335.3 🏥 內科專科考前版

335.3.1 Mechanistic Deep Dive

335.3.1.1 FGF-23 Biology

  • Phosphaturic hormone from osteocytes
  • Elevated early in CKD
  • ↑ Phosphate excretion + ↓ vitamin D
  • Predictive of CV events + mortality
  • Resistance to FGF-23 in advanced CKD

335.3.1.2 Hepcidin in CKD Anemia

  • Iron homeostasis regulator
  • ↑ In inflammation + CKD
  • Functional iron deficiency
  • HIF-PHI ↓ hepcidin → improved iron utilization

335.3.1.3 Vascular Calcification

  • Active process (osteoblast-like vascular smooth muscle)
  • Phosphate, Ca, FGF-23, klotho, inflammation
  • Atherosclerotic + medial
  • ↑ Mortality

335.3.1.4 Klotho-FGF-23 Axis

  • Klotho: co-receptor for FGF-23
  • ↓ Klotho in CKD progresses
  • Aging marker

335.3.2 Recent Trials & Updates

335.3.2.1 CREDENCE (2019) — Canagliflozin DKD

  • T2DM + CKD
  • ↓ ESKD, CV events
  • Foundation of SGLT2i in DKD

335.3.2.2 DAPA-CKD (2020) — Dapagliflozin

  • CKD with or without DM
  • ↓ ESKD progression
  • Extended indication beyond DM

335.3.2.3 EMPA-KIDNEY (2022) — Empagliflozin

  • Similar to DAPA-CKD
  • ↓ CKD progression + CV events

335.3.2.4 FIDELIO-DKD (2020), FIGARO-DKD (2021) — Finerenone

  • Non-steroidal selective MRA
  • DKD + albuminuria
  • ↓ CKD progression + CV events
  • FDA approved

335.3.2.5 FLOW (2024) — Semaglutide

  • CKD + DM
  • ↓ Composite renal outcome
  • 24% reduction
  • Adds GLP-1 RA to CKD armamentarium

335.3.2.6 CHOIR (2006), TREAT (2009) — ESAs

  • Higher Hgb target → ↑ CV events
  • Practice: don’t normalize Hgb (target 10-11.5)

335.3.2.7 Daprodustat (ASCEND-D, ASCEND-ND, 2021)

  • FDA approval 2023
  • Non-dialysis vs dialysis indications
  • Non-inferior to ESAs

335.3.2.8 EVOLVE (2012) — Cinacalcet

  • Mortality outcome neutral; reduced PTH, Ca×P

335.3.2.9 IMPACT-SHPT — Etelcalcetide

  • Reduced PTH effectively

335.3.3 High-Yield Specialist Points

335.3.3.1 When to Refer to Nephrology

  • eGFR < 30 (G4)
  • A3 (> 300 mg/g)
  • Rapid decline (> 5 mL/min/year)
  • Difficult management (HTN, K, MBD)
  • Cause unclear
  • Prepare for RRT

335.3.3.2 Renal Replacement Therapy Preparation

  • AV fistula 6-12 months before HD
  • PD catheter 4-6 weeks before
  • Transplant referral
  • Conservative management option (kidney supportive care)

335.3.3.3 Patient Education

  • Diet (Na, K, PO4, protein)
  • Medication adherence
  • Avoid nephrotoxins (NSAIDs)
  • Foot care (DM)
  • Vaccinations
  • Mental health support

335.3.3.4 ACE/ARB in CKD

  • First-line if proteinuria
  • Acute Cr ↑ acceptable up to 30% (still continue)
  • Hyperkalemia monitoring
  • Avoid combination ACE + ARB (ONTARGET)

335.3.3.5 SGLT2i in CKD

  • ↓ Glomerular hyperfiltration
  • Cardio-renal protective
  • Approved across CKD stages (eGFR ≥ 20-25 various)
  • Side effects: euglycemic DKA (DM), genital infections

335.3.3.6 Finerenone

  • Non-steroidal selective MRA
  • For DKD + albuminuria
  • 10-20 mg daily
  • Watch K+ (less than spironolactone)

335.3.3.7 GLP-1 RA in CKD

  • Semaglutide (FLOW 2024)
  • ↓ Renal events
  • CV benefit
  • Weight loss

335.3.3.8 Avoiding Nephrotoxins

  • NSAIDs
  • Aminoglycosides
  • Contrast (when possible)
  • Herbal medicines (䞭草藥 — important in Taiwan)
  • Tenofovir (consider alternatives)

335.3.3.9 Bone Mineral Disease Workflow

  • Monitor: Ca, P, PTH, vit D, ALP
  • Bone biopsy rarely
  • Treatment: phosphate binders, active D, calcimimetics
  • Parathyroidectomy for severe refractory

335.3.3.10 Vascular Calcification Imaging

  • Kauppila score (lateral spine X-ray)
  • CT calcium score
  • Predicts mortality

335.3.3.11 Calciphylaxis

  • Calcific uremic arteriolopathy
  • Painful necrotic skin lesions
  • High mortality
  • Treatment: sodium thiosulfate, wound care, parathyroidectomy if hyperPTH

335.3.4 Pearls

  • CKD: eGFR < 60 OR damage ≥ 3 mo
  • KDIGO G + A staging
  • Top causes: DM > HTN > GN > PKD
  • Top death cause: CV
  • HIF-PHI (roxadustat, daprodustat) NEW for anemia
  • Finerenone (FIDELIO/FIGARO) for DKD + albuminuria
  • SGLT2i + GLP-1 RA + ACE/ARB for DKD
  • Hgb target: 10-11.5 (CHOIR, TREAT)
  • Phosphate binders: non-Ca preferred to avoid Ca load
  • Vascular calcification: predicts mortality