Ασθενής µε ΝεφρικήΑνεπάρκεια

∆ηµήτριος Β. Βλαχάκος

Αναπλ. Καθηγητής Παθολογίας-Νεφρολογίας

Β΄ Προπαιδευτική Παθολογική Κλινική

Πανεπιστηµιακό Γενικό Νοσοκοµείο «ΑΤΤΙΚΟΝ»

General Medicare: population 2007(n = 26,313,160; mean age 75.5)

Data from Medicare database, patients aged ≥ 65 yoUS Renal Data System. 2009 Annual Report.

CKD 9.8%

Diabetes24.8%

CVD 49.4%

Υπερτασικά Ιατρεία στην Ελλάδα

ανά ειδικότητα

Η υπέρταση «ταξιδεύει» µε τον νεφρό!

PHR PNR HTN

ΗΤ ΝΤ ΗΤ

ΝΤ ΗΤ ΝΤ

ESRD Due to Any CauseIn 332,544 Men Screened for MRFIT

Adjusted Relative Risk§

1,0 1,2

22.1*

11.2*

6*

3.1*1.9*

0,0

5,0

10,0

15,0

20,0

25,0

Optimal Normal High

Normal

Stage 1 Stage 2 Stage 3 Stage 4

Blood Pressure Category

Adju

ste

d R

ela

tive

Ris

k

Hypertension

§ Men with optimal blood pressure was the reference category.

Klag MJ, et al. NEJM 1996;334:13-18.

* p<0.001

World Kidney Day 2009“Hypertension and Kidney Disease: a Marriage that

Should Be Prevented”

Age and Hypertension

ΕΠΙ∆ΗΜΙΑ

ΠΑΧΥΣΑΡΚΙΑΣ

9%

0.2%

3%

Patients aware of having CKD…… .

100%

50%

7.5%

5%

Effect of Muscle Mass on Serum CreatinineEffect of Muscle Mass on Serum Creatinine

Crea 1.3 mg/dl

GFR 106 ml/minGFR 36 ml/min

Estimates of GFR vs. Measured GFR

in MDRD Study Baseline Cohort

AJKD 2002: 39(2)

Ρυθµός Σπειραµατικής διήθησης

(ml/min)

(140-ηλικία σε έτη) Χ (Βάρος σε Kg)-------------------------------------------- -----------(72 ή 85 ) Χ Κρεα,mg%

130 120 110 100 90 80 70 60 50 40 30 20 15 10 0

Stage I

Kidney damage with normal or � GFR

Stage II

Kidney damagewith

mild �GFR

Stage III

Moderate�GFR

Stage IV

Severe�GFR

Stage V

Kidney failure

National Kidney Foundation. Am J Kidney Dis 2002; 39(2 Suppl 1):S1–S266

Glomerular filtration rate (mL/min/1.73m2)

Βλάβη Νόσος

60 ml/min

κφκφ ήπιαήπια µέτριαµέτρια σοβαρήσοβαρή τελικήτελική

Τροποποίησε την δόση των φαρµάκων

ανάλογα µε το eGFR

KI, suppl; 2011

Έλεγχος ούρων µε Dipstick

Trace 15 mg/dl

1+ 30 mg/dl

2+ 100 mg/dl

3+ 300 mg/dl

4+ 2000 mg/dl

Albuminuria predicts renal events

• UACR predicted renal events in patients with type 2 diabetes in the ADVANCE study

• 10,640 patients followed for4.3 years

• 10-fold increase in baseline UACR

• 3.3-fold increase in risk ofrenal event

• 10.5-fold increase in risk of renal event after correction for regression dilution

ADVANCE = Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation Ninomiya T, et al. J Am Soc Nephrol. 2009;20:1813–21.

32.0

16.0

8.0

4.0

2.0

1.0

0.5

0.25

3 30 300Microalbuminuria

Baseline UACR (mg/g)

P for trend < 0.0001Haz

ard

ratio

(95

% C

I)

Proteinuria Predicts Stroke and CHD Events in Patients With Type 2 Diabetes

P<0.001

40

30

20

10

0Stroke CHD

Events80604020

0

0.5

0.6

0.7

0.8

0.9

1.0

Sur

viva

l Cur

ves

for

CV

Mor

talit

y

Overall: P<0.001

Inci

denc

e (%

)Follow-Up (mo)

CHD = coronary heart disease; Prot = urinary protei n excretion; CV = cardiovascular.Miettinen et al. Stroke. 1996;27:2033-2039.

Prot 150-300 mg/LProt <150 mg/L Prot >300 mg/L

0 100

© 2005 The Johns Hopkins University School of Medici ne.

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WKD 2011 LogoProtect your kidneys, Save your heart

Meta Analysis: Lower Mean BP Results in Slower Rate s of Decline in GFR in Diabetics and Non-Diabetics

9595 9898 101101 104104 107107 110110 113113 116116 119119

r = 0.69; P < 0.05

MAP (mmHg)

GF

R

(mL

/min

/yea

r)

130/85 140/90

UntreatedHTN

00

--22

--44

--66

--88

--1010

--1212

--1414

Bakris GL, et al. Am J Kidney Dis. 2000;36(3):646-661.

Aggressive Blood Pressure ControlModification of Diet in Renal Disease Study

Klahr S et al: N Engl J Med 330:877-884, 1994

Mean GFR = 39 ml/min

0

3

6

9

12

< 1 g/day 1-2.9 g/day >= 3 g/day

Mea

n fa

ll in

GF

R

(ml/m

in/y

ear)

Low BP (125/75 mm Hg)Usual BP (130/80 mm Hg)

!!!

Irbesartan in Diabetic Nephropathy Trial:

Time to Doubling of Serum Creatinine, ESRD, or Death

Lewis EJ, et al. N Engl J Med. 2001;345:851-860.

Sub

ject

s (%

)

0 6 12 18 24 30 36 42 48 54

Follow-up (mo)

60

0

10

20

30

40

50

60

70

1,715 Type 2 Diabetics with Nephropathy

Change in Proteinuria

-35

-30

-25

-20

-15

-10

-5

0

5

Per

cent

Red

uctio

n

IrbesartanAmlodipinePlacebo

BP 141/77

BP 144/80

BP 140/77

ΣΤΟΧΟΣ ΘΕΡΑΠΕΙΑΣ

• The SBP and DBP targets are at least <140/90 mmHg

• The primary focus should be on achieving the SBP goal

• In patients with hypertension and diabetes, renal disease, proteinuria, stroke, and myocardial infraction the BP goal is <130/80 mmHg

SBP, systolic blood pressure; DBP, diastolic blood pressure; BP, blood pressure

14276 M

TNT(CAD pts)

0

5

10

15

20

25

30

35

0

1

2

3

4

5

≤ 60 61-70 71-80 81-90 91-100 > 100

On-treatment DBP (mmHg)

CV

eve

nts

(%)

Adj

uste

d H

R

ONTARGET (high risk pts, mainly with CAD)

On-treatment SBP (mmHg) 112 121 126 130 133 136 140 144 149 160

0

10

20

30

0

1

2

3

CV

eve

nts

(%)

Adj

uste

d H

R

VALUE(High risk pts)

On-treatment SBP (mmHg)

INVEST(CAD pts)

On-treatment SBP (mmHg)

110 >110to 120

>120to 130

>130to 140

>140to 150

>150to 160

>1600

10

20

30

40

50

60

CV

eve

nts

(%)

Car

diac

eve

nts

(%)

0

10

20

30

< 120 >120to 130

>130to 140

>140to 150

>150to 160

>160to 170

>170to 180

≥ 180

Recommendations for BP and RAS Management in CKD

BP = blood pressure; RAS = renin angiotensin system ; CCB = calcium channel blocker; BB = β-blocker; JNC 7 = The Seventh Report of the Joint N ational Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.ADA. Diabetes Care. 2005;28(suppl 1); Chobanian et al. JAMA. 2003;289:2560-2572; Kidney Disease Outcomes Quality Initiatives (K/DOQI). Am J Kidney Dis. 2004;43(5 suppl 1):S1-S290.

PatientGroup

Goal BP(mm Hg) First Line Adjunctive

+ Diabetes <130/80 ACE-I or ARB Diuretics then CCB or BB

− Diabetes + Proteinuria

<130/80 ACE-I or ARB Diuretics then CCB or BB

− Diabetes − Proteinuria

<130/80 No specific preference:

Diuretics then ACE-I, ARB, CCB, or BB

EXPECT TO NEED TO USE 3+ AGENTS TO ACHIEVE GOALSRecommendations largely consistent across JNC 7, AD A, and K/DOQI

© 2005 The Johns Hopkins University School of Medici ne.

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