Defining Optimal Care of CKD : ( CV Risk management … … )
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Defining Optimal Care of CKD : (CV Risk management … …) NTUH Quality Wins 洪洪洪洪洪 2009/10/18
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Quality Wins. NTUH. Defining Optimal Care of CKD : ( CV Risk management … … ). 洪冠予醫師 2009/10/18. Q1 . What’s the Mission of this talk ? … …. 孟子 見 梁惠王 : 王 : 『 叟，不遠千里而來，亦將有以利吾國乎 ?』 孟子 : 『 王何必曰利，亦有仁義而已矣。 』. (n=2,434, CAD 18.9%). - PowerPoint PPT Presentation
Transcript of Defining Optimal Care of CKD : ( CV Risk management … … )
Defining Optimal Care of CKD :
(CV Risk management … …)
NTUH
QualityWins
洪冠予醫師2009/10/18
Q1. What’s the Mission of this talk ? … …
孟子見梁惠王 :
王 : 『叟，不遠千里而來，亦將有以利吾國乎 ?
』孟子 : 『王何必曰利，亦有仁義而已矣。』
(n=2,434, CAD 18.9%)
DM, HT, and Hyperlipidemia associated with increased CKD risk
AVD : Athrosclerotic vascular disease Adjusted for age, sex, region, coronary artery disease, cerebrovascular accident, transient ischemic attack, and peripheral vascular disease
Kuo HW et al. AJKD, 49:46-55, 2007
All-cause mortality attributable to CKD:a prospective cohort study (462,293 adults) in Taiwan
(Lancet. 2008 Jun 28;371(9631):2173-82)
Mortality Risks for All Causes and CV Diseases and Reduced GFR in a Middle-aged Working Population in Taiwan (AJKD 2008 Aug 14. [Epub ahead of print])
標竿學習 … …
Q2. 貴院的 CKD 衛教計畫，重點項目為 :
# Who ?
# What ?
# When ?
# How ?
腎臟病防治的重點是什麼 ?
Kidney protection: a key target in the management of patients with diabetes
(J Hypertens 2009 May;27(suppl 1):S15–S18)
MicroalbuminuriaLVHarteriopathy
Overt CVD,Advanced CKD, or both.
【 RAA Dual Blockade for Cardiorenal Protection: An Update 】Am J Kidney Dis 2009 Feb; 332-345
Am J Med (2008 Apr);121: 265-71
Renin Concentration (PRC) vsvs Renin Activity (PRA)
Am J Med (2008 Apr);121: 265-71
標竿學習 … … Q3. 貴院 CKD 病人 CVD 現況與醫療計畫為何 ?
# 1
# 2
CKD HD PD
(+)
(-)By what standard ?
ARB ACEI CCB β-blocker
滿意尚可不好
Kidney protection: a key target in the management of patients with diabetes
(J Hypertens 2009 May;27(suppl 1):S15–S18)
(NEJM 2002,April 11)
糖尿病腎病變的整合照顧
(AURORA, NEJM 2009;360:1395-407)
Q4. Is Statin beneficial for CKD?
[AJKD 2009; 53(5):723-5]
[NEJM 2009; 360:1455-7]
Staging of CKD
BMJ 2006; 333: 733-7
Mortality Risks for All Causes and CV Diseases and Reduced GFR in a Middle-aged Working Population in Taiwan (AJKD 2008 Aug 14. [Epub ahead of print])
(Am J Cardiol 2008;102:1668 –73)
(GFR <60 /min) (GFR <50 /min)
Q5. 結構面 : Def. of Critical CKD Stage ?
Kidney Dysfunction as a CV Risk FactorArch Intern Med 2008;168(6):617-624
Q6. From CKD to CVD: same mechanism ?
CV risk
Oxidative Stress
TraditionalRisk Factors
Inflammation
Insulin resistance(metabolic syndrome)
Insulin Resistance, Adiponectin and Chronic Inflammation in Dialysis (HD & PD) Patients
(Huang JW, Hung KY, et al. AJKD 2004;43:1047-55)
[Chiang CK, et al. Am J Nephrol 2009;29:392-397]
[NEJM 2008; 359:2195-2207]
Implications of the Jupiter Trial ?
Fetuin-A, insulin resistance in non-diabetic HD Patients
Chronic inflammation, Insulin resistance in DM HD Patients(Hung KY, et al. Diabetes Care 2007;30:3-7)
(Hung KY, et al. Eur J Endocrin 2009;160:1-9)
Q7. Will you prescribe Cardio-protective agents
for your CKD patients ?
1. Yes, always2. Often3. Seldom4. No, never
Q8. Risk management: “Frequency and items of measurement” ?
CKD
Staging
Serum [Cre]
UAE
I
II
III
IV
V
Q9. From CKD to CVD: mechanism ?
CV riskOxidative StressInflammationInsulin Resistance
TraditionalRisk Factors
JASN 2008;19:1065–70
