Chronic Kidney Disease (CKD) and Diabetes

1、目前的幾個名詞 Kidney, not Renal (or Reno) CKD, not CRF DKD (= diabetic nephropathy) AKI, not ARF Still ESRD (End Stage Renal Disease) Still RRT (Renal Replacement Therapy)ESRD Incidence Counts and Ratesby Primary Diagnosis (USRDS, 2006)Better CKD Management?Glomerulus = filtering unitImportance of Diabeti

2、c Kidney Disease Kidney disease as diabetic complication: 30% of Type 1 Diabetes 40% of Type 2 Diabetes CKD amplifies CVD risk of diabetesDiabetic Kidney Disease Screening WHEN Type 1: after 5 years, then annually Type 2: at diagnosis, then annually HOW Albumin-to-Creatinine ratio in random urine Mi

3、croalbuminuria = 30-300 mg/g Macroproteinuria Estimate GFR (eGFR) from serum creatinine using formulas Retinopathy: useful clueStages of CKDStageICD-9GFR (mL/min/1.73M2)1585.1 91 + damage2585.260-89 + damage3585.330-594585.415-295585.5 156585.6ESRD on RRTAction Plan in the Clinic Determine AKI vs. C

4、KD? Estimate GFR and rate of decline Identify kidney disease requiring specific Rx Slow progression of CKD Review medications Identify + treat systemic complications Prepare for replacement therapyDepending on CKD StageFormulas for Estimating GFR Cockcroft-Gault MDRD (Modification of Diet in Renal D

5、isease Study) GFR calculator () GFR depends on: Serum creatinine Age Gender RaceInterventions to Slow CKD Progression Strong evidence Blood pressure control ACEI / ARB Glucose control in DM Weaker evidence Protein restriction Lowering LDL cholesterolManagement of Albuminuria in Normote

6、nsive Diabetic Normotensive DM patients with macroalbuminuria should be treated with ACEI / ARB Treatment with an ACE inhibitor or an ARB should be considered in normotensive persons with diabetes and microalbuminuriaAKI Superimposed on CKD Dehydration BP too low Obstruction Contract dye Drugs Nephr

7、otoxic or allergic or hemodynamic NSAID (including Cox-2 inhibitors) ACEI / ARBSystemic Complications of CKD Hypertension Cardiovascular disease Anemia Calcium-phosphorus-parathyroidAmerican Heart Association Patients with CKD Should be considered as highest-risk group for CVD Should be treated as s

8、uchSarnak, Circ, 2004Left Ventricular Hypertrophy in CKDRisk factors: HTN and AnemiaLevin, AJKD. 1999; Foley, KI, 1995Erythropoietin Stimulating Agent in CKD Administration (SQ q 1-4 wk) Epoietin- (start 75-150 units/kg) Darbepoetin (start 0.45 g/kg) Target Hgb (11-12 g/dL) Adverse effects Iron defi

9、ciency (may need IV iron) HypertensionWhat is Renal Diet? Low sodium Low potassium What about DASH? Low phosphorus Adding glucose and fat targets? Should be individualizedWhen to Start Replacement Therapy Phophorus higher than hct Pale and sallow Needs a razor blade to scratch the itch Vomiting day & night Legs twitching Hands flapping Uremic smell you cannot stand Too late! Should start no later than mildly symptomatic Usually GFR 7-8 mL/minPreparation for RRT GFR 20 mL/min (depends on r