/80mmHg혈당: DM CKD HbA1c 7.0%Acidosis: HCO3- 22 mEq/L

(20-23)

Diet:

protein 0.8g/kg/day, salt intake to <2 g/day

sodium

KDIGO

Guideline for the Evaluation and Management of CKD

Kidney

Int

2013; 3 : 1-150Slide21

Prevention of CKD progression

Traditional

혈압 조절

혈당 조절 단백뇨 조절 (ACE inhibitor, ARB)Beneficial

단백제한 Hyperlipidemia 조절금연 그밖에 anemia, acidosis, CKD-MBD 조절 Slide22

Blood pressure target in CKD

Guideline

Condition

Goal BP

Drug

JNC8 (2014)

DM

<140/90

Thiazide,

ACEi

or ARB, CCB

CKD

<140/90

ACEi or ARB ESH/ESC (2013) DM<140/90ACEi or ARB CKD, no 단백뇨<140/90ACEi or ARB CKD + 단백뇨<130/80ACEi or ARB

KDIGO

(2012)

CKD ,

no

단백뇨

<140/90

ACEi

or ARB

CKD +

단백뇨

(>30mg/g ACR)

<130/80ACEi or ARB Harrison 19thCKD + 단백뇨 (>1g/day)<130/80ACEi or ARB Slide23

BP and RAAS interruption

3.1.4: We recommend that in

both diabetic and

non-diabetic adults with CKD

and urine albumin excretion <30 mg/24 hours (or equivalent) whose office BP ≤ 140/90

mmHg (1B)

3.1.5: We suggest that in

both diabetic and non-diabetic adults

with CKD

and

with urine albumin

excretion of ≥

30 mg/24 hours (or equivalent) whose office BP ≤ 130/80 mm Hg (2D)3.1.6: We suggest that an ARB or ACE-I be used in diabetic adults with CKD and urine albumin excretion 30–300 mg/24 hours (or equivalent). (2D)3.1.7: We recommend that an ARB or ACE-I be used in both diabetic and non-diabetic adults with CKD and urine albumin excretion ≥ 300 mg/24 hours (or equivalent). (1B)3.1.8: There is insufficient evidence to recommend combining an ACE-I with

ARBs

to prevent

progression of CKD

(Not Graded)

KDIGO

Guideline for the Evaluation and Management of CKD

Kidney

Int

2013; 3 : 1-150Slide24

Glycemic Control in CKD

3.1.15: We recommend a target hemoglobin A1c (HbA1c

) ~ 7.0

% to prevent

or delay progression of the microvascular complications of diabetes, including diabetic kidney disease. (1A)3.1.16: We recommend not treating to an

HbA1c target

of <7.0%

risk of hypoglycemia

. (1B)

3.1.17: We suggest that target HbA1c be

extended above

7.0%

with

comorbidities or limited life expectancy and risk of hypoglycemia (2C) KDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150Slide25

Protein, Salt intake 3.1.13: We suggest lowering protein intake to

0.8g/kg/day in adults with diabetes (2C) or without

diabetes (2B) and GFR <30 ml/min/1.73 m2 3.1.14: We suggest avoiding high protein intake

(>1.3g/kg/day

) in adults with CKD at risk of

progression

. (2C

)

3.1.19: We recommend lowering salt intake to <

2 g

/day sodium (5g/day sodium chloride) in adults, unless contraindicated (CKD). (1C) KDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150Slide26

Acidosis3.4.1: We suggest that in people with CKD and serum

bicarbonate concentrations <22

mmol/l (20-23) treatment with oral

bicarbonate supplementation be given to maintain normal range (2B)Alkali

supply

Metabolic acidosis

에 의한

catabolic status

를 개선하여

CKD progression

slow Harrison 19thKDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150 Slide27

증례 3

투석을 받는 50세 여자.

환자는 EPO 를 투여 받고 있었으며 검사 결과 다음과 같다.

Hb

8 g/dl,

Hct

27%

ferritin 90

ug

/L, transferrin saturation 15% Slide28

적절한 조치는? 1) EPO

항체 검사

2)

수혈3) 골수 검사

4) IV iron 5) 경과 관찰 Slide29

증례 요약 Anemia investigation: CBC/DC, reticulocyte, ferritin, TSAT, VitB12, FolateHb

Target

: 10-11.5 g/dl (

harrison), <13 g/dl (KDIGO)Iron supply: TSAT ≤30% & ferritin ≤500 ng/ml (≤500 µg/l)

KDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150Slide30

Cause of anemia

Harrison

19thSlide31

Investigation of AnemiaIn

patients with CKD and anemia (regardless of age and CKD stage), include the following tests in initial evaluation of the anemia (Not Graded):

Complete

blood count (CBC), which should include Hb

concentration, red cell indices, white blood cell count and differential, and platelet count Absolute reticulocyte count

Serum

ferritin level

Serum

transferrin saturation (TSAT)

Serum

vitamin B12 and folate levels Slide32

Treatment of AnemiaRecombinant human

ESA

(Erythropoiesis-stimulating agent)

Iron supply: TSAT ≤30% & ferritin ≤

500 ng/ml (≤500 µg/l) 투석전, 복막투석 경구 투여, 위장장애

,

혈액

투석시

IV

Vit

B12, folate

Resistant to ESA: inflammation, inadequate dialysis, severe hyperparathyroidism, blood loss, hemolysis,

infection, malignancy

Target: 10-11.5 g/dl (harrison), <13 g/dl (KDIGO)Slide33

증례 4

혈액 투석 중인

65

세 여자. 혈액 검사 결과 다음과 같다.

환자는 Calcitriol, Calcium acetate 를 복용하고 있었다.

BUN/Cr 70/6

.5 mg/dl,

Ca/P 11.5/6.0 mg/dl

PTH 450

pg

/mLSlide34

변경 가능한 약제는? 1) Cinacalcet

2)

Paricalcitol

3) Calcium carbonate 4) Parathyroidectomy

5) Calcium gluconate Slide35

증례 요약 Secondary Hyperparathyroidism

의 치료

- Prevention: control of hyperphosphatemia

- Phosphate binder : Calcium based, non-calcium based

- Active vitamin D - Calcitriol ↑absorption of Ca & P, Paricalcitol - Calcimimetics

(

Cinacalcet

):

Ca

에 대한

sensitivity

높임Slide36

Definition of CKD-MBD

A

systemic disorder of mineral and

bone metabolism due to CKD one or a combination of the following:

- Abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism - Abnormalities in bone turnover,

mineralization

, volume, linear growth,

or strength

- Vascular

or other soft-tissue

calcification

Adapted with permission from Moe et al.KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD)Kidney Int 2009: 76 (Suppl 113)Slide37

Mineral metabolism abnormalities

Abnormalities of

Ca

, P, PTH, or

Vit.D metabolism

Harrison 18

th

Harrison 19

th

Fig 333e-2Slide38

Mineral metabolism abnormalities

FGF-23

Family of

phosphatonin, osteocyte 에서

secretionIncrease early in the course CKDincrease renal phosphate excretionStimulate PTHSuppression of 1,25 (OH)2D3

Independent risk factor of LVH, mortality

FGF-23

증가시

therapeutic Ix

Harrison 19

th

p1815 Slide39

Mineral metabolism abnormalities

3.3.1: We recommend measuring serum levels of

calcium

, phosphate, PTH, and alkaline phosphatase activity at least once in adults with GFR

< 45ml/min/1.73 m2 (GFR categories G3b-G5) in order to determine baseline values and inform prediction equations if used. (1C)

3.3.3: In people with GFR <45ml/min/1.73m

2

(GFR categories G3b-G5), we suggest maintaining

serum phosphate concentrations in the normal range

according to local laboratory reference values. (2C)

3.3.4

: In people with GFR <45ml/min/1.73m

2

(GFR categories G3b-G5) the

optimal PTH level is not known. We suggest that people with levels of intact PTH above the upper normal limit of the assay are first evaluated for hyperphosphatemia, hypocalcemia, and vitamin D deficiency. (2C) KDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150Slide40

Mineral metabolism abnormalities

K/DOQI™ Clinical Practice

Guidelines on

Bone Metabolism Target LevelsSlide41

Treatment Mineral metabolism abnormalities

Hyperphosphatemia

Tx

.

- Aluminum-containing phosphate binders : excellent phosphate binding capacity and low

cost

:

aluminum

accumulation

osteomalacia

& encephalopathy

-

Ca-containing phosphate binders : slightly lower phosphate-binding capacity : cost-effective, no risk of aluminum accumulation : increased Ca loading (hypercalcemia)  excessive inhibition of

PTH

adynamic

bone disease

: vascular calcificationSlide42

Treatment Mineral metabolism abnormalities

Hyperphosphatemia

Tx

.

- non Ca-based phosphate binders :

Sevelamer

hydrochloride/Lanthanum carbonate

:

relatively low

phosphate

binding capacity and high

price

Secondary Hyperparathyroidism

Tx. - Prevention: control of hyperphosphatemia - Phosphate binder - Calcitriol : ↑absorption of Ca & P - Paricalcitol : less hyper Ca - Calcimimetics (Cinacalcet): target Ca sensing receptor, Ca에 대한 sensitivity를 높여줌 Slide43

Bone abnormalities

High-turnover bone diseases

- Osteitis

fibrosa

cystica :↑P, ↓Ca, ↑PTH, ↓calcitriol

: Osteoblast,

osteoclast ↑

: bone pain, spontaneous

Fx

.

Low-turnover bone diseases

-

Adynamic

bone disease

:↓PTH

(by calcitriol

, Ca-P

binder)

: Osteoblast, osteoclast ↓

:

Fx

.

Risk

-

Osteomalacia

(renal rickets)

: Vit.D deficiency, metabolic acidosis : Osteoblast

↑ : spontaneous Fx. Slide44

Vascular calcification

Low

PTH, low turn over > advanced hyperparathyroidism Hyperphosphatemia, hypercalcemia

Increased use of oral calcium Non calcium based phosphate binder preferred Slide45

Vascular calcification Slide46

Vascular calcification

Calciphylaxis

(calcific uremic

arteriolopathy

)- Rare, serious disorder- Systemic medial calcification of arterioles  ischemia, subcutaneous necrosis

-

Risk factor: warfarin (decrease

Vit

K dep GLA

prot.

regeneration)

Early

calciphylaxis

Progressive

calciphylaxis

Advanced

calciphylaxisSlide47

CKD and CVD4.1.1: We recommend that all people with CKD be considered

at

increased risk for cardiovascular disease. (1A)

4.1.2: We recommend that the level of care for ischemic heart disease offered to people with CKD should

not be prejudiced by their CKD. (1A)4.1.3: We suggest that adults with CKD at risk for atherosclerotic events be offered treatment with antiplatelet agents

unless there is an increased bleeding

risk that

needs to be balanced against the possible

cardiovascular benefits

. (2B)

KDIGO

Guideline for the Evaluation and Management of CKD

Kidney Int 2013; 3 : 1-150Slide48

CKD and CVD4.1.4: We suggest that the level of care for heart

failure offered

to people with CKD should be the same as

is offered to those without CKD. (2A)4.1.5: In people with CKD and heart failure, any escalation in therapy and/or clinical deterioration should prompt monitoring

of

eGFR

and serum

potassium concentration

. (Not Graded)

KDIGO

Guideline for the Evaluation and Management of CKD

Kidney

Int 2013; 3 : 1-150Slide49

증례 5

70

세 여자가 부종과 호흡곤란으로 왔다

. 환자는 20년째 당뇨병 치료 중에 있었으며 천진상 심낭 마찰음이 들렸다

. 검사 결과 다음과 같다.

Hb

9.0 g/dl,

BUN/Cr 100/

5.0 mg/dl,

Ca/P 7.1/7.0 mg/dl

K 6.0

mEq

/L, HC03- 18mEq/LSlide50

환자에서 응급 혈액 투석을 결정하는데 중요한 요소는?

1)

Hb

9.0 g/dl2) BUN/Cr 100/5.0 mg/dl3) Ca/P 7.1/7.0 mg/dl

4) K 6.0 mEq/L5) 심낭 마찰음Slide51

증례 요약 Uremic pericarditis투석전

,

투석 시작

8주이내 주로 발생Hemorrhagic pericardial fluid

Dialysis initiation Ix or intensification of dialysis (without heparin)Recurrent effusion 시 drain 고려감별

: viral,

malig

, Tb, autoimmune

cause, after MI ,

minoxidil

overuseSlide52

Preparation for RRT

5.1.1: We recommend referral to specialist kidney

care services

for people with CKD in the following circumstances (

1B): AKI or abrupt sustained fall in GFR;

GFR <

30 ml/min/1.73 m

2

(GFR

categories G4-G5

)*;

consistent

finding of significant albuminuria

(ACR≥ 300 mg/g or AER≥ 300 mg/24 hours, approximately equivalent to PCR ≥500 mg/g or PER ≥ 500 mg/24 hours); progression of CKD urinary red cell casts CKD and hypertension refractory to treatment with 4 or more antihypertensive

persistent abnormalities of serum potassium;

recurrent

or extensive nephrolithiasis;

hereditary

kidney disease.

KDIGO

Guideline for the Evaluation and Management of CKD

Kidney

Int 2013; 3 : 1-150Slide53

Indication of RRT5.3.1: We suggest that dialysis be initiated when one

or more

of the

following are present:

symptoms or signs attributable to kidney failure (serositis, acid base or electrolyte abnormalities, pruritus

);

inability to control

volume status or blood pressure

;

progressive deterioration

in nutritional status refractory to

dietary intervention; cognitive impairment. This often but not invariably occurs in the GFR range between 5 and 10 ml/min/1.73 m2. (2B) KDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150Slide54

Summary

Definition and

classification of CKD,

+ albuminuria stagesManagement of progression and complications of CKD, and highlights recommendations to lower blood

pressure goals in the setting of proteinuriaCardiovascular disease risk and highlights the need for individualized decision making in some circumstancesReferral to specialists and

the

need

for individualized

decision making in some circumstances

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