慢性肾脏病患者疾病管理教材.pptVIP

Algorithm for Diuretic Use Renal Insufficiency CrCl 50 Loop Diuretic Determine Effective Dose: 5-10X Usual Dose Administer as Frequently as Necessary Thiazide According to CrCl 20ml/min 20-50 50ml/min 50-100mg/ 50-100mg/ 25-50mg/ day day day ADD Add Distal Diuretic Drug From Brater DG N Eng J Med 1998;339:387 Alterations in Bone and Mineral Metabolism PTH Pi Ca2+ Renal Mass 25(OH)D3 1,25(OH)2D3 1-alpha-hydroxylase 1-alpha-hydroxylase + Acidosis + Hyperparathyroid Related Bone Disease Impaired Absorption Osteitis Fibrosa Cystica Reduced Renal Mass GFR 65 40 25 Increased PTH Secretion Decreased 1,25-D Hyperphosphatemia Hypocalcemia Calcium and Phosphorus Balance:National Kidney Foundation Recommendations (KDOQI) In addition, it has become clear that CKD patients have a nutritional deficiency of 25-OH Vitamin D which itself leads to an increase in PTH secretion Levels of 25-OH D should be measured when PTH-Intact 70pg/ml and supplementation instituted if necessary, a level of 30ng/ml is abnormal and 15ng/ml, moderate to severe Treatment 5ng/ml 50,000U Ergocalciferol/wk x12, then q mo x6 5-15ng/ml 50,000/wk x 4, then q mo x 6 16-30ng/ml 50,000/month x 6 Measure 25(OH)-D at 6months Maintenance 800-1200 IU qd (AJKD, 39, 2002, pS214) Calcium and Phosphorus BalanceKDOQI Recommendations Stage 3 CKD, GFR 30-59 Measure Ca, Phos and PTH-I every 12 months Target levels Calcium WNL for lab Phos 2.7- 4.6 mg/dL Ca X Phos 55 PTH-I 30-70 pg/ml Stage 4 CKD, GFR 15-29 Measure Ca, Phos and PTH-I every 3 months Target levels Ca preferably WNL for lab Phos 2.7-/= 4.6mg/dL Ca X Phos 55 PTH-I 70-110 pg/ml Calcium and Phosphorus BalanceKDOQI Recommendations How are these goals achieved ? Control of dietary phosphorus intake to 0.8-1g/d May need initiation of “Phosphate binders” with meals When 25(OH)-D 30pg/ml and PTH-I target, initiate treatment with e