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1 2012 개원의와함께하는임상강좌 경희대학교의과대학신장내과학교실 정경환 When to Call Nephrology delayed referral of patients with late-stage chronic kidney disease is associated with suboptimal outcomes, including increased mortality. New England Journal of Medicine 2010:362;158 Case 1 55 세남자가전신부종과호흡곤란으로왔다. 과거력 : 10 년전부터당뇨병 (+), 고혈압 (+) Lab : BUN/Cr 50/4.5mg/dl (egfr 14.5ml/min/1.73m 2 ) Ca/P 7.4/4.3mg/dl, K 5.8 mmol/l Hb 9.7 g/dl, total CO mmol/L PTH 362pg/ml, HbA1c 7.6 % UA prot 3+, RBC 0-1/HPF DM retinopathy (+) Kidney sono: RK-10.6cm LK-11.1Cm Chest PA: Pulmonary congestion 2012 개원의와함께하는임상강좌

2 맞춤진료 : 증례위주의실전강의 Case 2 60세여자가사지무력감으로왔다. 최근부종으로약제가추가되었다고한다. 과거력 : 10년전부터당뇨병 (+), 고혈압 (+) 약물력 : Inhibace 1T, Cozaar 1T, glimepride 1T, Aldactone1T Lab: BUN/Cr 57/2.2 mg/dl (egfr 24.2 ml/min/1.73m 2 ) Na/K/Cl 132/7.8/103 mmol/l Case 3 50세남자가건강검진상신기능이상으로왔다. 과거력 : 10년전HTN (+) Lab: BUN/Cr 15/1.4 mg/dl (egfr 57 ml/min/1.73m 2 ) Na/K/Cl 139/4.5/101 mmol/l, total CO 2 24mmol/L Ca/P 9.0/4.3mg/dl, Hb 12 g/dl UA prot 1+, RBC 0-1/HPF 1. 한국인만성콩팥병의실태 2012 개원의와함께하는임상강좌

3 정경환 : 만성콩팥병환자 - 언제의뢰해야하나? Three major cause of ESRD in KOREA 투석환자등록사업 개원의와함께하는임상강좌

맞춤진료 : 증례위주의실전강의 국내 3 차의료기관의당뇨병조절상태및합병증 Korean Diabetes J,

빠른인구의고령화로제2형당뇨병환자증가 당뇨병의조기발병에따른당뇨병합병증발생증가

당뇨병말기신부전환자의투석기회확대 Diabetes (DM) and hypertension (HTN)

4 맞춤진료 : 증례위주의실전강의 국내 3 차의료기관의당뇨병조절상태및합병증 Korean Diabetes J, 2009 The cause of increase in diabetic ESRD 빠른인구의고령화로제2형당뇨병환자증가 당뇨병의조기발병에따른당뇨병합병증발생증가 당뇨병성만성콩팥병환자의생존기간연장? 신대체요법필요시까지생존? 당뇨병말기신부전환자의투석기회확대 Diabetes (DM) and hypertension (HTN) often coexist in CKD Distribution of CKD, HTN, & diabetic patients in Medicare population, USRDS, 개원의와함께하는임상강좌

5 정경환 : 만성콩팥병환자 - 언제의뢰해야하나? But few are aware of it even those with egfr less than 30 Percent Report Being Aware of Having Weak of Failing Kidneys egfr of egfr of Men Women Coresh, et al., 2007 Early treatment can make a difference 100 No Treatment Current Treatment GFR (ml/min/ ) Early Treatment 10 0 Kidney Failure Time (years) 2. 신장전문의 Refer time 2012 개원의와함께하는임상강좌

6 맞춤진료 : 증례위주의실전강의 2012 개원의와함께하는임상강좌

7 정경환 : 만성콩팥병환자 - 언제의뢰해야하나? 당뇨병성만성신장병환자에서신장내과전과시기가예후에미치는영향 경희의료원 1996 년 년, n=238 ER: 전과시점에서투석까지 1 개월이상 LR: 전과시점에서투석까지 1 개월미만 The Korean Journal of Nephrology 2009 당뇨병성만성신장병환자에서신장내과전과시기가예후에미치는영향 The Korean Journal of Nephrology 개원의와함께하는임상강좌

8 맞춤진료 : 증례위주의실전강의 당뇨병성만성신장병환자에서신장내과전과시기가예후에미치는영향 Risk Factors of 1 Year Mortality Rate after Start of RRT The Korean Journal of Nephrology 2009 Impact of nephrology care Comparative Prospective Cohort Study (overt nephropathy, n=52, 1yr) Between Primary Health Care Doctors and a Nephrologist Am J Kidney Dis, 2006 Impact of nephrology care Comparative Prospective Cohort Study Between Primary Health Care Doctors and a Nephrologist Am J Kidney Dis, 개원의와함께하는임상강좌

9 정경환 : 만성콩팥병환자 - 언제의뢰해야하나? 신장전문의 early refer 의장점 Good control of anemia, hypertension and hyperparathyroidism Avoid of nephrotoxic drug Informed selection of dialysis modality Timely placement of appropriate dialysis access Non-emergent initiation of dialysis Lower morbidity and improved rehabilitation Preemptive transplant Late refer Late refer: defined as initiation of dialysis <1 6 months (usually <3 months) after initial referral to a nephrologist increased patient morbidity and mortality increased use of temporary venous catheters at initiation of haemodialysis less use of peritoneal dialysis reduced likelihood of listing on a transplant waiting list and of transplantation increased need for and duration of hospital admission increased initial costs of care following the commencement of dialysis Cause of late referral Unavoidable cause (12-60%) 환자의투석에대한공포 질병의무증상상태 Referral biases of physicians refer time 에대한인식부족 신장전문의와 communication 문제 Economic factor 2012 개원의와함께하는임상강좌

10 맞춤진료 : 증례위주의실전강의 Cause of late referral Multivariate Multinomial Logistic Regression Showing the Independent Association of Select Socioeconomic Indices of Patients and Timing of Referral Am J Kidney Dis. 2005;46(5):881-6 Problems of late referral Metabolic and hematologic complication Hospitalization and cost Selection of dialysis modality Emergent first dialysis and permanent access Loss of kidney function and rehabilitation Mortality Time Referral to the Nephrologist Guideline Organization CARI-Australia 2003 CSN-Canada 1999 Recommendation (Evidence Level) Patients with Ccrea < 30 ml/min/1.73m 2. Earlier referral should be considered in patients who are hypertensive or who have significant proteinuria (>1g/24hours). (Level B) Refer patients with Ccreat <30ml/min to a nephrologist for opinion regarding management of renal failure (Opinion) Comments Reasons for timely referral - high risk progressive deterioration renal function - specialist management of renal failure - adequate preparation for dialysis EBPG-Europe November 2002 A. Referral should be considered when GFR<60ml/min and is mandatory when GFR<30ml/min B. If GFR is not available, referral should be when on 2 con secutive measurements Screa > 150µmol/L (1.7 mg/dl) in men and 120µmol/l (1.35 mg/dl) in women. (Opinion) 2012 개원의와함께하는임상강좌

11 정경환 : 만성콩팥병환자 - 언제의뢰해야하나? Time Referral to the Nephrologist KDOQI-US February 2004 UK-Guidelines August 2002 In general, patients with GFR <30 ml/min/1.73 m 2 should be referred (stage 4). (Opinion) Patients with progressive RF should be referred early with Screa μmol/l ( mg/dl) to enable dialysis to be started in a planned fashion. (Good Practice) Consultation and/or co-management with a kidney disease care team is advisable during Stage 3 (30-59ml/min), and referral to a nephrologist in Stage 4 (15-29ml/min) recommended Kidney function may need to be monitored four times per year or more Other indications for referral Acute renal failure Proteinuria Immediate referral/discussion - most patients with acute renal failure unless the cause and solution are obvious Routine referral prot/creat >100mg/mmol or albumin/creat ratio >30mg/mmol prot/creat >45mg/mmol or albumin/creat ratio >15 mg/mmol and hematuria Urgent referral - Heavy proteinuria with low serum albumin (nephrotic syndrome) Other indications for referral Haematuria Hypertension Hyperkalaemia Macroscopic haematuria with negative urological investigations Macroscopic haematuria with stable renal impairment Microscopic haematuria with proteinuria as above Immediate referral - malignant hypertension Routine referral - uncontrolled (>150/90) BP despite 4 agents in a patient with stage 3+ CKD Immediate referral - Hyperkalaemia K + >7mmol/L 2012 개원의와함께하는임상강좌

12 맞춤진료 : 증례위주의실전강의 Automatic egfr by the laboratory reporting is best GFR is the accepted measure of kidney function GFR is difficult to infer from serum creatinine alone Automatic reporting identifies CKD patients with apparently normal serum creatinine Reduces barrier to early detection and identifies people at high risk for contrast agents and other nephrotoxins Caveats to egfr An estimate based on population data--not the patient s actual GFR Not reliable when used with patients: with GFR above 60 ml/ min/1.73 m 2 with rapidly changing creatinine levels (acute kidney injury in the ICU) with extremes in muscle mass (cachexia or paraplegia) under age 만성콩팥병의 primary care 2012 개원의와함께하는임상강좌

13 정경환 : 만성콩팥병환자 - 언제의뢰해야하나? What can primary care providers do? Recognize and test at-risk patients Educate patients about CKD and treatment Focus on good glycemic control in people with diabetes For those with CKD: 혈압조절철저히 130/80mmHg ~ 125/75mmHg ACE inhibitor나 ARB 약제로치료 대부분에서병합치료가필요함 이뇨제병합치료 What can primary care providers do? egfr과소변albumin Creatinine ratio check Treat cardiovascular risk, especially with smokers and hypercholesterolemia Screen for anemia (Hb), malnutrition (albumin), metabolic bone disease (Ca, P, PTH) Refer to dietitian for nutritional guidance Consult or team with a nephrologist Nephrology referral suggestions To assist with diagnostic challenge (decision to biopsy) To assist with therapeutic challenge (blood pressure) Rapid decline of estimated GFR Most primary kidney diseases (glomerulonephridites) Preparation for renal replacement therapy, especially when GFR less than 개원의와함께하는임상강좌

14 맞춤진료 : 증례위주의실전강의 Nephrology referral suggestions Regardless of when you refer: Obtaining preliminary evaluation (ultrasound, screening serologies) Providing consultant with patient history including serial measures of renal function Primary care providers First line of defense against CKD Primary care professionals can play a significant role in early diagnosis, treatment, and patient education Therapeutic interventions for diabetic CKD are similar to those required for optimal diabetes care Control of glucose, blood pressure, and lipids A greater emphasis on detecting CKD, and managing it prior to referral, can improve patient outcomes CKD is Part of Primary Care 2012 개원의와함께하는임상강좌

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