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Curs 5 27 noiembrie 2015
Prof. Univ. Dr. Eugen MoaProf. Univ. Dr. Eugen Moa
Disciplina de NefrologieDisciplina de Nefrologie
Universitatea de Medicina si Farmacie din Craiova
Boala cronica de rinichiBoala cronica de rinichi
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1.Conceptul de Boala cronic derinichi2. Diagnosticul precoce al BCR
3. Abordarea BCR n stadiile 3-54. Este posibil optimiarea ngri!iriiBCR
Agenda
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C"ronic #idne$ Disease %C#D& C#D is a gradual and permanent loss o' (idne$
'unction C#D most 're)uentl$ results 'rom anot"er
disease t"at damages t"e (idne$s* primaril$diabetes or "ig" blood pressure
As C#D progresses* (idne$ 'unction declines and
e+entuall$ patients reac" End ,tage RenalDisease and need renal replacement t"erap$ %atransplant or dial$sis&
CKD
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Kidney n!erna!iona" #u$$"emen!s %201&' &( 1)*+2
KDIGO 2012 Guideline for Evaluation and Management of CKD
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5
,edu-erea$ersis!en! a ,/
noma"ii* morfo"ogi-e rena"e* bio-3imi-e
%s4nge sau urin'
nsufi-ienarena" -roni-
Eamen sumar deurin %di$6s!i-' %Crea!inin seri-'
Es!imare ,/
De!erminarea ra$or!u"ui"buminu8Crea!inin %,C' 9n urin
s$on!an emis
1
2
2 de!erminri "a & "uni
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KDIGO 2012 Guideline for Evaluation and Management of CKD
Kidney n!erna!iona" #u$$"emen!s %201&' &( 1)*+2
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Kidney n!erna!iona" #u$$"emen!s %201&' &( 1)*+2
KDIGO 2012 Guideline for Evaluation and Management of CKD
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Kidney Disease C"assifi-a!ion!o n-"ude "buminuria
:3e ;a!iona" Kidney /ounda!ion 3as u$da!ed i!s-3roni- idney disease %CKD'-"assifi-a!ion sys!em!o in-"ude
6 -ause6 g"omeru"ar fi"!ra!ion ra!e %/,'
6 a"buminuria "eve"s
Kidney Int. 201&
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Kidney n!erna!iona" #u$$"emen!s %201&' &( 1)*+2
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Kidney n!erna!iona" #u$$"emen!s %201&' &( 1)*+2
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,tadiile BCR
11
#!adiu 1 #!adiu 2 #!adiu 5#!adiu &a #!adiu =
De$"in -om$ensa!> ?Com$ensa!>Po"iurie
?De-om$ensa!> Uremie/Diali
#!adiu &b
,e!en ie a@o!a! fi
01m/min 1-m/min
51-45m/min
44-3m/min
21-5m/min
65m/mine78R
Risc categ.2Risc categ.
3
Risc categ.
RAC63
RAC 3-3
RAC 93
Risc categ.2Risc categ.
3
Risc categ.
Risc categ.3Risc categ.
4
Risc categ.2
Risc categ.3Risc categ.
4
Risc categ.3
Risc categ.4Risc categ.
4
Risc categ.4
Risc categ.4Risc categ.
4
Risc categ.4
Categoriile de risc %mortalitate general* C:* diali& e+aluate con'orme+e$ A et al* Kidney Int %2& ; raportul albumin/creatinin urinar== eR87 > 8iltratul glomerular estimat plec?nd de la creatinina ser
Risc scaut
Risc moderatcrescut
Risc inalt
Risc 'oarteinalt
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Epidemiologia BCR
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:3e g"oba" e$idemi- of -3roni- idney disease %CKD'
is a signifi-an! $ub"i- 3ea"!3 issue affe-!ing u$ !o 10A
of !3e adu"! $o$u"a!ion in !3e UK( and 11A in !3e U#.
P,EBE;CE
Medscape Diabetes & Endocrinology 2011
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0,3
0,4
7,6
5,3
5,9
Milioane de pacieni
15-29
30-59
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Chronic !idne" diseaseChronic !idne" disease#$%DA&'$$#$%DA&'$$
%. Mota 1(()(Maria Mota1(*()( +imona #opa2(*()( Adrian Co+ic ()* 7abriel @ircescu ()* Adalbert ,c"iller ()* @ircea enescu ()* Dan:lduiu ()* @irela 7"erman-Cprioar ()* Cristian ,eranceanu ()* iliana u ()* Costel ,p?nu ()* Constantin :eran ()* Aurel Bio()* Cristina Cpu ()* aul 7usbet"-atomir ()* iliana 7?rnea ()* Foan @i"ai aiu ()* G+idiu 7olea ()* :iorel Fancu ?tea ()
1National Main Investigator, 2National Sub-Investigator, 3Romanian Society of Neprology, !Romanian Society of "iabetes, Nutritionand Metabolic "iseases, #Steering $ommitee
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De,nition of terms
HC#D Ias dened as e78R 6 m/minper .
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C7D89 e0F$ :MD$D;3ml-min-1(5mp and-or
AC$63mg-gC7D
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C7D89 e0F$ :C7D;3ml-min-1(5mp and-or
AC$63mg-gC7D
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. Conceptul de Boala cronic de rinic"i2. Diagnosticul precoce al BC$
3. Abordarea BCR n stadiile 3-54. Este posibil optimiarea ngri!irii BCR
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Diagnosticul BCR
Diagnosticul Bolii cronice de rinic"ipresupune;* 2 consultaJii la 3 luni inter+al* 2 determinri creatinin seric :eF0
3m4-min;* 2 determinri ale albuminei= Ki creatininei
urinare= n urina spontan emis :$AC?3mg-g;
&otal @3 $'N
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@L,MRAREA 8MNCOFEF RENAE
Ce este R87P
R87 este egal cu
totalul ratelor ltrriine'ronilor 'uncionalidin rinic"i.
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E:AMAREA 8MNCOFEF RENAE
Ce indic R87P
$F0este acceptat ca ind cel maibun indeQ al 'unciei renale i sepoate estima utili?nd creatinina
seric* seQul* +?rsta* greutatea irasa.
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sCr 120( CrC" 2) m"8min sCr 120( CrC" 1&0 m"8min
EBU,E /U;C:E ,E;E
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E:AMAREA 8MNCFEF RENAE
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E:AMAREA 8MNCFEF RENAE
Cum a'ectea +?rsta R87P
R87 scade cu +?rsta c"iar i la pacieni 'arBCR.otui eQist o mare +ariabilitateindi+idual i moti+ele declinului nu suntcunoscute.
G R87 scaut la +?rstnici este un predictorindependent el e+oluiei ne'a+orabile cum ar
BC: i decesul.
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E:AMAREA 8MNCFEF RENAE
,cderea R87 la+?rstnicinecesit
a!ustarea doelordemedicamente.
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E:AMAREA 8MNCFEF RENAE
Ce este formula Croc!croft< 0ault
A 'ost de+oltat n 1
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E:AMAREA 8MNCFEF RENAE
Ce repreint ecuaia MD$D
Este o ecuaie cu 4 +ariabile de+oltat n111 'olosind date de la 2 de pacienicu BCR i R87 5-1 ml/min/.
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Rata ltrrii glomerulare
formula MD$D *
R87 %ml/min/* *23& Q *
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%stimarea $F0 cu C"statin C
C"statin C9 protein cu greutate molecularmic* produs de toate celulele nucleate* cu orata de producie constant* neinUuentat de
dieta* +?rst sau masa muscular a pacientului.
C$statin C ndeplineste criteriile de mar(erendogen al R87
nu a intrat n practica ne'rologic curent* ind'olosit doar n cercetare
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%A4UA$%A FUNC&>%>$%NA4%
Ce este ecuaia C7D
C#D-EF 'ost de+oltat n 21 pentru aestima R87 utiliind creatinina serica*+?rst* seQ i ras i are o acurateeasemntoare cu @DRD in subgrupul de
pacieni cu R876 ml/min i mult maimare in subgrupul cu R879 ml/min
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>denti,carea populaEiei larisc < Cauele BCR
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Primary Diagnosis for Pa!ien!s 3o #!ar! Dia"ysisPrimary Diagnosis for Pa!ien!s 3o #!ar! Dia"ysis
Dia,ete-
.0$1/
perten-ion
2*/
Glomerulonephriti-
1%/
Other
10/
United States Renal Data System. Annual data report. 2000.
o$ of patient-
3ro4ection
+./ CI
1)= 1) 1))2 1))+ 2000 200= 2000
100
200
&00
=00
500
+00
700
r25++$(/2&%6.2&
2(16%..
.2062&0
;o
.ofdia"ysis$a!ien!s
%!3ousands'
Diabe!es and Fy$er!ension 6:3e Mos! Common Causes of E#,D
VoI Diabetes and Vig" Blood ressure
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VoI Diabetes and Vig" Blood ressureCause #idne$ Damage
igh ,lood pre--uresi"en!"y damages !3e ar!eries and -a$i""aries(!3e added $ressure -auses !3e Ga""s of !3e vesse"s in !3e idney !obrea and s-ar
n dia,ete-inf"amma!ion of b"ood vesse"s and -3anges in b"oodsugar "eve"s "ead !o damage of !3e idney
:3ese redu-e !3e b"ood vesse" diame!er< fur!3er in-reasing b"ood$ressure and -ausing more damage
FE:FH D#E#ED
:3e /i"!ering Uni! of !3e Kidney * :3e "omeru"us
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Cauele BCR
GWVare A@ et al* AX#D 22 51;53-52
Cardiologie
Dia.e
tolo
gi
e
Nefr
olo
gie
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opulaJia cu risc de BCR1. Diabe! @a3ara!
2. F:
&. I50 ani
=. Jo"i -ardio6vas-u"are %P( M( BC( JBP'
5. Jo"i s!ru-!ura"e a"e rini-3iu"ui( "i!ia@ rena"( 3i$er!rofie de$ros!a!'
+. Jo"i sis!emi-e %"u$us eri!ema!os sis!emi-'
7. s!ori- fami"ia" $o@i!iv %rude de gradu" -u nefro$a!ii sau sub
!ra!amen! subs!i!u!iv rena"'
. , 9n an!e-ende!e
). Fema!urie sau $ro!einurie des-o$eri!e 9n!4m$"!or
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Algoritmul dediagnostic
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4
opulaJie larisc
:8;
%-&
$AC
e$F0
$AC
e$F0
%-&
AsistenJ uual @8
$AC33g-g
i-saue$F0
?3m4-min
rotocol asistenJ @8rotocol asistenJ N
$AC?33mg-g
i-saue$F0
3m4-min
Retestare anual
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Diagnosticul BC$ Gn stadiiiniEiale :1
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. Conceptul de Boala cronic de rinic"i2. Diagnosticul precoce al BCR. Aordarea BC$ Gn stadiile
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@ani'estri clinice n stadiile 3-5BCR
43&%
#!adiu 1 #!adiu 2 #!adiu 5#!adiu &a #!adiu =
Medici de familie Nefrologi
De$"in -om$ensa!> ?Com$ensa!>
Po"iurie
?De-om$ensa!> Uremie/Diali
#!adiu &b
,e!en ie a@o!a! fi
78 F: %506+0A'FB#nemieF 6PF P=( 3Ca(F P:F( 3 vi!D
F: %506+0A'FB#nemiaF 6PF P=( 3Ca(F P:F( 3 vi!D-ido@F KMa"nu!ri ie
F: %+0670A'FB#nemieF 6PF P=( 3Ca(F P:F( 3 vi!D-ido@F K,e!en iea$LsareMa"nu!ri ie
78 F: %I70A'FB#nemieF 6PF P=( 3Ca(F P:F( 3 vi!D-ido@F K,e!en iea$LsareMa"nu!ri ie
9e:iuni vi-cerale
Peri-ardi!6en!ero-o"i!Po"inevri!En-efa"o$a!ie
01m/min 1-m/min
51-45m/min
44-3m/min
21-5m/min
65m/mine78R
Risc categ.2Risc categ.3
Risc categ.
RAC63
RAC 3-3
RAC 93
Risc categ.2Risc categ.3
Risc categ.
Risc categ.3Risc categ.4
Risc categ.2
Risc categ.3Risc categ.4
Risc categ.3
Risc categ.4Risc categ.4
Risc categ.4
Risc categ.4Risc categ.4
Risc categ.4
Categoriile de risc %mortalitate general* C:* diali& e+aluate con'orm e+e$ A et al* Kidney Int %2& ; raportul albumin/creatinin urinar== eR87 > 8iltratul glomerular estimat plec?nd de la creatinina seric
#AUC>+>M#&'MA&>CH
@onitoriarea n stadiile 3 5 BCR
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@onitoriarea n stadiile 3-5 BCR
44&&
#!adiu 1 #!adiu 2 #!adiu 5#!adiu &a #!adiu =
Medici de familie Nefrologi
De$"in -om$ensa!> ?Com$ensa!>Po"iurie
?De-om$ensa!> Uremie/Diali
#!adiu &b
,e!en ie a@o!a! fi
I&A
#A
$ACeF0 :sCr;
Ag-AcICJBK
VbCa* G4* V*25%GV&D
#A
$ACeF0 :sCr;
Ag-AcICJBK
I( :fertina(&+A&;
Ca( #'*( #&I(2):'I;D
EAB* Na* #
#A
$ACeF0 :sCr;
Ag-Ac IC-BK
I :feritina(
&A+&;Ca( #'*( #&I(2):'I;D
%AB( Na( 7
Albuminaseric
I&A
#A
$ACeF0 :sCr;
Ag-Ac IC-BK
I :feritina(
&+A&;Ca( #'*( #&I(2):'I;D
%AB( Na( 7
Aluminasericeiuni+isceraleericardit
7-enterocolitoline+rit
01m/min 1-m/min
51-45m/min
44-3m/min
21-5m/min
65m/mine78R
Risc categ.2Risc categ.3
Risc categ.
ACR63
ACR 3-3
ACR 93
Risc categ.2Risc categ.3
Risc categ.
Risc categ.3Risc categ.4
Risc categ.2
Risc categ.3Risc categ.4
Ris( categ.3
Risc categ.4Risc categ.4
Risc categ.4
Risc categ.4Risc categ.4
Risc categ.4
1 "un& "uni+ "uni
Consu"!a ii * 2 Consu"!a ii * = Consu"!a ii * 12
+ "uni
Consu"!a ii * 2
= 8rec+enJa poate +aria n 'uncJie de situaJia clinic sau de tipul tratamentuluiY E+aluarea serologiei pentru +irusurile "epatitice %B* C& trebuie 'cut imediat dup diagnostic* urmat de +accinare* dup ca
n!erva" moni!ori@are
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Kidney n!erna!iona" #u$$"emen!s %201&' &( 1)*+2
@suri terapeutice
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@suri terapeutice
4&'
#!adiu 1 #!adiu 2 #!adiu 5#!adiu &a #!adiu =
Medici de familie Nefrologi
De$"in -om$ensa!> ?Com$ensa!>Po"iurie
?De-om$ensa!> Uremie/Diali
#!adiu &b
,e!en ie a@o!a! fi
I&AI&A
01m/min 1-m/min
51-45m/min
44-3m/min
21-5m/min
65m/mine78R
Risc categ.2Risc categ.3
Risc categ.
ACR63
ACR 3-3
ACR 93
Risc categ.2Risc categ.3
Risc categ.
Risc categ.3Risc categ.4
Risc categ.2
Risc categ.3Risc categ.4
Ris( categ.3
Risc categ.4Risc categ.4
Risc categ.4
Risc categ.4Risc categ.4
Risc categ.4
1 "un& "uni+ "uni
Consu"!a ii * 2 Consu"!a ii * = Consu"!a ii * 12
+ "uni
Consu"!a ii * 2
= 8rec+enJa poate +aria n 'uncJie de situaJia clinic sau de tipul tratamentului
Z [n ne'ropatiile cu mecanism imunologicY E+aluarea serologiei pentru +irusurile "epatitice %B* C& trebuie 'cut imediat dup diagnostic* urmat de +accinare* dup ca.
n!erva" moni!ori@are
n!i3i$er!ensive
Diure!i-e
Fi$o"i$emian!e
C3e"a!ori( Bi! D(rvi! D
#E( fier P8B
n!i3i$er!ensive
Diure!i-e
Fi$o"i$emian!e
C3e"a!ori( Bi! D(rvi! D
#E( fier P8B
Ji-arbona!
Ce!oana"ogi aaesen ia"i
n!i3i$er!ensive
Diure!i-e
Fi$o"i$emian!e
C3e"a!ori( Bi! D(rvi! D
#E( fier P8B
Ji-arbona!
Ce!oana"ogi aaesen ia"i
munosu$resoare( -or!i-oi@i
Alegeremetod
n!i3i$er!ensive
Diure!i-e
Fi$o"i$emian!e
C3e"a!ori( Bi! D(rvi! D
#E( fier P8B
Cale abord
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acienJii cu BCR stadiile 3-5 Ki/sau cu risc nalttrebuie monitoriaJi de ne'rologi
CreKterea ecienJei ngri!irii presupune;* Colaboarea cu medicii de 'amilie* Ameliorarea cadrului legislati+ %barem in+estigaJii Ki
medicamente* tari'e pentru consultaJii&
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Kidney n!erna!iona" #u$$"emen!s %201&' &( 1)*+2
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Metodele de tratament sustitutiv renal sunt compleele treuie utiliate astfel GncLt s permit91;$ecuperarea cLt mai un a pacientului
2;Cea mai un utiliare a resurselor
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Fntegrarea metodelor detratament substituti+ renal estenecesar at?t din punct de
+edere medical c?t Ki din punctde +edere economic \Educarea bolna+ilor !oac un rol
central n integrarea metodelorde tratament substituti+ renal \
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. Conceptul de Boala cronic de rinic"i2. Diagnosticul precoce al BCR
3. Abordarea BCR n stadiile 3-5*. %ste posiil optimiarea Gngri/irii BC$
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CondiJii
BC$ stadiile 1
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Death i- far more common than
E;RD in CKD patient-
Kei!3 D# e! a". r-3 n!ern Med 200=< 1+= +5)6++&
1$1
1+$.
1$%
2&$%1+$+
&.$*
0
.
10
1.
20
2.
%0
%.
&0
&.
.0
2 % &
Ked up for up to '' month-
E;RD
Death
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guide"ines.diabe!es.-a N 16006J;:; %22+6=+=' Ndiabe!es.-a
Co$yrig3! O 201& Canadian Diabe!es sso-ia!ion
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Fn Romania eQista* con'orm studiului REDAGRR*.34. %@DRD&* ..
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Boala cronic de rinic"i %BCR& este o boal cuetiologie multi'actorial i necesit o abordaremultidisciplinar
Ec"ipa multidisciplinar pentru ingri!irea integrata pacienilor cu boala cronic de rinic"i trebuie sainclud medici de 'amilie* ne'rologi* diabetologi*cardiologi
entru diagnosticul bolii cronice de rinic"i suntnecesare dou consultaii la inter+al de 3 luni cudeterminarea creatininei serice si estimarea R87%eR87 6m/min&* determinri ale albuminei= Ki
@esa!e