336.4 📋 章末速蚘 Summary

336.4.1 🔑 䞀句話瞜結

CKD treatment 2024 paradigm = 4 pillars + adjunctive + complication management4 pillars(1) ACE/ARB (foundational, proteinuric CKD)(2) SGLT2i (CREDENCE/DAPA-CKD/EMPA-KIDNEY) paradigm-shifting for DKD + non-DKD(3) Finerenone (FIDELIO-DKD/FIGARO-DKD) non-steroidal MRA for DKD + albuminuria(4) GLP-1 RA (FLOW 2024 semaglutide) broadest cardio-renal-metabolic benefitcombined effect ↓ CKD progression > 50% in DKDadjunctive therapiesstatin (primary prevention if eGFR < 60 + albuminuria), BP < 130/80 (KDIGO 2021), HbA1c < 7%, smoking cessation, dietary Na/PO4/K restrictioncomplications managementanemia (iron + ESAs target 10-11.5 + HIF-PHIs roxadustat/vadadustat/daprodustat FDA 2023), CKD-MBD (phosphate binders non-Ca preferred + active vit D + cinacalcet/etelcalcetide + parathyroidectomy refractory), acidosis (sodium bicarbonate target HCO3 22-26), hyperkalemia chronic (patiromer + sodium zirconium cyclosilicate), CV (statin + ASA + BP + DM control); emerging therapiessparsentan (FSGS + IgA, DUPLEX/PROTECT), iptacopan (C3G + IgA + aHUS), inaxaplin (APOL1 nephropathy), eculizumab/ravulizumab (aHUS), belimumab (lupus nephritis BLISS-LN); bardoxolone withdrawn (CV mortality concerns)。

336.4.2 💊 治療粟芁

  • Pillar 1 (ACE/ARB)lisinopril/ramipril/perindopril/losartan/valsartan/candesartan max tolerated; acute Cr ↑ 30% OK; monitor K; avoid combo
  • Pillar 2 (SGLT2i)dapagliflozin 10 mg, empagliflozin 10 mg, canagliflozin 100 mg; eGFR ≥ 20-25 cutoff; continue to dialysis
  • Pillar 3 (Finerenone)10 mg → 20 mg daily; eGFR ≥ 25, K ≀ 4.8 at start; monitor K
  • Pillar 4 (GLP-1 RA)semaglutide 1 mg/week (FLOW), dulaglutide, liraglutide; tirzepatide (GIP+GLP-1) emerging
  • anemiairon (oral or IV) → ESAs (epoetin, darbepoetin target Hgb 10-11.5) → HIF-PHIs (roxadustat, vadadustat, daprodustat) oral alternative
  • CKD-MBDnon-Ca phosphate binders (sevelamer, lanthanum, ferric citrate, sucroferric oxyhydroxide) + active vit D (calcitriol, paricalcitol) + calcimimetics (cinacalcet oral, etelcalcetide parenteral) + parathyroidectomy refractory
  • hyperkalemia chronicpatiromer (Veltassa) + sodium zirconium cyclosilicate (SZC, Lokelma)
  • acidosissodium bicarbonate target HCO3 22-26
  • emergingsparsentan (atrasentan ETA + ARB) for FSGS/IgA, iptacopan (factor B inhibitor) for C3G/IgA, inaxaplin (APOL1)

336.4.3 🎯 盧醫垫的考前提醒

  1. 4 pillars CKD treatment paradigmACE/ARB + SGLT2i + finerenone + GLP-1 RA — 任䞀族猺郜 suboptimal
  2. SGLT2i 䞉倧 CKD trialsCREDENCE (canagliflozin DKD) + DAPA-CKD (dapagliflozin CKD ± DM) + EMPA-KIDNEY (empagliflozin) — 郜 ↓ CKD progression + CV events
  3. finerenone (FIDELIO-DKD + FIGARO-DKD) is non-steroidal selective MRA — less hyperkalemia + less anti-androgen than spironolactone
  4. FLOW (2024)semaglutide in T2DM + CKD → 24% ↓ renal composite endpoint — adds GLP-1 RA to CKD armamentarium
  5. HIF-PHIs (FDA 2023)roxadustat (Evrenzo), vadadustat (Vafseo), daprodustat (Jesduvroq) — oral alternative to injectable ESAs; ↑ EPO + ↓ hepcidin
  6. chronic hyperkalemia in CKDpatiromer + sodium zirconium cyclosilicate (SZC) — newer K binders better tolerated than Kayexalate; allow continuation of ACE/ARB/MRA
  7. CKD-MBD phosphate binder evolutionnon-Ca-based (sevelamer, lanthanum, ferric citrate, sucroferric oxyhydroxide) preferred to avoid Ca load + vascular calcification
  8. emerging therapies for specific GNsparsentan (DUPLEX FSGS, PROTECT IgA) + iptacopan (APPLAUSE-IgAN) + inaxaplin (APOL1 nephropathy, AMPLITUDE trial)
  9. bardoxolone methyl withdrawnBEACON trial 顯瀺 ↑ CV mortality despite eGFR improvement — important to remember (䞍芁再考)
  10. statin in CKDSHARP trial (simvastatin + ezetimibe) ↓ CV events; primary prevention if eGFR < 60 + albuminuria; benefit less clear in dialysis (4D, AURORA, SHARP analyses)