慢性肾脏病

CKD的发生率和发病率呈上升趋势,已经成为全球关注的公共卫生问题.2008年我国学者发表于<美国肾脏病杂志>的流行病学资料显示,在北京地区成年人(≥18岁)中CKD发生率为13.0%,在18～39岁、40～59岁、60～69岁及70岁以上年龄组中,CKD发病率分别为10.0%、14.2%、20.8%和30.5%,与欧美工业国家相似[1].临床实践和基于循证医学的大量研究表明,与高血压、糖尿病、高脂蛋白血症、吸烟、酗酒、活动少一样,CKD是CVD又一重要风险因子,CKD主要有两个结局:肾功能损伤导致肾衰竭及发生心血管疾病.     

Chronic kidney disease: evolving strategies for detection and management of impaired renal function

Nephrologists have long been concerned about late referral of patients with severe kidney disease, and resultant poor outcomes on dialysis. But there is an increasing realisation that mild to moderate chronic kidney disease is far more common than previously appreciated. Furthermore, the main consequence of chronic kidney disease is not progression to dialysis, but increased risk of cardiovascular disease. Chronic kidney disease is at least as common and important a risk factor for cardiovascular disease as diabetes mellitus. The MDRD formula is a well-validated formula to estimate glomerular filtration rate, which is now being widely implemented by clinical chemistry laboratories, and should increase the recognition of chronic kidney disease. The K/DOQI classification of chronic kidney disease has gained international acceptance and provides the structure to guide referral and management. This classification, and associated guidelines, also focus attention on areas where evidence is lacking, and which urgently require research. These current developments will substantially change and improve how chronic kidney disease is identified and managed.     

Chronic kidney disease and atherosclerosis

Atherosclerosis is common in patients with chronic kidney disease (CKD), and cardiovascular disease (CVD) represents a major cause of death in these patients, especially, in patients with end-stage renal disease(ESRD). The pathological features in ESRD patients are intimal atherosclerosis and medial calcific sclerosis. The important risk factors for CVD in ESRD patients are hypertension, dyslipidemia and CKD bone and mineral disorder (CKD-MBD). Atherosclerosis has been evaluated by measurements of intima-media thickness and pulse-wave velocity. Although the target blood pressure still undetermined, hypertension would be treated with renin-angiotensin system inhibitors. In addition, treatment of dyslipidemia with statins may lead to favorable CVD outcome. Finally, inhibition of vascular calcification should be important by treatment with active vitamin D and sevelamer.     

Chronic kidney disease and cardiovascular disease: pathophysiologic links.

This is the second in a series of three articles about the risk factors and complications related to chronic kidney disease and their impact on cardiovascular disease. This article focuses on identifying pathophysiologic mechanisms by which two traditional risk factors of cardiovascular disease (hypertension and dyslipidemia), and two nontraditional risk factors associated with chronic kidney disease (anemia and abnormalities in bone and mineral metabolism) contribute to the markedly increased cardiovascular morbidity and mortality seen in individuals with chronic kidney disease.     

Chronic kidney disease and its complications

Chronic kidney disease (CKD) is a complex disease affecting more than 20 million individuals in the United States. Progression of CKD is associated with a number of serious complications, including increased incidence of cardiovascular disease, hyperlipidemia, anemia, and metabolic bone disease. CKD patients should be assessed for the presence of these complications and receive optimal treatment to reduce their morbidity and mortality. A multidisciplinary approach is required to accomplish this goal.     

Chronic kidney disease and cardiovascular disease: a case presentation.

This is the third in a series of three articles examining cardiovascular disease (CVD) in the patient with chronic kidney disease (CKD). CVD is a leading cause of morbidity and mortality in patients with CKD, including those in the early stages. Early diagnosis of CKD and recognition of both traditional and nontraditional renal-related CVD risk factors are vital in improving outcomes for this population. Care of the patient with CKD should center on reduction of both types of risk factors for CVD. The ANNA Nephrology Nursing Standards of Practice and Guidelines for Care provide the basis for planning and providing care for patients with CKD and for reducing the risk of CVD in this patient population.     

Chronic kidney disease anaemia 1: diagnosis and screening

This is a two-part unit on managing anaemia in chronic kidney disease. Part 1 outlines the prevalence, causes and signs and symptoms of the condition, which, until recently, was underrecognised and under-treated.     

Chronic kidney disease in children

Methods for assessment of chronic kidney disease (CKD) are advancing worldwide. To this end, the Subcommittee of Measures for Pediatric CKD in the Japanese Society for Pediatric Nephrology was started in 2006. This Subcommittee has embarked on a multidisciplinary study for determining the normal/usual baseline value of serum creatinine and cystatin C, and standardizing the method of inulin clearance in children. For adults, pharmacotherapies such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to be effective in non-diabetic nephropathy. This same treatment for childhood CKD is generally adopted, but there is no corresponding evidence of similar efficacy. We believe a randomized controlled trial to that end should be undertaken.     

Chronic kidney disease: prevention and treatment of common complications

Chronic kidney disease is a progressive condition that results in significant morbidity and mortality. Because of the important role the kidneys play in maintaining homeostasis, chronic kidney disease can affect almost every body system. Early recognition and intervention are essential to slowing disease progression, maintaining quality of life, and improving outcomes. Family physicians have the opportunity to screen at-risk patients, identify affected patients, and ameliorate the impact of chronic kidney disease by initiating early therapy and monitoring disease progression. Aggressive blood pressure control, with a goal of 130/80 mm Hg or less, is recommended in patients with chronic kidney disease. Angiotensin-converting enzyme inhibitors and angiotensin-II receptor antagonists are most effective because of their unique ability to decrease proteinuria. Hyperglycemia should be treated; the goal is an AIC concentration below 7 percent. In patients with dyslipidemia, statin therapy is appropriate to reduce the risk of cardiovascular disease. Anemia should be treated, with a target hemoglobin concentration of 11 to 12 g per dL (110 to 120 g per L). Hyperparathyroid disease requires dietary phosphate restrictions, antacid use, and vitamin D supplementation; if medical therapy fails, referral for surgery is necessary. Counseling on adequate nutrition should be provided, and smoking cessation must be encouraged at each office visit.     

Diagnosis: Chronic kidney disease, now what!

The occupational health nurse can play an important role in supporting employees with CKD and ESRD by recognizing risk factors such as diabetes and hypertension associated with CKD. The occupational health nurse should encourage compliance with treatment regimens that retard or delay progression of kidney disease into the next stage, especially blood pressure and glucose control. When employees are in need of diagnostic testing, the occupational health nurse can describe the testing procedures such as laboratory values, ultrasounds, and biopsies, and explain the five stages of CKD. The occupational health nurse can assist employees in Stage 4 or 5 CKD in deciding on a treatment option modality that best suits their individual lifestyles, after they have seen a nephrologist and kidney patient educator. In addition, the occupational health nurse can guide employees with difficult lifestyle changes and provide support during the adjustment process. The occupational health nurse also can play a key role in facilitating and coordinating those changes with the renal social worker. Together they can explore available resources, such as the NKF, the American Association of Kidney Patients, and kidneydirections.com. See the Sidebar on pages 295 to 296 for other available resources. Kidney disease can be a devastating diagnosis. Support and education are key to a successful lifestyle transition. Employees who have CKD and work with an occupational health nurse who is informed about their disease and its stages of progression can benefit from educational processes that create informed choices to delay or retard the progression of their renal disease.