2002 증례 1 40 세 남성이 건강검진상 신장이상으로 왔다 환자는 수년전 부터 소변 검사상 혈뇨와 단백뇨가 있었다고 한다 혈압은 13080mmHg ID: 675323
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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
는
?
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 : 1-150Slide16Slide17
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
는
Metabolic acidosis
에 의한
catabolic status
를 개선하여
CKD progression
을
slow Harrison 19thKDIGO Guideline for the Evaluation and Management of CKDKidney Int 2013; 3 : 1-150 Slide27
증례 3
혈
액
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
를
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