335.4 📋 章末速蚘 Summary

335.4.1 🔑 䞀句話瞜結

CKD = eGFR < 60 OR kidney damage (albuminuria, hematuria, abnormal imaging, biopsy) ≥ 3 months台灣 ~ 12% 成人盛行率top causesDM (DKD) > HTN > GN (IgA, FSGS, lupus) > PKD > tubulointerstitial > vascular > hereditary (Alport, Fabry, sickle cell)KDIGO 2012 + 2024 staging(1) G stage by eGFR G1 ≥ 90, G2 60-89, G3a 45-59, G3b 30-44, G4 15-29, G5 < 15 or RRT(2) A stage by UACR A1 < 30, A2 30-300, A3 > 300 mg/gcomplications 6 倧(1) cardiovascular (top death cause, CHD risk equivalent)(2) anemia (low EPO + iron deficiency + inflammation/hepcidin) — treatment: iron + ESAs + HIF-PHIs roxadustat/vadadustat/daprodustat (NEW, FDA 2023)(3) CKD-MBD (hyperphosphatemia + ↓ calcitriol + 2° hyperPTH + ↑ FGF-23 + vascular calcification) — treatment: phosphate binders (non-Ca preferred) + active vit D + cinacalcet/etelcalcetide + parathyroidectomy(4) fluid + electrolyte (hyperK + acidosis — sodium bicarbonate target HCO3 22-26)(5) uremia (encephalopathy, neuropathy, pruritus, bleeding, pericarditis)(6) endocrine + nutrition (PEW, insulin resistance, hypothyroidism, infertility)target therapies 2024SGLT2i (CREDENCE/DAPA-CKD/EMPA-KIDNEY) + finerenone (FIDELIO/FIGARO) + GLP-1 RA (FLOW 2024 semaglutide) + ACE/ARB + statin — DKD nephroprotection paradigm。

335.4.2 💊 治療粟芁

  • CKD progression slowingACE/ARB (first-line if proteinuria) + SGLT2i (CREDENCE/DAPA-CKD/EMPA-KIDNEY) + finerenone (FIDELIO/FIGARO) + GLP-1 RA (FLOW 2024) + BP < 130/80 + statin
  • anemia of CKDiron first → ESAs (target Hgb 10-11.5, CHOIR/TREAT caution higher) → HIF-PHIs (roxadustat, vadadustat, daprodustat) NEW oral option
  • CKD-MBDphosphate binders (non-Ca preferred: sevelamer, lanthanum, ferric citrate, sucroferric oxyhydroxide) + active vit D (calcitriol, paricalcitol) + cinacalcet (calcimimetic) + etelcalcetide (parenteral) + parathyroidectomy refractory
  • acidosissodium bicarbonate to target HCO3 22-26
  • hyperkalemiadietary restriction + K binders (patiromer, sodium zirconium cyclosilicate) + adjust ACE/ARB if needed
  • CV riskstatin (primary prevention if eGFR < 60 + albuminuria), AC for AF (CHA₂DS₂-VASc-based but balance bleeding)
  • bleeding (uremic)DDAVP, cryoprecipitate
  • late CKD (G4-G5)refer to nephrology, prepare RRT (AV fistula 6-12 mo, PD catheter 4-6 wk), transplant evaluation, conservative care option

335.4.3 🎯 盧醫垫的考前提醒

  1. CKD definitioneGFR < 60 OR kidney damage (albuminuria, hematuria, abnormal imaging, biopsy, transplant) ≥ 3 months — duration 是 key
  2. KDIGO G + A stagingG1-G5 by eGFR + A1-A3 by UACRcombined predicts CKD progression + CV events
  3. CKD top death cause = cardiovascularCHD risk equivalent— statin for primary prevention if eGFR < 60 + albuminuria
  4. DKD (diabetic kidney disease) treatment paradigm 2024ACE/ARB + SGLT2i + finerenone + GLP-1 RA — all 4 pillars 郜有 nephro/cardio-protective evidence
  5. landmark trialsCREDENCE (canagliflozin DKD)、DAPA-CKD (dapagliflozin DKD + non-DM CKD)、EMPA-KIDNEY (empagliflozin)、FIDELIO-DKD + FIGARO-DKD (finerenone)、FLOW (semaglutide CKD 2024)
  6. HIF-PHIs (NEW 2023 FDA)roxadustat (Evrenzo), vadadustat (Vafseo), daprodustat (Jesduvroq) — oral HIF-PH inhibitors → endogenous EPO + ↓ hepcidin → effective for renal anemia; alternative to injectable ESAs
  7. CHOIR (2006) + TREAT (2009) lessonsdon’t normalize Hgbtarget 10-11.5 g/dLhigher target → ↑ CV events
  8. CKD-MBD 病理生理hyperphosphatemia → 2° hyperPTH → ↑ FGF-23 → ↓ calcitriol → bone disease + vascular calcificationFGF-23 是 earliest biomarker
  9. phosphate binder selectionnon-Ca-based (sevelamer, lanthanum, ferric citrate, sucroferric oxyhydroxide) preferred 避免 Ca load + vascular calcificationCa-based (Ca carbonate, Ca acetate) acceptable in early stages
  10. CKD acidosis treatment with sodium bicarbonatetarget HCO3 22-26evidence (UBI trial) of slowing CKD progression + preventing bone disease + muscle wasting