肾性骨病指南

1993
1994
1995
1996
Year of ESRD Incidence or Transplantation
1999 annual report of the US Renal Data System
Cardiovascular Mortality in the General Population and in Dialysis Patients
K/DOQI Clinical Practice Guidelines on Bone Metabolism and Disease in Chronic Kidney Disease
Published October 2003
KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease
James T. McCarthy, MD Mayo Clinic Sharon Moe, MD Indiana University Isidro B. Salusky, MD UCLA School of Medicine Donald J. Sherrard, MD VA Puget Sound Miroslaw Smogorzewski, MD University of Southern California Kline Bolton, MD RPA Liaison
Traditional Risk Factors
Smoking Genetics
Non-traditional Risk Factors
Elevated IL-1, Il-6, TNFa Oxidation (OxLDL) Advanced glycation end-products
Diabetes HTN
/professionals/kdoqi
NKF-K/DOQI Definition of CKD
Structural or functional abnormalities of the kidneys for >3 months, as manifested by either: 1. Kidney damage, with or without decreased GFR, as defined by
1999
2005
DOQI
Dialysis Anemia Access
K/DOQI
KDIGO
*updates
Nutrition (00) Hep C (’08) Dialysis (’01)* Bone/Mineral (’08) Anemia (’01)* Access(‘01)* CKD class. (’02) Bone/Mineral (’03) Lipids (’03) Htn (’04) CV (’05) Diabetes (’07) /welcome.htm
Estimate progression; Treat complications; Prepare for replacement
Prevalence of Abnormal Mineral Metabolism in CKD
>4.6
KI (2007) 71, 31-38. Levin et. al.
Chronic Kidney Disease-Related Mineral and Bone Disorder: Public Health Problem
Kerry Willis PhD National Kidney Foundation
Adjusted 1st Year Patient Death Rates by Treatment Modality and Year of Incidence, 1986-96
Complications 7.7 m 3.8%
11.3 m 5.6% Increased risk
CKD risk reduction; Screening for CKD
0.3 m 0.2% Kidney failure
Replacement by dialysis & transplant
Normal
• kidney transplantation 2. GFR <60 ml/min/1.73 m2, with or without kidney damage
KDOQI: CKD Staging
Stage Description GFR
(ml/min/1.73 m2)
1 2 3 4
Kidney damage with normal or GFR Kidney damage with mild GFR Moderate GFR Severe GFR
“Normal”
“Normal”
35 - 70
70 - 110
Treatment Recommendations (Stages 3 & 4)
• Decrease total body phosphorus burden by dietary restriction and phosphorus binder therapy- 2.7- 4.6 mg/dL; begin when EITHER elevated serum phosphorus OR elevated serum PTH • Treat elevated PTH with active oral vitamin D sterol to target of 35-70 (CKD 3) or 70-110 (CKD 4) pg/mL by intact assay • Normalize serum calcium
Chair: Shaul G. Massry, MD KECK School of Medicine Work Group Members: Glenn M. Chertow, MD, MPH University of California, San Francisco Keith Hruska, MD Barnes Jewish Hospital Craig Langman, MD Children’s Memorial Hospital Hartmut Malluche, MD University of Kentucky Kevin Martin, MD, BCh St. Louis University Linda M. McCann, RD, CSR, LD Satellite Dialysis Centers Vice-Chair: Jack W. Coburn, MD VA Greater Los Angeles
General population
Male Female Black White
Dialysis population
Male Female Black White
100
Annual mortality (%)
10 1
0.1
0.01
25–34
35–44
45–54
55–64
65–74
75–84
85
90 60-89 30-59 15-29
5
Kidney failure
< 15
(or dialysis)
CKD is a Public Health Problem
• CKD is common • CKD is harmful • We have treatment
Conceptual Model for CKD
• pathologic abnormalities • markers of kidney damage
– urinary abnormalities (proteinuria) – blood abnormalities (renal tubular syndromes) – imaging abnormalities
Homocysteine Age Dyslipidemia
Fracபைடு நூலகம்ures
Cardiovascular disease in CKD
Carbonyl stress
Low fetuin-A
Abnormal bone
Abnormal mineral metabolism
Classification Issues in Bone and Mineral Disorders
Treatment Recommendations Stage 5 (dialysis)
• Normalize serum phosphorus by diet and phosphorus binder therapy- 3.5-5.5 mg/dL (1.13 -1.78 mmol/L); limit elemental calcium intake from binders to 1500 mg/day • Treat elevated PTH with active vitamin D sterol to target of 150-300 pg/mL (16-32 pmol/L) by intact assay • Normalize serum calcium- ideally 8.4 -9.5 mg/dL (2.10-2.38 mmol/L), and always < 10.2 mg/dL (2.55 mmol/L); Ca X P < 55 mg2/dL2
• The term renal osteodystrophy is used to describe different entities
• The predominant use is to describe a disorder of bone remodeling. However this does not take into account new data that there is increased morbidity/mortality of abnormal serum biochemistries (i.e. phosphorus), nor increased awareness of vascular disease related to bone and mineral disorders in CKD patients.
K/DOQI™ Clinical Practice Guidelines on Bone Metabolism Target Levels
CKD Stage 3 P (mg/dL) Ca (mg/dL) Intact PTH (pg/mL) *Evidence 2.7 - 4.6 CKD Stage 4 2.7 - 4.6 CKD Stage 5 (on dialysis) 3.5 - 5.5* 8.4 - 9.5; Hypercalcemia = >10.2 150 - 300*
Damage
GFR
CKD death
Screening for CKD risk factors: diabetes hypertension age >60 family history US ethnic minorities
Diagnosis & treatment; Treat comorbid conditions; Slow progression
35
Dialysis All ESRD Cadaveric Transplant Living Related Transplant
Deaths/100 patient-years
30 25
21.5
20 15 10 5 0 1986
19.8
4.1 2.0
1987
1988
1989
1990
1991
1992
Age (years)
NKF’s Clinical Practice Guidelines
• • • • • Evidence Based Review Publication and Dissemination Implementation Reassess Impact Update
1997