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Chronic Kidney

Disease (CKD)

. .

service plan .

1. Excretory & Regulatory

Solute : electrolyte & non-electrolyte

Solvent : water

2. Synthetic

Erythropoietin RBC stimulation

1,25-(OH)2 Vitamin D3 (Calcitriol)

Etc.

Renal Function

Renal Function GFR

(90 ml/min./1.73 m2)

1. Direct clearance of substance

Creatinine

CCr = UCr x V (urine volume) (ml/min.)

PCr

Inulin Gold standard

Radioisotope

Cystatin C

GFR Measurement

2. Formula

Cockcroft-Gault CCr (ml/min)

= (140 - Age) x Body weight x (0.85 if Female)

72 x SCr

MDRD (with non-enzymatic method) eGFR (ml/min/1.73m2)

= 186 x (SCr)-1.154 x (Age)-0.203 x (0.742 if Female)

x (1.210 if African-American)

GFR Measurement

2. Formula

CKD-EPI (with enzymatic method)

GFR Measurement

Serum

Cr eGFR (ml/min/1.73m2)

Female 0.7 144 (Scr/0.7)

-0.329 (0.993)Age

> 0.7 144 (Scr/0.7)-1.209 (0.993)Age

Male 0.9 141 (Scr/0.9)

-0.411 (0.993)Age

> 0.9 141 (Scr/0.9)-1.209 (0.993)Age

Definition : Renal function

GFR (Glomerular filtration rate)

Uremic toxin excretion

Serum BUN, Cr

Renal Failure

AKI (Acute Kidney Injury)

Renal function in 48 hours

CKD (Chronic Kidney Disease)

Renal function in > 3 months

Renal Failure

AKI CKD

Reversible !

Irreversible

Chronic Kidney Disease

(CKD)

Definition: duration 3 months

1. Kidney damage

Pathology

Structure: Stone, Cyst, Mass, etc.

Function: Proteinuria, Albuminuria

Hematuria, Abnormal Cast

And / Or

2. GFR < 60 ml/min/1.73 m2

Clues in Diagnosis of CKD

(from AKI)

1. Uremia > 3 months

- Previous high serum BUN, Cr

- Clinical : nausea, edema, hematuria,

nocturia

2. Small size kidneys : < 9 cm

3. U/A: Broad cast

4. Anemia

5. Renal osteodystrophy

Stages of CKD Stage Description GFR Prevalence in THAI (2550)

1 Kidney damage with normal GFR

90

2 Kidney damage with mild GFR

60-89

3a Mild to moderate GFR

45-59

3b Moderate to severe GFR

30-44

4 Severe GFR 15-29

5 Kidney failure < 15

8.9 %

8.7 %

(4,500,000 Thai)

(120,000 ChiangMai)

Survival curves for all-cause mortality by urinary protein concentration (U-Prot) in NIDDM and non-DM patients

Stroke. 1996;27:2033-2039

Stages of CKD

Morbidity Risk

Green Low

Yellow Moderate

Orange High

Red Very High

CKD

18.3% increased

CKD

RRT UC 2554 3,000 2558 5,247 2559 6,318

ESRD 2555 (prevalence) 1. DM = 36.6% 2. HT = 26.8% 3. Unknown = 22.8%

Failure of CKD screening?

20.4%

ESRD 2555 (incicence) 1. DM = 40.7% 2. HT = 27.3% 3. Unknown = 13.7%

Better CKD screening?

>10,000

/

(Renal Replacement Therapy, RRT) . (2559)

ESRD RRT () ESRD ()

(%)

.

(+ Outsource)

.

HD 496 1,434 1,782

CAPD 618 574 882

KT 34 1,114

(35%) 2,042 (65%)

3,156 4,601 68.6 %

.. .. 2558

.. .. 2559

. . 2559

.. .. 2559

1. eGFR < 4 ml/min/1.72 m2/yr

50%

61.0 % 60.1 % 59.6 % 61.4 %

2. CKD (DM, HT)

60 % 70 % 80 % 90 %

12.0 % 30.6 % 46.9 % 64.4 %

3. CKD Clinic . F2

M1 100 %

M2 100 %

F2 100 %

100 % (3/3)

100 % (6/6)

100 % (23/23)

- CKD 11 - NCD 12

. 2559

- 64.4 %

1 - 67.1 %

- 69.0 %

Gap CKD

..

CMBIS (

CKD ..)

CKD ( eGFR < 4 ml/min/1.72 m2/yr) 2559 61.4% ( 50%) 2560 65% CKD Clinic

2560 2561 2562 2563 2564

Service Excellence (6 23 )

6: (Service Plan) 14

16:

1. eGFR < 4 ml/min/1.72 m2/yr

65 % 66 % 67 % 68 % 69 %

2560 - 2564

2560

1. CAPD . 2560

2. 2

. 2560, . 2560

3. CKD Clinic . F 5 (., ., ., ., .)

. . 2560

4.

. 2560 ( service plan )

Health Outcome 1. CKD > 65% ( eGFR < 4 ml/min/1.73 m2/yr) ( : HDC .)

Service Outcome 1. > 50% . F3 2. . M2, F1, F2 > 50% > 70 100 ( 1 : 50 , 2 : 50 ) 3. serum Cr enzymatic method 100% . F2 4. DM, HT CKD > 80% ( : HDC .)

/ 2560

http://www.thaincd.com/document/file/download/knowledge/ (CKD).pdf

/

/

ESRD

dialysis

NCD clinic

&

Peritoneal dialysis

COE

ESRD Palliative

Care

1.

2.

/ KM

SI3M

1.

NCD-CKD system manager

2. (HIS)

SI3M

CKD clinic NCD clinic

4

NCD clinic

(DHS)

7

1

district health system

(..++)

CKD clinic

.

CKD V/S

. . 1

(.) (care giver)

Initial investigation for CKD

U/A : proteinuria, albuminuria, sediment Protein dipstick > +1

DM, HT: Albumin dipstick > +1 (20 mg/L)

or urine albumin-creatinine ratio (UACR) > 0.03 (30 mg/g)

RBC > 5 / HPF

Serum creatinine, eGFR

Plain KUB (or ultrasound)

Others (depend on patient)

3 CKD

CKD 60

(autoimmune diseases)

(systemic infection)

CKD (gout) NSAIDs

(nephrotoxic agents) (renal mass)

3

Screening for Proteinuria in DM = 50

= 270

eGFR urine analysis (UA) /

eGFR > 60 mL/min/1.73m2 UA ( microalbuminuria DM)

eGFR 60 U prot > 1+

eGFR 15-59 (CKD stage 3-4) eGFR 60 mL/min/1.73m2 UA

serum creatinine eGFR

serum creatinine enzymatic method non-enzymatic method

enzymatic method CKD-EPI eGFR

serum creatinine non-enzymatic method non-enzymatic formula MDRD eGFR

2

Key message ()

2

/

key message

Key message /

2

NCD/CKD

.

3

NCD/CKD

NCD/CKD

.

4

5

CKD Clinic 1. 2.

3.

4. 5.

(function) NCD clinic 4 1. 5

1. 2. case manager/coordinator 3. 4. /

5.

2.

1. 2. 3.

4.

3. 1. 2. 3.

4. (43 ) Health Data Center

4.

.

1. index case

eGFR Group Individual education

(Discharge) Vascular Access ESRD

2. ./. case CKD stage 3-5 case

F/U

serum Cr enzymatic method . F 2560

DHS DHS

.

.

./. ./.

. . . .

CKD stage

Stage 4-5

ESRD RRT RRT

Stage 3-4

Stage 1-3

M2/F CKD stage 3-4 DM, HT

DM, HT CKD stage 1-2 3 F/U clinic DM, HT DM DM clinic HT DM HT clinic CKD 3 1 eGFR 4 CKD clinic

w1 w2 w3 w4

A B

C

D

M2/F

NCD

NCD-CKD clinic

CKD clinic

M2/F

(5-10 )

( ) , , ,

(30-40 )

(5-10 )

(30-40 )

A/S/M1 CKD stage 4-5

DM, HT M2/F

w1 w2 w3 w4

1 A B C D

2

clinic . NCD clinic ( )

DM clinic Cardio clinic CKD clinic

clinic clinic

A/S/M1

( ) , , ,

:

RRT

CKD clinic

2

1. DM, HT

2. DM, HT

1

1. CKD Clinic .

14

1. - CKD BP < 140/90 mmHg

2. - ACEi/ARB

3. - eGFR < 4 ml/min/1.72 m2/yr

4. - Hb > 10 gm/dl

CKD clinic

14 ()

5. - () - HbA1c 6.5% 7.5%

6. - Statin

7. - serum K < 5.5 mEq/L

8. - serum HCO3 > 22 mEq/L

CKD clinic

14 ()

9. - urine protein

10. - UPCR

11. - UPCR < 500 mg/g cr

12. - Serum PO4 4.6 mg%

13. - Serum iPTH (< 500)

14. emergency vascular access RRT

CKD .

.. . . .

PREVALENCE OF CKD

Stage Description GFR Thai Seek project (2550)

0 At increased risk 90

Recommended

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