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-JapanFriendshipHospital,Beijing,ChinaLiPing,肾脏疾病的新分类,急性肾脏损伤（AcuteKidneyInjuries,AKI）慢性肾脏病（ChronicKidneyDisease,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。,AKINOrganizingCommittee2019,2019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,(Acuterise0.5mg/dl),2019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,JHimmelfarb.KidneyInternational(2019)71,971976.,AKI的RIFLE分期与预后,2019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.NephrolDialTransplant(2019)20:354360,R,I,F,L+E,尿量能否界定CRRT的介入时机,ARandomizedControlledstudy28例冠脉搭桥术后AKI患者Earlygroup尿量30ml/h持续3h,14casesLategroup尿量20ml/h持续2h,14cases,86%,14%,Earlygroup,Lategroup,Souichi.HemodialysisInternational.2019;8:320-325,RIFLE分期与CRRT介入时机,Chih-ChungShiao.CriticalCare.2009,13:R171,25%,27%,13%,Chronickidneydisease（CKD）,Chronickidneydisease(CKD)isaworldwidepublichealthproblemwithanincreasingincidenceandprevalence,pooroutcomes,andhighcost.OutcomesofCKDincludenotonlykidneyfailurebutalsocomplicationsofdecreasedkidneyfunctionandcardiovasculardisease.,LeveyAS,etal.AnnInternMed.2019;139:137-147.,Kidneydamage,Kidneydamageisdefinedaspathologicabnormalitiesormarkersofdamage,includingabnormalitiesinbloodorurinetestsorimagingstudies.Persistentproteinuriaistheprincipalmarkerofkidneydamage.Analbumincreatinineratiogreaterthan30mg/gintwoofthreespoturinespecimensisusuallyconsideredabnormal.,LeveyAS,etal.KidneyInt.2019;67:2089-2100.,NKF.AmJKidneyDis.2019;39:S1-246.,GFRcanbeestimatedfromcalibratedserumcreatinineandestimatingequations,suchastheModificationofDietinRenalDisease(MDRD)StudyequationortheCockcroft-Gaultformula.TheMDRDformulaisrecommendedbyEuropeanandAmericanguidelinesforestimatingGFR，whichhasnotbeenfullyvalidatedindifferentpopulationsandatdifferentstagesofCKD,NKF.AmJKidneyDis.2019;39:S1-246.,GFR,ToevaluatewhethertheMDRDequationscouldbeappliedaccuratelytoChinesepatientswithCKD,GFRestimatedbyusingMDRDequation7(7GFR),theabbreviatedMDRDequation(aGFR),andtheCockcroft-Gaultequation(cGFR)werecomparedinpatientswithdifferentstagesofCKD.DualplasmasamplingoftechnetiumTc99m-labeleddiethylenetriaminepentaaceticacidplasmaclearancewasusedasthereferencestandardGFR(sGFR)forcomparisonof7GFRs,aGFRs,andcGFRsatdifferentstagesofCKD.Thestudyenrolled261patientswithCKD,including146menand115women.Allpatientswereolderthan18years.,ZuoL,etal.AmJKidneyDis.2019;45(3):463-72.,Comparisonof7GFRwithsGFRshowedthat7GFRcorrelatedsignificantlywithsGFR,buttheregressionlinewassignificantlydifferentfromtheidenticalline,ComparisonofEquation-EstimatedGFRsWith99mTc-DTPAPlasmaClearance,ZuoL,etal.AmJKidneyDis.2019;45(3):463-72.,TheregressionlineshowedthatMDRDequation7overestimatedGFRatlowlevelsandunderestimatedGFRatnear-normallevels,ZuoL,etal.AmJKidneyDis.2019;45(3):463-72.,*P0.05comparingestimatedGFRwithsGFR.P0.001comparingaccuraciesofanequationwiththoseinCKDstages4to5.,ZuoL,etal.AmJKidneyDis.2019;45(3):463-72.,*P0.05comparingestimatedGFRwithsGFR.P0.001comparingaccuraciesofanequationwiththoseinCKDstages4to5.P0.001comparingaccuraciesoftheC-GequationwiththoseoftheMDRDequations.,ZuoL,etal.AmJKidneyDis.2019;45(3):463-72.,TheMDRDequation7toestimateGFR(7GFR,ml/minper1.73m2)=170Pcr-0.999age-0.176BUN-0.170albumin0.3180.762(iffemale)1.211(ifChinese)AbbreviatedMDRDequationtoestimateGFR(aGFR,ml/minper1.73m2)=186Pcr-1.154age-0.2030.742(iffemale)1.233(ifChinese),WherePcrisinmg/dl,BUNisinmg/dl,albuminising/dl,andageisinyears.,Maetal.JAmSocNephrol2019;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%,ThirdNationalHealthandNutritionExaminationSurvey,Stage(Ccr：1529ml/min),Stage(Ccr15ml/min),TotalSubjects,7.60,4.3%,0.40,0.2%,0.30,0.2%,CoreshJ,etal.AmJKidneyDis.2019;41:1-12.,ChadbanSJ,etal.JAmSocNephrol.2019;14(7Suppl2):S131-8.,Approximately16.4%haveatleastoneindicatorofkidneydamage,9.7%,RenalImpairment,Proteinumia,1.1%,Hematuria,3.7%,0.1%,0.3%,0.6%,0.8%,11,247Australiansaged25yrorover,GFR60ml/min/1.73m2（11.2%）,ChenJ,etal.KidneyInt.2019;68(6):2837-45,TheoverallprevalenceofCKDwithGFR60mL/min/1.73m2was2.53%.,ChenJ,etal.KidneyInt.2019;68(6):2837-45.,Overall,theage-standardizedprevalencesofGFR60to89,30to59,and30mL/min/1.73m2were39.4%,2.4%,and0.14%,respectively.,Subjects:2353residentsolderthan40years.Results:Approximately11.3%ofsubjectshadatleastoneindicatorofkidneydamage.(1).Albuminuria(albumin/creatinine30mg/g),6.2%;(2).GFR60ml/min/1.73m2,5.2%;(3).Hematuria,0.8%;(4).Non-infectivepyuria,0.09%.,ZhangL,etal.NephrolDialTransplant.2019;22:1093,Casesofrenalbiopsiesperformedeachyear,LiLS,LiuZH.KidneyInt.2019;66(3):920-3.,*P1.0g/24hGlomerulosclerosis2CrescentformationInterstitialinjury2,Multivariteanalysisofinfluercingfactorsforhypertensionin540patientswithIgAN,ZhuangY,ChenX,etal.ChinJInternMed.2000;39:371-375.,TheprevalenceofhypertensioninIgANwas39.6%(214/540)atthetimeofrenalbiopsy.,Characteristicsoftubulointerstitiallesions(TIL)in609patientswithIgAN,DegreeandpercentofTIL:mildTIL47.1%,moderateTIL21.7%,severeTIL16.6%,Non-TIL14.6%.RelatedfactorswithseverityofTIL:hypertension,thelevelofproteinuria,thescoresofvascularlesion,totalglomerularlesion,hypercellularity,glomerulosclerosis,ZhangY,ChenX,etal.ChinJInternMed.2019;40:613-617.,PreventionofCKD,PrimarypreventionofCKDwillrelyoncontrollingtheobesityandassociatedtype2diabetesaswellashypertension.suchasweightreduction,exercise,anddietarymanipulations.SecondarypreventionofprogressionofCKDneedspharmacologicalapproaches.,MolichM,etal.JAmSocNephrol.2019;14:S103107.AppelLJ.JAmSocNephrol.2019;14:S99102.MoserM.JClinHypertens.2019;6:S413.,ManagementofCKD,CurrentmanagementoptionsforCKDarebasedonthecontrolofknownriskfactorssuchashypertension,proteinuria,hyperlipidaemia,andsmoking.Controlofhypertensionisthesinglemosteffectiveintervention.AntihypertensiveapproacheswithinhibitorsofACEorangiotensin-2-receptorblockershavebeenwidelyadvocated.Controlofproteinuriaandtheinhibitionoftherennin-angiotensinsystemareimportantfactorsinslowingtheprogressionofdiabeticandnon-diabeticCKD.,RemuzziG,etal.AnnInternMed.2019;136:604615.GaedeP,etal.NEnglJMed.2019;348:383393.,我们所面对新的挑战,CVDisanepidemic,Diabetesisanepidemic,CKDisanepidemic,CVDandDMareleadingcausesofCKD,CKDisariskfactorforCVD,Dialysisiscostly,Dialysisislifesaving,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,单纯血尿轻度蛋白尿,合并高血压大量蛋白尿,透析肾移植,降压药糖皮质激素免疫抑制剂,西医无特殊治疗,疗效有限药副作用大,肾功能不全尿毒症前期,晚期CKD5期,西医无特殊治疗,低蛋白饮食必需氨基酸,寻找并去除危险因素,治标不治本器官来源不足医疗费用高,中医治疗优势,针对血尿蛋白尿治疗,降低蛋白尿减少副作用,延缓肾脏疾病进展,推迟进入透析时间,减少医疗费用,CKD中医治疗十法,滋养肝肾法症属肝肾阴虚者，或辨证属气阴两虚以阴虚为主者，方选杞菊地黄汤、归芍地黄汤、一贯煎合二至丸、桑麻丸等加减。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、尿热、尿痛者，可用知柏地黄汤加滑石、车前子等。,健脾益肾法,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。,益气养阴法,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；气虚明显加入红参另煎兑服；阴虚明显加黄芪、石斛；兼阳虚加仙茅、仙灵脾等；兼浊毒者加入生大黄，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、黄连、黄柏；合并周围神经病变加当归、菊花等。,阴阳双补法,适于CKD晚