2023 KDIGO CKD Cov Lus Qhia Tau Los, Xauj Cov Ntsiab Lus Hloov Kho Cov Tshuaj Hauv Kab Lus no!
Jun 25, 2023
Thaum Lub Rau Hli 16, 2023, ntawm 60th European Renal Association Congress (ERA), cov kws tshaj lij los ntawm KDIGO tau tshaj tawm cov xov xwm yuav los tom ntej thiab qee cov ntsiab lus tseem ceeb ntawm 2023 KDIGO Kab Mob Raum Kab Mob (CKD) Cov Lus Qhia.
Nyem rau cistanche deserticola vs tubulosa rau mob raum
Prof. Magdalena Madero los ntawm Mexico yog yav dhau los tus kws kho thoob ntiaj teb ntawm AJKD, yav dhau los tus tswv cuab ntawm KDIGO pawg thawj coj, thiab tus lwm thawj ntawm International Society of Nephrology rau Latin America thiab Caribbean. Hauv lub rooj sib tham no, nws tau qhia meej txog qhov hloov tshiab tshiab ntawm cov lus qhia no ntawm kev kho CKD, suav nrog cov txheej txheem los ncua kev mob raum thiab tswj cov teeb meem. Siv ib qho piv txwv tshwj xeeb, nws qhia txog kev siv cov kev hloov tshiab no.
Txoj kev tshawb fawb SPRINT luam tawm ntawm NEJM hauv 2021 tau qhia tias hauv cov neeg mob CKD uas tsis muaj ntshav qab zib, ntshav siab txo qis tuaj yeem txo qhov kev pheej hmoo ntawm kev tuag ntau dua piv nrog cov qauv ntshav txo qis, nrog rau qhov phom sij piv (HR) ntawm 0.73 (95 feem pua CI, 0.63~0.86, Daim duab 1).
Daim duab 1 Cov txiaj ntsig ntawm kev txo cov ntshav siab vs cov ntshav siab txo qis ntawm kev pheej hmoo ntawm kev tuag hauv cov neeg mob CKD
Txawm li cas los xij, kev soj ntsuam ntawm cov ntsiab lus thib ob ntawm SPRINT txoj kev tshawb fawb pom tau tias kev txo qis ntshav siab tau txo cov kab mob plawv (HR {{0}}}.81; 95 feem pua CI, {{10}}}. 63-1.05) thiab tag nrho-ua rau kev tuag (HR=0.72; 95 feem pua CI, 0.53-0.99), tab sis tsis txhim kho cov ntsiab lus ntawm lub raum, xws li eGFR txo qis los ntawm ntau tshaj 50 feem pua los yog kab mob raum kawg (ESRD; HR=0.90; 95 feem pua CI, 0.{19}}.83). Nws yog ib qho tsim nyog sau cia tias kev siv tshuaj tiv thaiv kab mob siab tsis tuaj yeem ncua kev loj hlob ntawm cov kab mob raum hauv cov neeg mob CKD uas muaj ntshav qab zib.
Phau ntawv KDIGO no muaj 2 qhov hloov tshiab hauv qab no rau SGLT-2i:
Kev pom zoo 1: Siv SGLT-2i los kho cov neeg laus CKD nrog eGFR Ntau dua lossis sib npaug li 20ml/min/1.73㎡, UACR Ntau dua lossis sib npaug rau 200mg/g, thiab lub plawv tsis ua haujlwm (1A).
Kev pom zoo 2: Siv SGLT-2i los kho cov neeg laus CKD nrog eGFR Ntau dua lossis sib npaug ntawm 20-45 ml/min/1.73㎡ thiab UACR < 200 mg/g (2B).
Feem ntau, ntau cov kev tshawb fawb thiab Meta-analysis tau pom tias SGLT-2Kuv muaj txiaj ntsig zoo rau kev ncua sijhawm ntawm kev mob raum, tiv thaiv cov hlab plawv, thiab tiv thaiv qhov tshwm sim ntawm lub plawv tsis ua haujlwm hauv cov neeg mob CKD.
Kev tswj hwm ntawm CKD hauv cov lus qhia no zoo ib yam li kev tswj cov ntshav qab zib nephropathy tau luam tawm xyoo 2022. SGLT-2i thiab renin-angiotensin inhibitors (RAASI) yog lub hauv paus thiab thawj txoj kev kho mob rau CKD. Txawm li cas los xij, cov txheej txheem tswj xyuas tshwj xeeb yuav tsum tau tos rau kev tshaj tawm cov lus qhia no. Rau kev tshuaj ntsuam xyuas tus neeg mob, cov kev pab cuam cuam tshuam, thiab kev soj ntsuam, saib daim duab hauv qab no (Daim duab 2).
Daim duab 2 SGLT-2i kev npaj kho mob rau cov neeg mob CKD uas muaj ntshav qab zib
Lus Ceeb Toom: 2023 KDIGO CKD cov lus qhia zoo ib yam li cov phiaj xwm saum toj no, thov tos kom tso tawm cov phiaj xwm tshwj xeeb.
Nws yog ib qho tsim nyog sau cia tias qhov kev tshawb fawb tau taw qhia tias hauv cov neeg mob tau txais RAASi ntxiv rau SGLT-2i kev kho mob, qhov kev poob qis txhua xyoo ntawm eGFR tsuas yog -1.85ml/min/1.73㎡, thiab nws tau kwv yees tias nws yuav siv li 25 xyoo los txhim kho lub raum tsis ua haujlwm; thaum tsuas yog cov neeg mob tau txais kev kho mob RAASi, uas nws qhov kev poob qis txhua xyoo yog -4.6ml/min/1.73㎡, tuaj yeem ua rau lub raum tsis ua haujlwm li ntawm 10 xyoo; thaum cov neeg mob CKD uas tsis tau txais kev kho mob, lawv cov eGFR poob qis txhua xyoo yog 12ml / min / 1.73㎡, tuaj yeem tsim lub raum tsis ua haujlwm li ntawm 5 xyoos (Daim duab 3). Cov ntaub ntawv no qhia tias RAASi ntxiv rau SGLT-2kuv txoj kev kho mob muaj kev tiv thaiv tseem ceeb ntawm kev ncua sijhawm ntawm CKD mus rau lub raum tsis ua haujlwm.
Daim duab 3 Daim ntawv qhia kev pheej hmoo ntawm lub raum tsis ua haujlwm
Lus Cim: Cov kab grey yog cov neeg mob CKD uas tsis tau txais kev kho mob, kab txiv kab ntxwv yog cov neeg mob uas tau txais kev kho mob RAASi nkaus xwb, thiab kab xiav yog cov neeg mob uas tau txais RAASi ntxiv rau SGLT-2i.
Nws paub zoo tias cov neeg mob muaj kev pheej hmoo siab rau hyperkalemia nrog txo eGFR thiab nce proteinuria (Fig. 4).
Daim duab 4 Risk table of hyperkalemia hauv CKD cov neeg mob uas muaj lossis tsis muaj ntshav qab zib
Txhawm rau tiv thaiv hyperkalemia hauv cov neeg mob CKD, muaj 3 kab kev kho mob.
Kev kho thawj kab: ① optimize serum bicarbonate; ② optimize ntshav qab zib tswj; ③ xav txog cov tshuaj diuretics thiab SGLT-2i ua cov tshuaj ntxiv.
Kev kho mob thib ob: Ntsuas cov ntsiab lus ntawm cov poov tshuaj ions hauv kev noj zaub mov, thiab xav txog kev kho cov khoom noj kom txo tau cov khoom noj.
Txoj kev kho thib peb: ① Kho cov tshuaj thiab tsis txhob siv cov tshuaj uas yuav ua rau kom ntshav poov tshuaj ntau ntxiv; ②Siv cov khoom sib pauv kom txo cov poov tshuaj.
Hais txog kev tswj hwm uric acid, tam sim no tsis muaj pov thawj pom tias txo qis uric acid hauv cov neeg mob CKD nyuaj nrog asymptomatic hyperuricemia yog qhov zoo los ncua kev loj hlob ntawm CKD. Cov lus pom zoo rau kev kho mob tshwj xeeb yog raws li hauv qab no:
Kev pom zoo 1: CKD cov neeg mob uas muaj cov tsos mob hyperuricemia yuav tsum tau txais kev kho mob urate-lowering (1C).
Kev pom zoo 2: Rau cov neeg mob uas muaj CKD thiab asymptomatic hyperuricemia, nws tsis pom zoo kom siv cov tshuaj urate-lowering kom ncua kev loj hlob ntawm CKD (2D).
Txawm hais tias metabolic acidosis yog ib qho kev mob tshwm sim hauv cov neeg mob CKD, thiab nws txoj kev pheej hmoo tau pom nyob rau hauv daim duab hauv qab no (Daim duab 5), tsis yog txhua tus neeg mob CKD yuav tsum tau txais kev tswj cov kua qaub. Nws cov ntsiab lus ua tau raws li hauv qab no:
Xyaum taw tes 1: Xav txog kev noj zaub mov thiab / lossis kev kho tshuaj los tiv thaiv acidosis hnyav (bicarbonate phiaj<16mmol/L).
Tswv yim 2: Cov ntshav poov tshuaj concentration yuav tsum tau saib xyuas tsis tu ncua kom ntseeg tau tias cov ntshav poov tshuaj tsis tshaj qhov txwv ntawm qhov qub thiab tsis txhob cuam tshuam rau cov ntshav siab thiab ntim.
Daim duab 5 Risk ntawm metabolic acidosis
Lus Cim: Ntsuab yog qhov pheej hmoo tsawg, daj yog qhov nruab nrab muaj kev pheej hmoo, txiv kab ntxwv muaj kev pheej hmoo siab, thiab liab muaj kev pheej hmoo siab heev.
Although existing guidelines (Figure 6) state that daily protein intake can be >0.4 g/kg hauv cov neeg mob CKD, cov pov thawj rau cov lus qhia no laus dua thiab qis dua. Muab qhov no, xibfwb Magdalena Madero ntseeg hais tias nws yog ib qho tsim nyog yuav tsum nruj txwv tsis pub noj cov protein ntawm cov neeg mob. Yog li ntawd, nws xaiv qhov kev xaiv A.
Daim duab 6 Cov lus qhia ntsig txog kev noj zaub mov zoo rau CKD
Tsis tas li ntawd, cov neeg tsis noj nqaij lossis cov neeg tsis noj nqaij noj zaub mov muaj txiaj ntsig zoo rau cov neeg mob CKD, tab sis cov kev tshawb fawb no tseem pom tau tias kev noj cov protein cuam tshuam rau kev loj hlob ntawm cov kab mob raum thiab comorbidities hauv cov neeg mob.
xibfwb Magdalena Madero tau sau cov ntsiab lus hloov tshiab ntawm 2023 KDIGO CKD cov lus qhia, suav nrog plaub lub ntsiab lus hauv qab no:
Plaub qhov hloov tshiab tseem ceeb
①SGLT-2Kuv yuav tsum yog thawj zaug tshuaj rau CKD, proteinuria, ntshav qab zib, lossis lub plawv tsis ua haujlwm;
②Potassium tswj yog lub hauv paus ntawm RAASi thiab tsis-steroidal mineralocorticoid agonist kho;
③ Tsis muaj ntaub ntawv los txhawb kev tswj cov kab mob metabolic acidosis lossis asymptomatic hyperuricemia;
④ Muaj cov ntaub ntawv ntau ntxiv txog kev ua neej nyob thiab kev noj haus ntawm cov neeg mob CKD, txawm hais tias feem ntau yog cov kev tshawb fawb soj ntsuam.
Xib fwb Magdalena Madero tau ceeb toom rau peb ntxiv tias cov ntsiab lus saum toj no yog lub taub dej khov ntawm phau ntawv qhia no, thiab xav paub ntau ntxiv thov tos rau qhov kev tshaj tawm ntawm 2023 KDIGO CKD phau ntawv qhia. Nws tau tshaj tawm tias cov lus qhia no yuav raug tso tawm hauv ob peb lub lis piam tom ntej no. Thov ua tib zoo mloog mus rau Yimaitong raum channel kom paub txog cov kev hloov tshiab hauv cov lus qhia no!
Cov ntaub ntawv:
1. Magdalena Madero. KDIGO 2023 CKD GL: Ncua CKD Kev Txhim Kho thiab Cov Teeb Meem: Dab tsi tshiab? ERA 2023. Lub Rau Hli 16, 2023.
