如何减缓慢性肾脏疾病的恶化.ppt

如何減緩慢性腎臟疾病的惡化,宋 俊 明 醫師 成 大 醫 院 腎 臟 科,慢性腎臟病的治療,慢性腎臟疾病 Chronic Kidney Disease, CKD 定 義,腎臟結構或功能損壞  3個月-- 無論GFR是否下降-- 有病理、血液、尿液或影像上的變化 GFR < 60 ml/1.73m2  3個月，不論腎臟是否有損害,GFR 120 ml/min/1.73m2 90 60 30 15 0,慢性腎臟疾病(CKD)之分期,CKD, Stage-specific Recommendations for Detection, Evaluation, and Management,腎臟專科醫師於慢性腎臟疾病 防治過程中所扮演的角色,針對病患：擬定治療計畫及強化慢性腎病照護品質1. 正確診斷 ( Diagnosis ) 與治療 ( Treatment )2. 危險因子之評估 ( Assessment of risk )3. 正確分期 ( Staging )4. 延緩腎功能衰退 ( Slow progression )5. 處理併發症 ( Management of complications )6. 腎臟替代療法之選擇與預備 ( Selection andpreparation of RRT ),RRT: renal replacement therapy,常見慢性腎臟病的原因與類型,1. 腎絲球病變▪ 原發性腎絲球受損，如：慢性腎絲球腎炎▪ 續發性腎絲球受損，如：高血壓腎絲球硬化、糖尿病腎病變、紅斑性狼瘡等疾病所引起 2.腎小管或間質病變 ▪ 如慢性腎盂腎炎、長期的止痛藥、腎結石、腎腫瘤、尿道或輸尿管狹窄、痛風、藥物濫用 3.先天性的腎臟病變▪ 多囊性腎臟病▪ Alport’s syndrome,TsengWang,慢性腎臟病的危險因子,Heart 2001;86: 459-466,腎臟病的高危險群,1. 糖尿病 2.高血壓 3.痛風 4.家族慢性腎臟病病史 5.高齡：65歲以上老人 (因器官容易退化) 6.藥物濫用者：不當的長期自行服用消炎止痛藥或來路不明的 中藥及草藥，尤其含「馬兜鈴酸」的藥材藥物 容易造成腎臟的傷害。

TsengWang,Progression of Renal Disease,,,,,,,,,,,,,End Stage Renal Disease,,,,,,100,80,60,40,20,GFR, mL/min/1.73m2,Age, years,0,25,35,45,55,65,75,,,,,,,5.0 mL/min/yr,,3.0 mL/min/yr,2.0 mL/min/yr,1.0 mL/min/yr,1.0 mL/min/yr Starting at age 45,Hebert LA, et al. Kidney Int 2001; 59: 1211-26,TsengWang,K/DOQI Clinical Guideline for CKD,引起GFR急性下降之危險因子 容積下降，dehydration 注射顯影劑 抗生素 (eg,aminoglycoside, amphotericin B) 止痛藥物 NSAIDs，包括 COX-2 inhibitorsACE inhibitor 和 ARBCyclosporin 和 Tacrolimus 泌尿道阻塞 K/DOQI Am J Kidney Dis 2002; 39(2) Suppl 1,TsengWang,腎 毒 性 藥 物,Alteration of RBF (腎臟血流改變) NSAIDs, ACEIs/ARBs, cyclosporin, radiocontrast agentsDirect tubular injury (直接腎小管損傷) Aminoglycosides, amphotericin B, radiocontrast agentsIntratubular obstruction (腎小管阻塞) Acyclovir, sulfonamidesAllergic interstitial nephritis (過敏性間質性腎炎) NSAIDs, penicillins, cephalosporins, sulfonamidesRapid progression interstitial fibrosis (快速進行性間質性腎炎) Chinese herbal drugs,Modified from K/DOQI AJKD 2002; 39(2) Suppl 1,TsengWang,避免腎功能急速惡化之一般原則,避免脫水（容積下降）。

瞭解腎毒性藥物（A）盡量避免使用B）評估使用之利弊C）如何避免特殊藥物之腎毒性D）定期追蹤腎功能E）如何治療腎功能急速惡化K/DOQI AJKD 2002; 39(2) Suppl 1,在台灣，尚需注意中草藥及成藥,TsengWang,治療慢性腎臟病及 延緩腎功能衰退,TsengWang,英國前膽性糖尿病研究證實 (UKPDS*) HbA1C 每降低 1 % 便能明顯減少慢併症之發生,Adapted from the UKPDS results are from an epidaemiological analysis,*UKPDS: the United Kingdom prospective diabetes study,,,Optimize glucose control (A),Diabetes Care 2008; 31(Suppl 1): S12-S53,,,糖尿病患者的血糖控制,Parving HH et al. Am J Kidney Dis 1993; 22: 188-95,糖尿病腎病變與高血壓：即使未使用ACEI/ARB，降低血壓就能減緩腎功能的惡化及降低蛋白尿。

Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661.,Parving HH, et al. Br Med J. 1989. Moschio G, et al. N Engl J Med. 1996. Viberti GC, et al. JAMA. 1993. Bakris GL, et al. Kidney Int. 1996. Klahr S, et al. N Eng J Med. 1994. Bakris GL. Hypertension. 1997. Hebert L, et al. Kidney Int. 1994. The GISEN Group. Lancet. 1997. Lebovitz H, et al. Kidney Int. 1994.,www.hypertensiononline.org,降低血壓可減緩糖尿病及非糖尿病GFR的下降,UKPDS: United Kingdom Prospective Diabetes Study ABCD: Appropriate Blood Pressure Control in Diabetes Trial MDRD: Modification of Dietary Protein in Renal Disease,HOT: Hypertension Optimal Treatment Trial AASK: African-American Study of Kidney Disease,,糖尿病併高血壓的患者 常需使用較多種類的降血壓藥物,TsengWang,嚴密的血壓控制比血糖控制更重要 (UKPDS),Stroke,Any Diabetic Endpoint,DM Deaths,Microvascular Complications,,,,,,,,,,,,,,,,,,,,,,,,-50,-40,-30,-20,-10,0,% Reduction In Relative Risk,Tight Glucose Control(Goal <6.0 mmol/l or 108 mg/dL),Tight BP Control(Average 144/82 mmHg),32%,37%,10%,32%,12%,24%,5%,44%,,Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661,*,*,*,*,*P <0.05 compared to tight glucose control,www.hypertensiononline.org,TsengWang,Optimize blood pressure control (A)Goals: SBP/DBP <130/80 mm Hg (B),Diabetes Care 2008; 31(Suppl 1): S12-S53,糖尿病患者的血壓控制,TsengWang,糖尿病腎病變的治療：ACEI 與 ARB,,第二期,第三期,第四期,第五期,TsengWang,AIPRI: Reduction of risk for progressive renal insufficiency with ACE-I (doubling of serum creatinine and start of renal replacement therapy),Maschio G, et al. N Engl J Med. 1996;334(15):939-945.,www.hypertensiononline.org,ACEI 在非糖尿病腎臟疾病的腎臟保護作用,TsengWang,ACE-I+Verapamil: Additive Reduction of Proteinuria in Type 2 DM at 1 yr,Bakris GL, et al. Kidney Int. 1998;54:1283-1289. Reprinted by permission, Blackwell Science, Inc.,www.hypertensiononline.org,ACEI 併用 NDHP-CCB 的腎臟保護作用,TsengWang,N Engl J Med 1994;330:877-84,The MDRD Study: The Modification of Diet in Renal Disease Study,Fig. Comparison of GFR decline between diet groups in the MDRD study,Usual diet 1.3 g/kg BW/day Low protein diet 0.6 g/kg BW/day,,The MDRD Study,低蛋白飲食對CKD的影響,TsengWang,CKD 病患在食物蛋白質與磷的限制,Harrison’s Principles of Internal Medicine 16th Edition,TsengWang,CKD 與血脂異常(dyslipidemia),,Am J Kidney Disease 2003;41(4):11-21,NKF-K/DOQI : National Kidney Foundation Kidney Disease Outcomes Quality Initiative,TsengWang,Fig. Effect of lipid reduction on the progression of renal disease: a meta-analysis,Kidney Int 2001:59;260-269,降血脂藥物對CKD的影響：減緩GFR的下降,TsengWang,Statins 對慢性腎病的作用：降低蛋白尿,Am J Kidney Dis 2003; 41: 565-70,。