Transcript 点击阅读

肾脏疾病的诊治进展与临证经验
China-Japan Friendship Hospital,
Beijing, China
Li Ping
肾脏疾病的新分类
急性肾脏损伤（Acute Kidney Injuries, AKI）
慢性肾脏病（Chronic Kidney Disease, CKD）
AKI的诊断标准
2005年9月阿姆斯特丹AKI的国际研讨会
符合下列条件之一：
◆ 肾功能在48小时内突然降低
–至少两次Scr升高绝对值>0.3mg/dl（26.5umol/L）
– Scr较前升高50%
◆ 持续6小时以上尿量<0.5ml/kg/h
单独应用尿量的改变作为诊断标准时，需要除外尿路梗
阻或其他可导致尿量减少的原因。
AKIN Organizing Committee 2005
AKI的RIFLE分级
反映预后
AKI合作研讨会标准
2005年9月阿姆斯特丹AKI的国际研讨会
I
Increased creatinine x0.5
or  0.3mg/dl
UO <0 .5ml/kg/h
x 6 hr
Increased creatinine x2
UO < 0.5ml/kg/h
x 12 hr
II
III
Increase creatinine x3
or creatinine 4mg/dl
(Acute rise 0.5 mg/dl)
High
Sensitivity
UO <0.3ml/kg/h
x 24 hr or
Anuria x 12 hrs
High
Specificity
AKI的改良RIFLE分级
反映预后
J Himmelfarb. Kidney International (2007) 71, 971–976.
AKI的RIFLE分期与预后
2005年bell等回顾性分析207名CRRT治疗的AKI患者
首次采用RIFLE分期评价AKI的预后
R
I
F
L+E
Bell. Nephrol Dial Transplant (2005) 20: 354–360
尿量能否界定CRRT的介入时机
A Randomized Controlled study
28例冠脉搭桥术后AKI患者
Early group 尿量<30ml/h 持续3h , 14 cases Late group 尿量<20ml/h 持续2h, 14 cases
Early group
86%
Late group
14%
Souichi. Hemodialysis International. 2004; 8: 320--325
RIFLE分期与CRRT介入时机
13%
25%
27%
Chih-Chung Shiao. Critical Care. 2009, 13:R171
Chronic kidney disease（CKD）
► Chronic kidney disease (CKD) is a worldwide
public health problem with an increasing
incidence and prevalence, poor outcomes,
and high cost.
► Outcomes of CKD include not only kidney
failure but also complications of decreased
kidney function and cardiovascular disease.
Levey AS, et al. Ann Intern Med. 2003; 139: 137-147.
NKF. Am J Kidney Dis. 2002; 39: S1-246.
Kidney damage
►
Kidney damage is defined as pathologic abnormalities or
markers of damage, including abnormalities in blood or urine
tests or imaging studies.
►
Persistent proteinuria is the principal marker of kidney
damage.
►
An albumin– creatinine ratio greater than 30 mg/g in two of
three spot urine specimens is usually considered abnormal.
Levey AS, et al. Kidney Int. 2005; 67: 2089-2100.
NKF. Am J Kidney Dis. 2002; 39: S1-246.
GFR
►
GFR can be estimated from calibrated serum creatinine and estimating
equations, such as the Modification of Diet in Renal Disease (MDRD)
Study equation or the Cockcroft-Gault formula.
►
The MDRD formula is recommended by European and American
guidelines for estimating GFR，which has not been fully validated in
different populations and at different stages of CKD
NKF. Am J Kidney Dis. 2002; 39: S1-246.
Application of GFR-estimating equations
in Chinese patients with CKD
◘ To evaluate whether the MDRD equations could be applied accurately
to Chinese patients with CKD, GFR estimated by using MDRD
equation 7 (7GFR), the abbreviated MDRD equation (aGFR), and the
Cockcroft-Gault equation (cGFR) were compared in patients with
different stages of CKD.
◘ Dual plasma sampling of technetium Tc 99m-labeled diethylene
triamine pentaacetic acid plasma clearance was used as the reference
standard GFR (sGFR) for comparison of 7GFRs, aGFRs, and cGFRs at
different stages of CKD.
◘ The study enrolled 261 patients with CKD, including 146 men and 115
women. All patients were older than 18 years .
Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.
Comparison of Equation-Estimated GFRs
With 99mTc-DTPA Plasma Clearance
Comparison of 7GFR with sGFR
showed that 7GFR correlated
significantly with sGFR, but the
regression
line
was
significantly different from the
identical line
MDRD Equation 7
Abbreviated MDRD Equation
C-G Equation
b (95% CI)
27.03(22.00–32.05)
27.73(22.61–32.86)
21.87(17.51–26.24)
m (95% CI)
0.63(0.57–0.69)
0.64(0.57–0.70)
0.56(0.50–0.61)
r
0.78
0.77
0.78
r2
0.60
0.59
0.61
69.76±34.15
70.79±34.79
59.63±30.15
Mean ± SD (mL/min/1.73 m2)
Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.
Performance of GFR-Estimating Equations: Bias, Precision, and Accuracy
The regression line showed that
MDRD equation 7 overestimated
GFR
at
low
levels
and
underestimated GFR at nearnormal levels
Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.
MDRD Equation 7
Abbreviated MDRD Equation
C-G Equation
b (95% CI)
18.09(11.39–24.79)
18.07(11.26–24.87)
15.62(9.60–21.64)
m (95% CI)
−0.24(−0.32–−0.15)
−0.22(−0.30–−0.13)
−0.37(−0.46–−0.29)
r
0.32
0.29
0.48
r2
0.10
0.08
0.23
1,182.94
1,107.74
2,096.52
Precision (mL/min/1.73 m2)
98.77
91.23
91.23
Accuracy within ±15%
36.40
34.10
30.65
Accuracy within ±30%
60.15
58.24
57.09
Accuracy within ±50%
74.33
74.33
80.08
Bias
Performance of the Abbreviated MDRD
Equation in Different Stages of CKD
99mTc-DTPA
Plasma Clearance (mL/min/1.73 m2)
<15
15∼29
30∼59
60∼89
>90
26.84
±22.80
35.64
±14.76
59.46
±18.04
82.04
±22.81
99.80
±28.73
Median of difference
(mL/min/1.73 m2)
11.35*
12.00*
12.45*
5.75
−14.30*
Accuracy within
±15%
10.34
16.67
29.03
48.28†
42.48†
Accuracy within
±30%
13.79
33.33
50.00
81.03†
73.17†
Accuracy within
±50%
24.14
40.00
72.58†
93.10†
92.68†
aGFR
(mL/min/1.73 m2)
NOTE. Values expressed as mean ± SD or median of difference (25%, 75% percentile).
*P < 0.05 comparing estimated GFR with sGFR.
†P < 0.001 comparing accuracies of an equation with those in CKD stages 4 to 5.
Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.
Performance of the C-G Equation in
Different Stages of CKD
99mTc-DTPA
Plasma Clearance (mL/min/1.73 m2)
<15
15∼29
30∼59
60∼89
>90
23.97
±14.97
31.03
±10.18
47.25
±14.02
67.67
±21.29
86.38
±26.26
Median of difference
(mL/min/1.73 m2)
9.97*
8.25*
1.43
−7.83*
−29.35*
Accuracy within
±15%
13.79
16.67
48.39†
46.55†
17.07‡
Accuracy within
±30%
17.24
33.33
77.42†‡
72.41†
53.66‡
Accuracy within
±50%
20.69
60.00
94.83†‡
94.83†
91.46†
cGFR
(mL/min/1.73 m2)
NOTE. Values expressed as mean ± SD or median of difference (25%, 75% percentile).
*P < 0.05 comparing estimated GFR with sGFR.
†P < 0.001 comparing accuracies of an equation with those in CKD stages 4 to 5.
‡P < 0.001 comparing accuracies of the C-G equation with those of the MDRD equations.
Zuo L, et al. Am J Kidney Dis. 2005; 45(3):463-72.
MDRD equations based on data from
Chinese CKD patients
• The MDRD equation 7 to estimate GFR (7GFR,
ml/min per 1.73m2) = 170 × Pcr-0.999 × age-0.176 ×
BUN-0.170 × albumin0.318 × 0.762 ( if female) ×
1.211 ( if Chinese)
• Abbreviated MDRD equation to estimate GFR
(aGFR, ml/min per 1.73m2) = 186 × Pcr-1.154 ×
age-0.203 × 0.742 ( if female) × 1.233 ( if Chinese)
Where Pcr is in mg/dl, BUN is in mg/dl, albumin is in g/dl, and age is in years.
Ma et al. J Am Soc Nephrol 2006; 17: 2937
Prevalence of chronic kidney disease and decreased kidney
function in the adult US population:
The prevalence of CKD in the US adult population was 11%
Third National Health and Nutrition Examination Survey
CKD
Total Subjects
Subjects (million) Prevalence
19.20
StageⅠ(Ccr≥90ml/min)
5.90
StageⅡ(Ccr：60～89ml/min) 5.30
StageⅢ(Ccr：30～59ml/min) 7.60
StageⅣ(Ccr：15～29ml/min) 0.40
0.30
StageⅤ(Ccr＜15ml/min)
11%
3.3%
3.0%
4.3%
0.2%
0.2%
Coresh J, et al. Am J Kidney Dis. 2003; 41: 1-12.
Prevalence of kidney damage in Austrinian adults:
AusDiab kidney study
11,247 Australians aged 25 yr or over
Proteinumia
Renal Impairment
0.6% 1.1%
9.7%
0.3%
0.1%
0.8%
3.7%
Hematuria
Approximately 16.4% have at least
one indicator of kidney damage
GFR <60 ml/min/1.73m2 （11.2%）
Chadban SJ, et al. J Am Soc Nephrol. 2003;14(7 Suppl 2):S131-8.
Prevalence of decreased kidney function
in 15,540 Chinese adults aged 35 to 74 years
The overall prevalence of CKD with GFR <60 mL/min/1.73m2 was 2.53%.
Chen J, et al. Kidney Int. 2005; 68(6):2837-45
Age-standardized and age-specific prevalence of decreased
kidney function with GFR <60 mL/min/1.73m2 estimated
using the simplified MDRD study equation in Chinese adults
aged 35 to 74 years
Age years
Percent (SE) Estimated population (SE)
Total
2.53 (0.16)
11,966,653 (756,537)
35–44
0.71 (0.12)
1,295,194 (228,878)
45–54
1.69 (0.25)
2,429,871 (354,784)
55–64
3.91 (0.44)
3,369,606 (383,422)
65–74
8.14 (0.83)
4,871,981 (513,043)
Overall, the age-standardized prevalences of GFR 60 to 89, 30 to 59,
and <30 mL/min/1.73m2 were 39.4%, 2.4%, and 0.14%, respectively.
Chen J, et al. Kidney Int. 2005; 68(6):2837-45.
Community-based screening for chronic kidney disease
among population older than 40 years in Beijing, China
◙ Subjects:
2353 residents older than 40 years.
◙ Results:
Approximately 11.3% of subjects had at least one
indicator of kidney damage.
(1).Albuminuria(albumin/creatinine≥30mg/g), 6.2%;
(2).GFR<60ml/min/1.73m2, 5.2%;
(3).Hematuria, 0.8%;
(4).Non-infective pyuria, 0.09%.
Zhang L, et al. Nephrol Dial Transplant. 2007; 22: 1093
Analysis based on 13,519 renal biopsies
in China
Cases of renal biopsies performed each year
Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.
The changing frequency of primary and secondary
glomerulonephritis from 1979 to 1999
*P < 0.01; **P < 0.001, compared with 1985.
Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.
Classification of renal diseases based
on 13,519 renal biopsies
Primary glomerular diseases
Secondary glomerular diseases
Systemic diseases
Metabolic diseases
Vascular diseases
Infections
Hereditary and congenital renal diseases
Tubulointerstitial diseases
Rare renal disease
Sclerosing glomerulonephritis
Unclassified
Total
No. of cases
%
9278
3359
2673
345
244
97
131
464
37
132
118
13,519
68.64
24.84
19.77
2.55
1.80
0.72
0.97
3.43
0.27
0.98
0.87
100.00
Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.
Prevalance of primary glomerular diseases
No. of cases
%
IgAN
4199
45.26
MsPGN
2377
25.62
MN
918
9.89
FSGS
557
6.00
IgMN
396
4.27
MPGN
314
3.38
EnPGN
255
2.75
CreGN
176
1.90
MCD
86
0.93
Total
9278
100.00
Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.
Glomerulonephritis in systemic diseases
No. of Cases
%
Systemic lupus erythematosus
1824
68.23
Henoch-Schönlein purpura
685
25.63
Anti-glomerular basement membrane disease
29
1.08
Rheumatoid arthritis
21
0.79
Sjögren's syndrome
19
0.71
Mixed connective tissue disease
9
0.34
Nephropathy in pregnancy
23
0.86
Neoplasm
11
0.41
Liver diseases
25
0.94
Multiple myeloma
27
1.01
Total
2673
100.00
Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.
Glomerular lesions in metabolic diseases
No. of Cases %
Diabetic nephropathy
222
64.35
Amyloidosis
76
22.03
Monoclonal immunoglobulin deposit disease
(MIDD)
35
10.14
Mixed cryoglobulinemia
9
2.61
Dense deposit disease
3
0.87
Total
345
100.00
Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.
Characteristics and changing tendency
of renal disease
Jan 1990-Dec 1991
Jan 2000-Dec 2001
No. of renal biopsy cases
214 cases
1525 cases
Average age
30.6±11.1 years
35.2±13.9years
Old patients
0.5%
6.8%
Acute renal failure
7.5%
14%
Primary glomerular disease 77.6%
65.4%
IgAN
47%
16.9%
Liu G, et al. J Clin Intern Med. 2004; 21: 834-838
The prevalence of ESRD

The worldwide rise in the number of patients with CKD is reflected
in the increasing number of people with end-stage renal disease
(ESRD)
treated
by
renal
replacement
therapy—dialysis
or
transplantation.

Two factors related to the prevalence of ESRD are important. The
first is the ageing of the population; The second factor is the
global epidemic of type 2 diabetes mellitus.
Lysaght MJ. J Am Soc Nephrol. 2002; 13: 37.
United States Renal Data System. Am J Kidney Dis. 2003; 42: S37.
King H, et al. Diabetes Care. 1998; 21: 1414.
Histology of Chinese chronic renal failure
(Scr>3mg/dl, N = 607)
No. of cases
%
252
41.50
IgAN
162
26.70
FSGS
58
9.60
MPGN
27
4.40
MN
5
0.82
218
35.91
Renal vasculitis
87
14.33
HSPN
3
0.49
LN
66
10.88
DN
19
3.13
Multiple myeloma
8
1.32
Amyloidosis
8
1.32
Monoclonal immunoglobulin deposit disease
8
1.32
Benign/malignant nephrosclerosis
11
1.81
Toxemia in pregnancy
3
0.49
Hereditary renal disease
5
0.82
Chronic interstitial nephritis
71
11.70
Unclassified
66
10.87
Total
607
100.00
Primary glomerular diseases
Secondary glomerular diseases
Li LS, Liu ZH. Kidney Int. 2004; 66(3): 920-3.
Chinese maintenance dialysis

According to the registration of dialysis and transplantation
in China in 1999, 41775 patients underwent maintenance
dialysis; among them, 89.5% was hemodialysis (HD) and
10.5% was peritoneal dialysis (PD).

The first cause of CRF in HD patients was glomerulonephritis
(50%), and then diabetic nephropathy (13.5%), hypertensive
nephrosclerosis (8.9%).
Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78.
Comparisons of incidence and prevalence of
ESRD in developed countries and China
Annual average
incidence of ESRD
Prevalence of ESRD
Europe
135 new patients per
million of population
700 patients per million
of population
USA
336 new patients per
million of population
1403 patients per million
of population
Annual incidence of
HD ＋ PD
Prevalence of
HD ＋ PD
135 ＋ 20 patients
per million of population
180 ＋ 34 patients
per million of population
Shanghai
These data showed that the annual incidence rate of dialysis in Shanghai, China was
coincident with the annual average incidence of ESRD in Europe. However,
prevalence of dialysis has marked difference between Europe and Shanghai. The
financial problem may be the most important cause of the difference formation.
Meguid El, et al. Lancet. 2005; 365: 331-340.
Shanghai dialysis and transplantation registration group. Chin J Nephrol. 2001; 17: 83-85.
1658 childhood with CRF in China
 The criterion of CRF was creatinine clearance (Ccr) < 50 ml/min/1.73
m2. The mean serum creatinine were 594.7μmol/L.
 The average annual cases accounted for 1.31% of the hospitalized
cases with urologic-kidney diseases.
 The male to female ratio was 1.49:1.
 The mean age at the disease onset was 8.18 years.
 The mean duration of pre-diagnosis of CRF was 2.53 years.
 The main primary renal diseases causing CRF
glomerulonephritis and nephrotic syndrome (52.7%).
were chronic
 One-fourth of all cases had congenital and hereditary renal diseases,
and the majority was renal hypoplasia and dysplasia.
Yang JY, et al. Zhonghua Er Ke Za Zhi. 2004; 42: 724-730.
The major outcomes of CKD
 The major outcomes of CKD include progression to
kidney failure, complications of decreased kidney
function, and CVD.
 Data from the NHANES III show the approximately 11%
of the U.S. adult population have CKD. The prevalence of
early stages of CKD (stages 1 to 4; 10.8%) is more than
100 times greater than the prevalence of kidney failure
(stage 5; 0.1%).
Coresh J, et al. Am J Kidney Dis. 2003; 41: 1-12.
ARF in CKD (A/C) is an important
complication of CKD
 104 patients of A/C
 accounted for 35.5% of ARF cases with renal biopsy
during the same period
 drug-induced
acute
renal
interstitial
or
tubulointerstitial disease, pre-renal ARF and flareup of lupus nephritis were the most common
causes of ARF in A/C patients.
 occurred more commonly in older patients
Zhang L, et al. Clin Nephrol. 2005; 63: 346-350.
CVD is the most important cause of
death among Chinese dialysis patients
 2529 cases with dialysis were dead in China in 1999.
Heart failure and cerebrovascular accident
accounted for 32% and 19%, respectively.
 Besides, 16% patients died of dialysis interruption
automatically, which might be related to the
financial problem.
 In another report, CVD is the single most important
cause of death among dialysis patients, accounting
for 51% of overall mortality.
Dialysis and Transplantation Registration Group. Chin J Nephrol. 2001; 17: 77-78.
CVD in 1239 Chinese CKD patients
Prevalence of CVD (%)
30
The most prevalent pathological
25
form of CVD was left ventricular
20
15
hypertrophy (LVH), accounting for
27.7
10
58.5% of total patients.
16.5
5
5.6
0
CHF
CAD
CVA
Hou FF, et al. Zhonghua Yi Xue Za Zhi. 2005; 85: 458-463.
Epidemiology of cardiovascular risk in
Chinese chronic kidney disease patients
 C reactive protein
 Female and anemia
 Calcium phosphate product
 Hypoalbuminemia
 Diabetes
 Age
 Hypertension
Hou FF, et al. Natl Med J China, 2005; 85: 753-759
Prevalence and characteristics of
Tuberculosis in 1,498 inpatients with CRF
80
70
60
50
CRF
Residents
40
30
20
10
0
prevalence of TB
anti-TB-AB
PPD tests
prevalence of TB
anti-TB-AB
PPD tests
CRF
4.74%
12.7%
15.5%
Residents
0.15%
72.1%
58.1%
Yuan FH, et al. Ren Fail. 2005; 27: 149-153.
Risk factors or risk markers of
chronic kidney disease
 Hypertension, diabetes, hyperlipidaemia, obesity, and
smoking as risk factors or markers in the general
population for the development of CKD.
 Most notable among the modifiable progression factors is
systemic hypertension.
 Proteinuria is a reliable marker of the severity of CKD and a
powerful and independent predictor of its progression.
 Non-modifiable factors include genetics, race, age, and sex.
Klag MJ, et al. JAMA. 1997; 277: 1293–1298.
Klahr S, et al. N Engl J Med. 1994; 330: 877–884.
Jafar TH, et al. Ann Intern Med. 2003; 139: 244–252.
IgAN is the most common CKD in China,
genetic factors contributing to its pathogenesis
 Li YJ, et al. Family-based association study showing that immunoglobulin A
nephropathy is associated with the polymorphisms 2093C and 2180T in the 3'
untranslated region of the Megsin gene. J Am Soc Nephrol. 2004; 15: 17391743.
 Li G, et al. Tandem repeats polymorphism of MUC20 is an independent factor
for the progression of immunoglobulin A nephropathy. Am J Nephrol. 2006; 26:
43-49.
 Lu JC, et al. Uteroglobin G38A polymorphism is associated with the
progression of IgA nephropathy in Chinese patients. Zhonghua Nei Ke Za Zhi.
2004; 43: 37-40.
 Chen X, et al. Association of angiotensin-converting enzyme gene
insertion/deletion polymorphism with the clinico-pathological manifestations in
immunoglobulin A nephropathy patients. Chin Med J (Engl). 1997; 110: 526-529.
 Megsin 基因与IgA肾病的发病有关
 MUC20，Uteroglobin，ACE 基因与IgA肾病的进展有关
Predictors of an unfavourable
outcome in IgAN
 impaired renal function,
 severe proteinuria,
 hypertension,
 glomerulosclerosis,
 interstitial fibrosis
D’Amico G. Am J Kidney Dis. 2000; 36: 227–237.
Risk factors predicting renal survival
of IgAN in 317 Chinese patients
Characteristics
P-value
Scr > 115 umol/L
UP > 1.0g/24h
Glomerulosclerosis > 2
Crescent formation
Interstitial injury > 2
Yang NS, et al. Chin J Intern Med. 2005; l44: 597-600.
Multivarite analysis of influercing factors
for hypertension in 540 patients with IgAN
Characteristics
OR
OR 95%CI
P value
Age
1.048
1.022-1.074
0.0001
Familial history of HT
6.732
1.662-27.264
0.0075
Proteinuria
1.018
1.011-1.025
0.0001
Serum creatinine
1.268
1.107-1.447
0.0004
Body weight
1.029
1.006-1.052
0.0092
Renal arteriolar lesion
2.193
1.637-2.938
0.0001
The prevalence of hypertension in IgAN was
39.6% (214/540) at the time of renal biopsy.
Zhuang Y, Chen X, et al. Chin J Intern Med. 2000; 39: 371-375.
Characteristics of tubulointerstitial lesions (TIL)
in 609 patients with IgAN
♣ Degree and percent of TIL:




mild TIL 47.1%,
moderate TIL 21.7%,
severe TIL 16.6%,
Non-TIL 14.6%.
♣ Related factors with severity of TIL :






hypertension,
the level of proteinuria,
the scores of vascular lesion,
total glomerular lesion,
hypercellularity,
glomerulosclerosis
Zhang Y, Chen X, et al. Chin J Intern Med. 2001; 40: 613-617.
Prevention of CKD
• Primary prevention of CKD will rely on
controlling the obesity and associated type
2 diabetes as well as hypertension.
– such as weight reduction, exercise, and
dietary manipulations.
• Secondary prevention of progression of
CKD needs pharmacological approaches.
Molich M, et al. J Am Soc Nephrol. 2003; 14: S103–107.
Appel LJ. J Am Soc Nephrol. 2003; 14: S99–102.
Moser M. J Clin Hypertens. 2004; 6: S4–13.
Management of CKD
• Current management options for CKD are based on
the control of known risk factors such as
hypertension, proteinuria, hyperlipidaemia, and
smoking.
• Control of hypertension is the single most effective
intervention. Antihypertensive approaches with
inhibitors of ACE or angiotensin-2-receptor blockers
have been widely advocated.
• Control of proteinuria and the inhibition of the renninangiotensin system are important factors in slowing
the progression of diabetic and non-diabetic CKD.
Remuzzi G, et al. Ann Intern Med. 2002; 136: 604–615.
Gaede P, et al. N Engl J Med. 2003; 348: 383–393.
我们所面对新的挑战
CVD is an epidemic
CVD and DM are
leading causes of CKD
Diabetes is an epidemic
CKD is a risk factor
for CVD
CKD is an epidemic
Dialysis is costly
Dialysis is life saving
中西医治疗CKD的现状分析
肾脏病的演变
肾脏病的表现
肾脏病的治疗
治疗的局限性
中医治疗优势
早期
CKD1期
单纯血尿
轻度蛋白尿
寻找并去除
危险因素
西医
无特殊治疗
针对血尿
蛋白尿治疗
中期
CKD2-3期
合并高血压
大量蛋白尿
降压药
糖皮质激素
免疫抑制剂
疗效有限
药副作用大
降低蛋白尿
减少副作用
中晚期
CKD4期
肾功能不全
尿毒症前期
低蛋白饮食
必需氨基酸
西医
无特殊治疗
延缓肾脏
疾病进展
透析
肾移植
治标不治本
器官来源不足
医疗费用高
推迟进入透析
时间,减少医
疗费用
晚期
CKD5期
尿毒症
CKD中医治疗十法
• 滋养肝肾法
• 症属肝肾阴虚者，或辨证属气阴两虚以阴
虚为主者，方选杞菊地黄汤、归芍地黄汤、
一贯煎合二至丸、桑麻丸等加减。稍有乏
力者可加太子参；有心悸怔忡者，可合用
生脉饮；失眠者加柏子仁或酸枣仁；口燥
咽干甚者加麦冬、五味子等；兼尿频、尿
急、尿热、尿痛者，可用知柏地黄汤加滑
石、车前子等。
健脾益肾法
• 适用证属脾肾气虚者，方选七味白术散、参苓白
术散加菟丝子、补骨脂；兼自汗者可合用玉屏风
散；兼腰膝冷痛者加狗脊、川牛膝；兼下肢水肿
者，可合用防已地黄汤或防已茯苓汤；兼有纳少
腹胀者可加砂仁、寇仁；兼心悸气促者，可合用
苓桂术甘汤等、葶苈大枣泻肺汤等。
益气养阴法
• 方选参芪地黄汤为主，兼下肢肿加车前子、冬葵
子、冬瓜皮、抽葫芦、防己；兼湿热者加白花蛇
舌草、石苇、；兼瘀血者加丹参、泽兰、红花；
兼气滞者加广木香、槟榔、陈皮、大腹皮；气虚
明显加入红参另煎兑服；阴虚明显加黄芪、石斛；
兼阳虚加仙茅、仙灵脾等；兼浊毒者加入生大黄，
或加用大黄灌肠；有痈疽者加金银花、蒲公英、
野菊花、天葵子、败酱草等；尿中有酮体加黄芩、
黄连、黄柏；合并周围神经病变加当归、菊花等。
阴阳双补法
• 适于CKD晚期阴阳两虚者，此为气阴两虚进
一步发展而来。方选桂附地黄汤等。兼水
湿用济生肾气汤，贫血明显者，以红参另
煎兑服，浊毒盛加生大黄。
祛风散热法
• 适于外感风热或风寒化热者，可用银翅散
加减。阴虚者可用银翅汤，咽痛合银蒲玄
麦甘桔汤（经验方，由银花、蒲公英、玄
参、麦冬、桔梗、甘草等）、升降散。热
毒甚者可合用五味消毒饮、黄连解毒汤。
清热利湿法
• 适用于兼湿热症状者。一般在扶正基础上
加入清利之品。湿热重宜先清利湿热，上
焦痰热可用贝母瓜萎散、杏仁滑石汤；中
焦湿热可用八正散去木通，或五麻散、石
苇散、程氏萆解分清饮。若湿热弥漫三焦
可用三仁汤、嵩芩清胆汤等以清热除湿，
宣畅三焦。
渗利水湿法
• 适于挟水湿者。仅下肢浮肿，可于扶正方
中加牛膝、车前子以渗利水湿。如水肿严
重则宜先渗利水湿，脾虚明显者可用防己
黄芪汤合防己茯芩汤、大橘皮汤；血瘀者
可用桂枝茯芩丸、当归芍药散加减；水肿
严重者，亦可前后分消，可用己椒苈黄丸、
疏凿饮子；水凌心肺可用苓桂术甘汤合葶
苈大枣泻肺汤。
理气开郁法
• 适于兼有气郁症状者。气郁的产生可与情
绪波动，焦虑忧郁，或水湿、湿热、瘀血
等因素导致气机受阻有关。可于扶正方中
加入调理气机之品。气郁严重者宜先理气
开郁，用逍遥散、柴胡疏肝散、越鞠丸、
四逆散等。水湿明显者，在渗利水湿方中
加入陈皮、广木香、槟榔、大腹皮、沉香
等理气之品，气行水亦行，有助于水肿消
退。
活血化瘀法
• 适用于瘀血症状明显或严重者，特别是合
并其它血管病变者，常选桂枝茯苓丸、血
府逐瘀汤、桃仁四物汤、桃核承气汤等方
加减治疗。慢性肾脏病病程较长，正气亏
虚，气机逆乱，血瘀证普遍存在，迁延难
愈，因此活血化瘀法较为常用，一般可在
扶正基础上加入活血化瘀之品。
泄浊解毒法
• 适用于终末期，浊毒弥漫，阴阳俱虚。轻
者可于扶正方中加入大黄以泄浊；重则可
配合大黄牡蛎方、大黄穿心莲方等煎汁灌
肠或肛门点滴。
Thank you!