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Chronisch nierfalen

Chronisch nierfalen. Diagnose, behandeling, epidemiologie, relatie met CV ziekte. Van creatinine naar GFR. creatinine uit spierweefsel filtratie vs tubulaire uitscheiding Cockcroft formule ( obsoleet ) MDRD = eGFR ml/min/1.73m 2 creatinine klaring ml/min.

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Chronisch nierfalen

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  1. Chronisch nierfalen • Diagnose, behandeling, • epidemiologie, relatie met CV ziekte

  2. Van creatinine naar GFR • creatinineuitspierweefsel • filtratievstubulaireuitscheiding • Cockcroft formule (obsoleet) • MDRD = eGFR ml/min/1.73m2 • creatinineklaring ml/min

  3. Begrippen klaring en MDRD/GFR alleen gebruiken in min of meer stabiele situaties en vooral niet bij ANF!!!

  4. Proteinurie Macro-albuminurie wordt ook proteinurie genoemd Paraproteine niet positief op stickje

  5. Erythrocyturie • Stickje: kwantitatief op hemoglobine of myoglobine (dus pos bij hemolyse, rhabdomyolyse • Glomerulaire hematurie: dysmorfe ery’s (>20%) en/of ery cylinders • Monomorfe hematurie: urologie

  6. Stadia van nierinsufficientie

  7. Nierfunctie en lftd

  8. Verwijsbeleid Landelijke Transmurale Afspraak Chronische nierschade 2009

  9. Oorzaken CNF • KlassiekeNierziektes : afnemendADPKD, CGN, CPN, IDDM, TIN, SLE • Nieuwkomers : toenemendDM2, hypertensie, atherosclerose

  10. Beleid stad 1 en 2 • asympt. urineafw: expectatief • Proteinurie voorspelt nierfunctie achteruitgang en CV-complicaties, mn in aanwezigheid van hypertensiestreefBP <125/75, voorkeur ACE/ARB’s cave de combinatie!! (ONTARGET studie)

  11. Gevolgen CNS stad 3-5

  12. BehandeldoelenCNS 3-5 1/2

  13. BehandeldoelenCNS 3-5 2/2

  14. Elevated risk for CV mortality in ESRD • CV mortality in ESRD in different studies: • 2,5 to 170 times that in the general population Sarnak & Levey, Sem Dial 1999: 12:69

  15. Poor outcome of CV events in dialysis Mortality after AMI is high Mortality has not improved over time Herzog NEJM 1998: 339: 799

  16. All-cause and CV risk in CKD N=1,120.295 Mean follow-up 2.84 yrs Risk proportional to renal function impairment Go et al NEJM, 2004; 351:1296-05

  17. Effect of renal function on prognosis already present in mild renal failure Hillege, Circulation 2000;102:203-10

  18. CV risk in CKD Proportional to renal function impairment Already elevated at mild-moderate renal function impairment (5-10% of the population)

  19. Long term risk management in renal patients: modifiable risk factors over time Bio-incompatibility contamination dialysate etc Blood pressure lipids smoking obesity in-activity Ca/PO anemia proteinuria inflammation AGEs ADMAs Progression of renal failure

  20. Guidelines CKD Prevention renal function loss and CV complications Treat hypertension 130/85; 125/75 Treat proteinuria (< 1 g/d) Control CaPO4 Treat anemia Stop smoking Control lipids Treat hyperhomocysteïnemia + + + - - -/+ - + + + - + - - Werkgroep KKcie NfN – herziening richtlijn CNI

  21. Guidelines CKD Prevention renal function loss and CV complications Prevention of renal function loss is powerful prevention against CVD Treat hypertension 130/85; 125/75 Treat proteinuria (< 1 g/d) Control CaPO4 Treat anemia Stop smoking Control lipids Treat hyperhomocysteïnemia + + + - - -/+ - + + + - + - - Werkgroep KKcie NfN – herziening richtlijn CNI

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