高血压英文ppt精品课件progressive chronic kidney

Progressive Chronic Kidney Disease Cherelle Fitzclarence August 2009 Overview Case studies Discussion Take home messages Case 1 50 yo diabetic 5 yr hx Initial poor control but good last 3 years with combo of insulin and oral hypoglycaemics Monitors own sugars Post prandial BSLs 150 8% of the surveyed group had diabetes and half of them were unaware of Dx 30% of those surveyed had hypertension with half being unaware of Dx 1 in 3 type 2 diabetics will develop nephropathy Take home message Type 2 Diabetes is now worldwide, the most common cause of end stage kidney disease Indigenous populations have much higher rates of end stage kidney disease (ESKD) Risk factors for ESKD Hypertension Diabetes Family history Ethnicity Smoking Obesity Case 1 Question 2 Which of the following is the most appropriate investigation when screening for CKD? 24 hr urinary protein 24 hr urinary albumin excretion Urinary prot/creat ratio on a spot urine Urinary alb/creat ratio on a spot urine MSU with dipstick, spot ACR, microscopy and culture Case 1 Question 2 Which of the following is the most appropriate investigation when screening for CKD? 24 hr urinary protein 24 hr urinary albumin excretion Urinary prot/creat ratio on a spot urine Urinary alb/creat ratio on a spot urine MSU with dipstick, spot ACR, microscopy and culture Discussion CARI/KCAT reviewed evidence Combo screening the best U/A MSU - m,c,s ACR BP Serum creatinine (GFR) This should be done yearly in high risk groups eg diabetics, ATSI Further discussion Take home message Single urine dipstick for protein limitations false positives, false negatives Kidney function should be measured at least yearly in those at increased risk CKD Screening should include measurement of BP, serum creatinine (GFR), MSU Protein creatinine ratio or albumin creatinine ration Case 1 Question 3 Which of the following is/are true statements concerning tests for assessing CKD? Serum creatinine is an accurate measure of renal function and if 20mls/min excludes clinically relevant renal disease Case 1 Question 3 Which of the following is/are true statements concerning tests for assessing CKD? Serum creatinine is an accurate measure of renal function and if 20mls/min excludes clinically relevant renal disease Discussion Serum creatinine can stay in the normal range until more than 50% of GFR is lost Serum creatinine is dependent on age, weight, gender and muscle mass Small people with low muscle mass, elderly, female may have significant renal impairment despite a normal creatinine GFR falls over hours, days or weeks in acute renal failure GFR falls over months, years in chronic renal failure eGFR is used to stage kidney disease Discussion Take home message eGFR is useful as a screening tool for CKD Should be used in conjunction with BP, U/A, ACR eGFR can be used to stage CKD Case 1 continues Over next 12 months, renal disease progresses Creat 312 Risk factors for cardiovascular disease poorly controlled BP 150 with 4 drug therapy on board ACEI, CCB, BB, Frusemide Hyperlipidaemia despite statin therapy ACR increasing despite ACEI Case 1 Question 4 In slowing the progression of renal disease and avoiding the development of malnutrition in CKD patients with an eGFR 15-30 mls/min, which of the following statements is/are correct? Nephrotic patients need a high protein diet Reducing proteinuria to 3g/24hrs) predicts the response to ACEI Case 1 Question 4 In slowing the progression of renal disease and avoiding the development of malnutrition in CKD patients with an eGFR 15-30 mls/min, which of the following statements is/are correct? Nephrotic patients need a high protein diet Reducing proteinuria to 3g/24hrs) predicts the response to ACEI Discussion CARI guidelines advise against excessive protein restriction for slowing renal function decline High protein diets do little to correct the malnourished state Control of BP can signifcantly reduce proteinuria esp ACEI, AR2B, aldosterone antagonists Take home message Low protein diets may slow progression CKD but only a small impact and may increase risk of malnutrition High protein diets are not effective in treating malnutrition and may accelerate CKD Lowering BP decreases proteinuria Degree of preservation of renal function achieved with AHA directly proportional to decrease in proteinuria ACEI/AR2Bs slow progression CKD more than explained just be AHA Case 1 Question 5 When a pt with T2DM is assessed for diabetic nephropathy, which of the following is correct? The absence of proteinuria excludes diabetic nephropathy Hypertension usually indicates the presence of concomitant macrovascular disease The severity of diabetic nephropathy is related to the severity of hypertension The absence of diabetic retinopathy excludes diabetic nephropathy Kimmelstiel-Wilson lesions must be present to diagnose diabetic nephropathy Case 1 Question 5 When a pt with T2DM is assessed for diabetic nephropathy, which of the following is correct? The absence of proteinuria excludes diabetic nephropathy Hypertension usually indicates the presence of concomitant macrovascular disease The severity of diabetic nephropathy is related to the severity of hypertension The absence of diabetic retinopathy excludes diabetic nephropathy Kimmelstiel-Wilson lesions must be present to diagnose diabetic nephropathy Discussion NHANES 3 study T2DM with creat 150 -1/3rd had no evidence of proteinuria Due to more of a Vasculopathy (particularly microvascular) than by classic histological changes of glomerular basement membrane thickening and mesangial expansion Vasculopathy is associated with hypertension and may not be associated with proteinuria Vasculopathy leads to progressive CKD, accelerated by diabetic control, hypertension, proteinuria Take home message Not all T2DM with CKD have proteinuria Hypertension is common and is associated with progressive CKD If hypertension is resistant, think RAS Diabetic retinopathy and nephropathy are commonly but not always bound together Case 1 Question 6 Which of the following is true regarding treatment aimed at slowing the progression of CKD and at preventing cardiovascular events such as AMI and CVA? The target BP is 1g/24hours 120/75 For diabetic CKD target BP 1g/day with normal eGFR Unexplained decline in kidney function (15% drop GFR over 3 months) Case 1 Question 7 In general, which of the following results in 50yo indicate need for referral to Nephrologist? Diabetic with eGFR 1g/day with normal eGFR Unexplained decline in kidney function (15% drop GFR over 3 months) Discussion Late referral to Nephrologist associated with poorer outcomes, greater morbidity for RRT and pall care groups Guidelines only and controversial if not sure err on side of caution In general, stable patients with eGFR 30 dont require referral but a significant number can benefit from referral and progression may be able to be averted Take home message Indications for referral to Nephrologist Proteinuria 1g/24 hrs eGFR 100 Treating the anaemia of CKD is not required until HB100 Treating the anaemia of CKD is not required until HB100 Once epo started ferritin 400-600 Transferrin saturation 20% prior to epo therapy Transferrin saturation 30-40% post epo starting Adequate iron stores required for epo to work Iron deficiency is most common cause of hyporesponsiveness to epo Take home message Impaired absorption of oral iron and increased utilization of iron with EPO therapy have contributed to the development of iron deficiency Optimize responsiveness to EPO targets for ferritin 300-600 and saturation 30-40% Case 1 CKD progresses and he needs dialysis. GP questions whether other therpay may have prevented such a rapid progression to ESKD Question 9 For which of the following therapies is there level 1 evidence for efficacy in the CKD population Cholesterol lowering with statins both to slow progressive decline of renal function and to reduce the increased cardiovascular risk associated with CKD Uric acid reduction slows progression Exercise and weight loss improve insulin resistance and slow progression Aldosterone blockade can further slow progression AR2B can further slow progression in pts on ACEI Case 1 CKD progresses and he needs dialysis. GP questions whether other therpay may have prevented such a rapid progression to ESKD Question 9 For which of the following therapies is there level 1 evidence for efficacy in the CKD population Cholesterol lowering with statins both to slow progressive decline of renal function and to reduce the increased cardiovascular risk associated with CKD Uric acid reduction slows progression Exercise and weight loss improve insulin resistance and slow progression Aldosterone blockade can further slow progression AR2B can further slow progression in pts on ACEI Discussion Decrease uric acid, cessation of smoking, weight loss all slow progression but evidence is poor; studies small, non randomised, case studies Statins thought to help but again studies not good no RCT AR2B and ACEI combo thought to help if patient proteinuric COOPERATE study Take home message Allopurinol, weight loss, cessation of smoking, exercise may all slow progression of CKD but no level one evidence Beneficial effect of lipid though to be present but still waiting level 1 evidence AR2B and ACEi together can help delay progression in pt with proteinuria Case 1 Question 10 In type