肾脏疾病的诊治进展与临证经验.ppt
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1、肾脏疾病的诊治进展与临证经验,China-Japan Friendship Hospital, Beijing, China Li Ping,肾脏疾病的新分类,急性肾脏损伤(Acute Kidney Injuries, AKI) 慢性肾脏病(Chronic Kidney Disease, 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。,AKIN Organiz
2、ing Committee 2005,2005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,(Acute rise 0.5 mg/dl),2005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,J Himmelfarb. Kidney International (2007) 71, 971976.,AKI的RIFLE分期与预后,2005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. Nephrol Dial Transplant (2005) 20: 35436
3、0,R,I,F,L+E,尿量能否界定CRRT的介入时机,A Randomized Controlled study 28例冠脉搭桥术后AKI患者 Early group 尿量30ml/h 持续3h , 14 cases Late group 尿量20ml/h 持续2h, 14 cases,86%,14%,Early group,Late group,Souichi. Hemodialysis International. 2004; 8: 320-325,RIFLE分期与CRRT介入时机,Chih-Chung Shiao. Critical Care. 2009, 13:R171,25%,27
4、%,13%,Chronic kidney disease(CKD),Chronic kidney disease (CKD) is a worldwide public health problem with an increasing incidence and prevalence, poor outcomes, and high cost. Outcomes of CKD include not only kidney failure but also complications of decreased kidney function and cardiovascular diseas
5、e.,Levey AS, et al. Ann Intern Med. 2003; 139: 137-147.,Kidney damage,Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Persistent proteinuria is the principal marker of kidney damage. An albumin creatinine
6、ratio greater than 30 mg/g in two of three spot urine specimens is usually considered abnormal.,Levey AS, et al. Kidney Int. 2005; 67: 2089-2100.,NKF. Am J Kidney Dis. 2002; 39: S1-246.,GFR can be estimated from calibrated serum creatinine and estimating equations, such as the Modification of Diet i
7、n Renal Disease (MDRD) Study equation or the Cockcroft-Gault formula. The MDRD formula is recommended by European and American guidelines for estimating GFR,which has not been fully validated in different populations and at different stages of CKD,NKF. Am J Kidney Dis. 2002; 39: S1-246.,GFR,To evalu
8、ate whether the MDRD equations could be applied accurately to Chinese patients with CKD, GFR estimated by using MDRD equation 7 (7GFR), the abbreviated MDRD equation (aGFR), and the Cockcroft-Gault equation (cGFR) were compared in patients with different stages of CKD. Dual plasma sampling of techne
9、tium Tc 99m-labeled diethylene triamine pentaacetic acid plasma clearance was used as the reference standard GFR (sGFR) for comparison of 7GFRs, aGFRs, and cGFRs at different stages of CKD. The study enrolled 261 patients with CKD, including 146 men and 115 women. All patients were older than 18 yea
10、rs .,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,Comparison of 7GFR with sGFR showed that 7GFR correlated significantly with sGFR, but the regression line was significantly different from the identical line,Comparison of Equation-Estimated GFRs With 99mTc-DTPA Plasma Clearance,Zuo L, et al. A
11、m J Kidney Dis. 2005; 45(3):463-72.,The regression line showed that MDRD equation 7 overestimated GFR at low levels and underestimated GFR at near-normal levels,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,*P 0.05 comparing estimated GFR with sGFR. P 0.001 comparing accuracies of an equation w
12、ith those in CKD stages 4 to 5.,Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.,*P 0.05 comparing estimated GFR with sGFR. P 0.001 comparing accuracies of an equation with those in CKD stages 4 to 5. P 0.001 comparing accuracies of the C-G equation with those of the MDRD equations.,Zuo L, et al.
13、Am J Kidney Dis. 2005; 45(3):463-72.,The MDRD equation 7 to estimate GFR (7GFR, ml/min per 1.73m2) = 170 Pcr-0.999 age-0.176 BUN-0.170 albumin0.318 0.762 ( if female) 1.211 ( if Chinese) Abbreviated MDRD equation to estimate GFR (aGFR, ml/min per 1.73m2) = 186 Pcr-1.154 age-0.203 0.742 ( if female)
14、1.233 ( if Chinese),Where Pcr is in mg/dl, BUN is in mg/dl, albumin is in g/dl, and age is in years.,Ma et al. J Am Soc Nephrol 2006; 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%,Third National Health and Nutr
15、ition Examination Survey,Stage(Ccr:1529ml/min),Stage(Ccr15ml/min),Total Subjects,7.60,4.3%,0.40,0.2%,0.30,0.2%,Coresh J, et al. Am J Kidney Dis. 2003; 41: 1-12.,Chadban SJ, et al. J Am Soc Nephrol. 2003;14(7 Suppl 2):S131-8.,Approximately 16.4% have at least one indicator of kidney damage,9.7%,Renal
16、 Impairment,Proteinumia,1.1%,Hematuria,3.7%,0.1%,0.3%,0.6%,0.8%,11,247 Australians aged 25 yr or over,GFR 60 ml/min/1.73m2 (11.2%),Chen J, et al. Kidney Int. 2005; 68(6):2837-45,The overall prevalence of CKD with GFR 60 mL/min/1.73m2 was 2.53%.,Chen J, et al. Kidney Int. 2005; 68(6):2837-45.,Overall
17、, the age-standardized prevalences of GFR 60 to 89, 30 to 59, and 30 mL/min/1.73m2 were 39.4%, 2.4%, and 0.14%, respectively.,Subjects: 2353 residents older than 40 years. Results: Approximately 11.3% of subjects had at least one indicator of kidney damage. (1).Albuminuria(albumin/creatinine30mg/g),
18、 6.2%; (2).GFR60ml/min/1.73m2, 5.2%; (3).Hematuria, 0.8%; (4).Non-infective pyuria, 0.09%.,Zhang L, et al. Nephrol Dial Transplant. 2007; 22: 1093,Cases of renal biopsies performed each year,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,*P 0.01; *P 0.001, compared with 1985.,Li LS, Liu ZH. Kidney I
19、nt. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Liu G, et al. J Clin Intern Med. 2004; 21: 834-838,The worldwide rise in the number of p
20、atients with CKD is reflected in the increasing number of people with end-stage renal disease (ESRD) treated by renal replacement therapydialysis or transplantation. Two factors related to the prevalence of ESRD are important. The first is the ageing of the population; The second factor is the globa
21、l epidemic of type 2 diabetes mellitus.,Lysaght MJ. J Am Soc Nephrol. 2002; 13: 37. United States Renal Data System. Am J Kidney Dis. 2003; 42: S37. King H, et al. Diabetes Care. 1998; 21: 1414.,Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.,Histology of Chinese chronic renal failure (Scr3mg/dl, N =
22、 607),According to the registration of dialysis and transplantation in China in 1999, 41775 patients underwent maintenance dialysis; among them, 89.5% was hemodialysis (HD) and 10.5% was peritoneal dialysis (PD). The first cause of CRF in HD patients was glomerulonephritis (50%), and then diabetic n
23、ephropathy (13.5%), hypertensive nephrosclerosis (8.9%).,Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78.,These data showed that the annual incidence rate of dialysis in Shanghai, China was coincident with the annual average incidence of ESRD in Europe. However, prev
24、alence of dialysis has marked difference between Europe and Shanghai. The financial problem may be the most important cause of the difference formation.,Meguid El, et al. Lancet. 2005; 365: 331-340. Shanghai dialysis and transplantation registration group. Chin J Nephrol. 2001; 17: 83-85.,The criter
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- 肾脏 疾病 诊治 进展 经验
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