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ทิศทางการพัฒนางาน CKD/CAPD ใน 1-5 ปี ข้างหน้า PowerPoint PPT Presentation


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ทิศทางการพัฒนางาน CKD/CAPD ใน 1-5 ปี ข้างหน้า. นพ.สุรพงษ์ นเรนทร์พิทักษ์ โรงพยาบาลอุดรธานี. หัวข้อบรรยาย(เดิม). - คำจำกัดความ & ระยะโรค - ระบาดวิทยา - สาเหตุ - ปัจจัยเสี่ยง - การคัดกรอง - การดำเนินโรค - การรักษาด้วยยา - การรักษาที่ไม่ใช้ยา - สิทธิการรักษา ESRD.

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ทิศทางการพัฒนางาน CKD/CAPD ใน 1-5 ปี ข้างหน้า

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Ckd capd 1 5

CKD/CAPD 1-5

.


Ckd capd 1 5

()

- &

-

-

-

-

-

-

-

- ESRD


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Definition of Chronic Kidney Disease

1. >3 , ( +/- GFR )

a.

b.

Markers of kidney damage include

- abnormal blood or urine composition

- abnormal imaging tests

2. GFR <60 mL/min/1.73 m2 >3 ,

( +/- kidney damage )

AJKD 2002; 39 (Suppl 1): S17


Ckd capd 1 5

CKD

Glomerular

Filtration Rate

ml / min / 1.73 m2

> 90

60 89

30 59

15 29

< 15

Stage

1

2

3

4

5

Kidney Damage with Normal Filtration

Kidney Damage with

Mildly Decreased Filtration

Moderately Decreased

Filtration

Severely Decreased

Filtration

ESRD

Kidney Failure

HD, CAPD

RRT

* Prevalence per adult population age > 20AJKD 2002; 39 ( Suppl 1 ) : S49.


Ckd capd 1 5

CKD

Glomerular

Filtration Rate

ml / min / 1.73 m2

> 90

60 89

45 - 59

30 -44

15 29

< 15

Stage

1

2

3

4

5

Kidney Damage with Normal Filtration

Kidney Damage with

Mildly Decreased Filtration

A

B

Mildly to Moderately Decreased

Moderately to Severely Decreased

Severely Decreased

Filtration

ESRD

Kidney Failure

HD, CAPD

RRT

volume 3 | issue 1 | JANUARY 2013 http://www.kidney-international.org


Ckd capd 1 5

Low risk

No CKD

Moderately increased risk

high risk

Very high risk


Ckd capd 1 5

F/U /


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Abbreviated MDRD-GFR equations

Original 1 = 186 x S.cr-1.154 x Age-0.203 x 0.742 ( if female ). NST

Re-expressed IDMS traceable 2

= 175 x S.cr-1.154 x Age-0.203 x 0.742 ( if female )

Japanese 3 = 168 x S.cr-1.044 x Age-0.274 x 0.775 ( if female )

Chinese 4 = 175 x S.cr-1.234 x Age-0.179 x 0.79 ( if female )

Thai 5 re-expressed IDMS traceable MDRD equation.

= 175 x (CrEnz)-1.154 x (Age)-0.203

x (0.742 if female) x 1.118 (if Thai)

or =186 x (CrJaffe)-1.154 x (Age)-0.203 x 0.742 (if female)

x 1.016 (if Thai)

1. JASN 2000; 11: 155A.2. Clin Chem 2007; 53: 766-72.

3. AJKD 2007; 50: 927-37. 4. JASN 2006; 17: 2937-44.

5. Praditpornsilpa K, WCN May 2008.


Prevalence studies in thailand

Prevalence studies in Thailand

8.6

CKD awareness = 1.9% among stages 1 - 4


2009 ckd epi creatinine equation

2009 CKD-EPI creatinine equation

2009 CKD-EPI creatinine equation: 141min(SCr/k, 1)max(SCr/k, 1) -1.209 0.993Age[1.018 if female] [1.159 if black], where

SCr is serum creatinine (in mg/dl), k is 0.7 for females and 0.9 for males, is 0.329 for females and 0.411 for males, min is the minimum of SCr/k or 1, and max is the maximum of SCr/k or 1.


Ckd capd 1 5

CKD

1.

2. DM

3. HT

4. (CGN)

5. Polycystic kidney disease

6.


Ckd capd 1 5

Diabetic Nephropathy (1)

1oPrevention ( Level A )

-

-

- Life style modification

( Level E )

UAE - in T1DM : UAE within 5 yrs

- in T2DM : UAE at initial

S.Cr & eGFR - q 1 yr

Diabetic Care 2010.


Ckd capd 1 5

Diabetic Nephropathy(2)

1. Adequate glycemic control can decrease

incidence of microvascular complication

Kumamoto study Diab Res clin Pract, 1995

UKPDS - Lancet, 1998.

- NEJM, 2008.

ADVANCE- NEJM, 2008.

VA Diabetic trial - NEJM, 2009.

2. A1C should be at 7%

or lower ( selected cases )

ADA, Diabetic Care 2010.


Ckd capd 1 5

Diabetic Nephropathy(3)

3.

< 130 / 80

4. Life style therapy

-

- DASH diet ( low salt ), high K, exercise)

- Smoking cessation

5. Pharmacologic therapy

ACEi or ARB

Diuretic : HCTZ or furosemide

ADA, Diabetic Care 2010.


Ckd capd 1 5

1. Blood pressure (intra glomerular pressure)

2. Proteinuria

3. Extent of tubulointerstitial diseases & baseline

K. function (baseline Scr, GFR)

4. Drugs (aspirin, acetaminophen, NSAID)

5. Vascular calcification [ Ca x P > 55 ] and

hyperphosphatemia

6. Dietary protein intake

7. History of AKI

8. Smoking

9. Hyperlipidemia

10. Genetic factors


Ckd capd 1 5

glycemic control in DM-CKD

- HbA1C 7.0%

- If eGFR<45 >30 = Metformin

- If eGFR < 30 ml / min / 1.73 m2

no glybenclamide,

no metformin


Ckd capd 1 5

Guideline on BP control in CKD

(NST CKD guideline, 2552)

- BP = 130 / 80

- ACEi or ARB as the 1st line drug

- Monitor Scr, S.K

- May need a combination of drugs


Ckd capd 1 5

Risk factor for CKD progression

1. Blood pressure (intra glomerular pressure)

2. Proteinuria

3. Extent of tubulointerstitial diseases & baseline

K. function (baseline Scr, GFR)

4. Drugs (aspirin, acetaminophen, NSAID)

5. Vascular calcification [ Ca x P > 55 ] and

hyperphosphatemia

6. < 0.8 g/kg/d

7. History of AKI

8. Smoking

9. Hyperlipidemia

10. Genetic factors


Ckd capd 1 5

Recommend lifestyle modifications

  • Salt intake 5 g / day (Na < 2 g/day)

  • 2. Vegetables & fruits

  • 3. Cholesterol & saturated fatty acid

  • 4. BMI < 25

  • 5. Exercise

  • 6. Alcohol

  • 7. No smoking

Clin Exp Nephrol 2009; 13: 231-233.


Ckd capd 1 5

Modification by diet of Factors that

delay progression of CKD

Determinant factors Diet modification

* High BP Salt, life style

Body weight

* High protein & P intake Protein & P restriction

* Metabolic acidosis acid ash

* Hypo KFruit (K, citrate)

HyperphosphatemiaP intake

Hyperlipidemiasaturated fat


Ckd capd 1 5

slow kidney disease progression

  • 2. ACE inhibitor & ARB

  • 3.

  • 4.

  • 5. phosphate

  • 6.

  • 8.


Ckd capd 1 5

Will power

Knowledge

CKD Team

IT

Budget

Personnel

..

- Awareness

- Screening

- Counseling

- Direct care

- Research

.

Home care


Ckd capd 1 5

When to start Renal Replacement Therapy

  • (Counseling)

  • eGFR 20 30 ml / min / 1.73 m2

  • 2. (Placement of dialysis catheter)

  • CAPD / HD

  • eGFR = 10 ml / min / 1.73 m2

  • 3. (Recommended to start RRT)

  • eGFR = 5 10

  • 4. (Must do)

  • uremic syndrome : weight loss acidosis,

  • hyper K, N & V


Ckd capd 1 5

()

()

-


Ckd capd 1 5

(ESA)


Ckd capd 1 5

ESRD


Ckd capd 1 5


Ckd capd 1 5

Zun Wu

P Watanapa


Ckd capd 1 5

23 (CKD clinic) CAPD

CAPD : HD = 1 : 2.7


Ckd capd 1 5

9 THAI(9 item Thai Health status Assessment Instrument) , ,

4

3

2


Ckd capd 1 5

.. 2550 . HD 38 , CAPD 14 52 ( CKD clinic& CAPD)

, , Hematocrit

57.5 14.6 (18.9 85 ) DM 46, HT 35, Gout 19, 19, / 6


Ckd capd 1 5

ESRD

4 Mobility, Self care, Usual activity (/), Illness/Discomfort (/)

2 Anxiety/Depression, Cognition (/)


Ckd capd 1 5

ESRD ()

Social function () HD CAPD

HD () 73.7

CAPD 100

( 2007; Vol.15 No.3)


Ckd capd 1 5

1. (RRT)

2.

3. CKD & RRT


Ckd capd 1 5

Thank you for attention


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