肾脏疾病的诊治进展与临证经验.ppt

肾脏疾病的诊治进展与临证经验,China-Japan Friendship Hospital, Beijing, China Li Ping,肾脏疾病的新分类,急性肾脏损伤（Acute Kidney Injuries, AKI） 慢性肾脏病（Chronic Kidney Disease, CKD）,AKI的诊断标准, 肾功能在48小时内突然降低 至少两次Scr升高绝对值0.3mg/dl（26.5umol/L） Scr较前升高50% 持续6小时以上尿量0.5ml/kg/h,符合下列条件之一：,单独应用尿量的改变作为诊断标准时，需要除外尿路梗阻或其他可导致尿量减少的原因。,AKIN Organizing Committee 2005,2005年9月阿姆斯特丹AKI的国际研讨会,AKI的RIFLE分级,反映预后,AKI合作研讨会标准,(Acute rise 0.5 mg/dl),2005年9月阿姆斯特丹AKI的国际研讨会,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,2005年bell等回顾性分析207名CRRT治疗的AKI患者 首次采用RIFLE分期评价AKI的预后,Bell. Nephrol Dial Transplant (2005) 20: 354360,R,I,F,L+E,尿量能否界定CRRT的介入时机,A Randomized Controlled study 28例冠脉搭桥术后AKI患者 Early group 尿量30ml/h 持续3h , 14 cases Late group 尿量20ml/h 持续2h, 14 cases,86%,14%,Early group,Late group,Souichi. Hemodialysis International. 2004; 8: 320-325,RIFLE分期与CRRT介入时机,Chih-Chung Shiao. Critical Care. 2009, 13:R171,25%,27%,13%,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 kidney function and cardiovascular disease.,Levey AS, et al. Ann Intern Med. 2003; 139: 137-147.,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 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.,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 (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,NKF. Am J Kidney Dis. 2002; 39: S1-246.,GFR,To 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 sampling 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 than 18 years .,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,Comparison of 7GFR with sGFR showed that 7GFR correlated significantly with sGFR, but the regression line was significantly different from the identical line,Comparison of Equation-Estimated GFRs With 99mTc-DTPA Plasma Clearance,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,The regression line showed that MDRD equation 7 overestimated GFR at low levels and underestimated GFR at near-normal levels,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,*P 0.05 comparing estimated GFR with sGFR. P 0.001 comparing accuracies of an equation with those in CKD stages 4 to 5.,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,*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 equation with those of the MDRD equations.,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,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) 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: 2937,CKD,Subjects (million),Prevalence,Stage(Ccr90ml/min),Stage(Ccr：6089ml/min),Stage(Ccr：3059ml/min),19.20,11%,5.90,3.3%,5.30,3.0%,Third National Health and Nutrition Examination Survey,Stage(Ccr：1529ml/min),Stage(Ccr15ml/min),Total Subjects,7.60,4.3%,0.40,0.2%,0.30,0.2%,Coresh J, et al. Am J Kidney Dis. 2003; 41: 1-12.,Chadban SJ, et al. J Am Soc Nephrol. 2003;14(7 Suppl 2):S131-8.,Approximately 16.4% have at least one indicator of kidney damage,9.7%,Renal Impairment,Proteinumia,1.1%,Hematuria,3.7%,0.1%,0.3%,0.6%,0.8%,11,247 Australians aged 25 yr or over,GFR 60 ml/min/1.73m2 （11.2%）,Chen 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%.,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.,Subjects: 2353 residents older than 40 years. Results: Approximately 11.3% of subjects had at least one indicator 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%.,Zhang L, et al. Nephrol Dial Transplant. 2007; 22: 1093,Cases of renal biopsies performed each year,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,*P 0.01; *P 0.001, compared with 1985.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Liu G, et al. J Clin Intern Med. 2004; 21: 834-838,The worldwide rise in the number of patients with CKD is reflected in the increasing number of people with end-stage renal disease (ESRD) treated by renal replacement therapydialysis or transplantation. Two factors related to the prevalence of ESRD are important. The first is the ageing of the population; The second factor is the global epidemic of type 2 diabetes mellitus.,Lysaght MJ. J Am Soc Nephrol. 2002; 13: 37. United States Renal Data System. Am J Kidney Dis. 2003; 42: S37. King H, et al. Diabetes Care. 1998; 21: 1414.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Histology of Chinese chronic renal failure (Scr3mg/dl, N = 607),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 diabetic nephropathy (13.5%), hypertensive nephrosclerosis (8.9%).,Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78.,These 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 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 dialysis and transplantation registration group. Chin J Nephrol. 2001; 17: 83-85.,The criterion of CRF was creatinine clearance (Ccr) 50 ml/min/1.73 m2. The mean serum creatinine were 594.7mol/L. The average annual cases accounted for 1.31% of the hospitalized cases with urologic-kidney diseases. The male to female ratio was 1.49:1. The mean age at the disease onset was 8.18 years. The mean duration of pre-diagnosis of CRF was 2.53 years. The main primary renal diseases causing CRF were chronic glomerulonephritis and nephrotic syndrome (52.7%). One-fourth of all cases had congenital and hereditary renal diseases, and the majority was renal hypoplasia and dysplasia.,Yang JY, et al. Zhonghua Er Ke Za Zhi. 2004; 42: 724-730.,The major outcomes of CKD include progression to kidney failure, complications of decreased kidney function, and CVD. Data from the NHANES III show the approximately 11% of the U.S. adult population have CKD. The prevalence of early stages of CKD (stages 1 to 4; 10.8%) is more than 100 times greater than the prevalence of kidney failure (stage 5; 0.1%).,Coresh J, et al. Am J Kidney Dis. 2003; 41: 1-12.,104 patients of A/C accounted for 35.5% of ARF cases with renal biopsy during the same period drug-induced acute renal interstitial or tubulointerstitial disease, pre-renal ARF and flare-up of lupus nephritis were the most common causes of ARF in A/C patients. occurred more commonly in older patients,Zhang L, et al. Clin Nephrol. 2005; 63: 346-350.,2529 cases with dialysis were dead in China in 1999. Heart failure and cerebrovascular accident accounted for 32% and 19%, respectively. Besides, 16% patients died of dialysis interruption automatically, which might be related to the financial problem. In another report, CVD is the single most important cause of death among dialysis patients, accounting for 51% of overall mortality.,Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78.,The most prevalent pathological form of CVD was left ventricular hypertrophy (LVH), accounting for 58.5% of total patients.,Hou FF, et al. Zhonghua Yi Xue Za Zhi. 2005; 85: 458-463.,CHF,CAD,CVA,Prevalence of CVD (%),27.7,16.5,5.6,C reactive protein Female and anemia Calcium phosphate product Hypoalbuminemia Diabetes Age Hypertension,Hou FF, et al. Natl Med J China, 2005; 85: 753-759,Yuan FH, et al. Ren Fail. 2005; 27: 149-153.,Hypertension, diabetes, hyperlipidaemia, obesity, and smoking as risk factors or markers in the general population for the development of CKD. Most notable among the modifiable progression factors is systemic hypertension. Proteinuria is a reliable marker of the severity of CKD and a powerful and independent predictor of its progression. Non-modifiable factors include genetics, race, age, and sex.,Klag MJ, et al. JAMA. 1997; 277: 12931298. Klahr S, et al. N Engl J Med. 1994; 330: 877884. Jafar TH, et al. Ann Intern Med. 2003; 139: 244252.,Li YJ, et al. Family-based association study showing that immunoglobulin A nephropathy is associated with the polymorphisms 2093C and 2180T in the 3 untranslated region of the Megsin gene. J Am Soc Nephrol. 2004; 15: 1739-1743. Li G, et al. Tandem repeats polymorphism of MUC20 is an independent factor for the progression of immunoglobulin A nephropathy. Am J Nephrol. 2006; 26: 43-49. Lu JC, et al. Uteroglobin G38A polymorphism is associated with the progression of IgA nephropathy in Chinese patients. Zhonghua Nei Ke Za Zhi. 2004; 43: 37-40. Chen X, et al. Association of angiotensin-converting enzyme gene insertion/deletion polymorphism with the clinico-pathological manifestations in immunoglobulin A nephropathy patients. Chin Med J (Engl). 1997; 110: 526-529.,Megsin 基因与IgA肾病的发病有关 MUC20，Uteroglobin，ACE 基因与IgA肾病的进展有关,impaired renal function, severe proteinuria, hypertension, glomerulosclerosis, interstitial fibrosis,DAmico G. Am J Kidney Dis. 2000; 36: 227237.,Yang NS, et al. Chin J Intern Med. 2005; l44: 597-600.,Characteristics,P-value,Scr 115 umol/L UP 1.0g/24h Glomerulosclerosis 2 Crescent formation Interstitial injury 2,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.,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 : hypertension, the level of proteinuria, the scores of vascular lesion, total glomerular lesion, hypercellularity, glomerulosclerosis,Zhang Y, Chen X, et al. Chin J Intern Med. 2001; 40: 613-617.,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, 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.,Management of CKD,Current 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 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.,我们所面对新的挑战,CVD is an epidemic,Diabetes is an epidemic,CKD is an epidemic,CVD and DM are leading causes of CKD,CKD is a risk factor for CVD,Dialysis is costly,Dialysis is life saving,中西医治疗CKD的现状分析,肾脏病的演变,肾脏病的表现,肾脏病的治疗,治疗的局限性,早期 CKD1期,中期 CKD2-3期,中晚期 CKD4期,尿毒症,单纯血尿 轻度蛋白