14. RIÑON DEL ENVEJECIMIENTO
Estudio: EEUU - veteranos 18 a 100 años - 2,598,548 una medición de sCr
Ann M. O’Hare. Mortality Risk Stratification in Chronic Kidney Disease: One Size for All Ages? J Am Soc Nephrol 17: 846 – 853, 2006.
15. • RR DISMINUYE CON LA EDAD
• 50 – 59 TFG no es riesgo en mayores de 65 años
Ann M. O’Hare. Mortality Risk Stratification in Chronic Kidney Disease: One Size for All Ages? J Am Soc Nephrol 17: 846 – 853, 2006.
16. Artur Olszewski et al. Chronic kidney disease in elderly – Fact or fiction?.p o l i s h a n n a l s o f m e d i c i n e 2 1 ( 2 0 1 4 ) 9 0 – 9 5
17. Artur Olszewski et al. Chronic kidney disease in elderly – Fact or fiction?.p o l i s h a n n a l s o f m e d i c i n e 2 1 ( 2 0 1 4 ) 9 0 – 9 5
18. Artur Olszewski et al. Chronic kidney disease in elderly – Fact or fiction?.p o l i s h a n n a l s o f m e d i c i n e 2 1 ( 2 0 1 4 ) 9 0 – 9 5
19. Artur Olszewski et al. Chronic kidney disease in elderly – Fact or fiction?.p o l i s h a n n a l s o f m e d i c i n e 2 1 ( 2 0 1 4 ) 9 0 – 9 5
31. • La Duración de la enfermedad renal debe ser
documentada o inferida basado en el contexto clínico
Ej: paciente con disminución de la función renal o
daño renal en ausencia de enfermedad aguda. Se
confirma si se sigue en el tiempo
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
32. • Reversibilidad:
La mayoría de enfermedades renales no tienen síntomas o hallazgos
hasta que son avanzadas y solo son detectadas cuando son crónicas
> causas irreversibles
Cronicidad no es sinónimo de irreversibilidad
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
33. La TFG es un componente de la función excretoria pero se acepta como el mejor índice
global de la función renal ya que generalmente se reduce después de un daño estructural
extenso y muchas otras funciones renales declinan en paralelo con la TFG
Se escogió el umbral de TFG < 60
mL/min/1.73 m2 por > 3 meses para indicar
ERC
Es menos de la mitad de un valor normal
en un adulto joven (125 mL/min)
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
34. Wesson L.20 Physiology of the Human Kidney. Grune & Stratton: New York, 1969.Normal values for GFR by age
35. Una TFG < 60 mL/min está
asociada con mayor riesgo
de complicaciones que el
paciente con ERC y TFG
conservada
Matshushita K, van de Velde M, Astor BC, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. The Lancet, vol 375,.4, p. 2073-
2081, 2010
36. Toxicidad por medicamentos
• Alteración de la farmacocinética de
medicamentos excretados por el riñón
• Riesgo incrementado de interacciones
medicamentosas
• A TFG menores se puede observar
farmacocinética y farmacodinamia de
medicamentos no excretados por el riñón
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
37. Complicaciones metabólicas y endocrinas
• Anemia
• Acidosis
• Malnutrición
• Desórdenes óseos y
minerales
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
38. • Parénquima
• Grandes vasos sanguíneos
• Sistemas colectores
Se infiere por marcadores más
que por examen directo del
tejido renal
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
39. Proteinuria
• Puede reflejar pérdida anormal de proteínas plasmáticas por:
Incremento en la permeabilidad glomerular a proteínas de alto peso molecular
(albuminuria o proteinuria glomerular)
Reabsorción tubular incompleta de proteínas de bajo peso molecular filtradas
normalmente (proteinuria tubular)
Incremento en la concentración plasmática de proteínas de bajo peso molecular (cadenas
livianas de Ig)
• Puede reflejar pérdida anormal de proteínas derivadas del riñón
(constituyentes de células renales tubulares por daño tubular) y del
tracto urinario bajo
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
40. Albuminuria
• Proteína plasmática encontrada en la orina de sujetos normales y en
mayor cantidad en pacientes con enfermedad renal
• La terminología clínica está cambiando a enfocarse en albuminuria
más que en proteinuria
La albúmina es el principal componente de las proteínas urinarias en la
mayoría de enfermedades renales
Datos epidemiológicos demuestran una relación fuerte de la cantidad de
albúmina urinaria con riesgo de enfermedad renal y cardiovascular
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
41. • Es común pero no uniforme en ERC
• Es el marcador más temprano de enfermedades glomerulares
(En ND aparece antes de la reducción en TFG)
• Marcador de nefroesclerosis hipertensiva pero puede no
aparecer hasta después de la reducción en la TFG
• Se asocia con HTA subyacente, obesidad y enfermedad vascular
cuando no se conoce la enfermedad renal subyacente
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
42. Equivalente a un
ACR ≥ 30 mg/g o
3 mg/mmol
• Es + de 3 veces el valor normal en adultos jóvenes (10
mg/24h)
• Puede ser detectable a veces como ‘’trazas’’ en tirilla
reactiva dependiendo de la concentración de la orina.
Aunque es consistente hasta que excede 300 mg/24h
• Está asociada con riesgo incrementado de complicaciones
de ERC
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
43. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
44. Anormalidades del sedimento urinario
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
45. Anormalidades en electrolitos debido a desórdenes
tubulares
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
46. Anormalidades patológicas observadas en el tejido renal
obtenido por biopsia
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
47. Historia de Trasplante Renal
• Los receptores de trasplante renal se definen como ERC independiente del nivel de TFG o
presencia de marcadores de daño renal
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
48. Anormalidades en imágenes
• Se considera que los pacientes con anormalidades significativas que persisten por más
de 3 meses tienen ERC
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
49. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
50. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
51. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
52. Levey AS, de Jong PE, Coresh J, et al. The definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report. Kidney Int 2011; 80: 17-28
ACR < 30 mg/g
ACR 30-299 mg/g
ACR >300 mg/g
53. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
54. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
55. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
56. PREDICCIÓN DEL PRONÓSTICO
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
57. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
Riesgo
moderadamente
incrementado
Alto riesgo
MUY ALTO
RIESGO
Bajo riesgo
58. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
59. EVALUACIÓN DE LA ERC
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
60. • Cuando la evidencia de ERC es comprobada por primera vez, la prueba
de cronicidad puede ser obtenida o confirmada por:
Revisión de previas mediciones de TFG
Revisión de previas mediciones de albuminuria o proteinuria y uroanálisis
Hallazgos imagenológicos como reducción del tamaño de los riñones y reducción en el
grosor cortical
Hallazgos patológicos como fibrosis o atrofia
Historia médica: especialmente duración de desórdenes que se conocen por causar ERC
Repetir las mediciones entre 3 meses y más allá
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
61. Para la mayoría de los pacientes están indicadas las
siguientes evaluaciones
• Tirilla reactiva en uroanálisis para detectar hematuria o
piuria. Si es (+), usar la microscopia de orina para detectar
cilindros eritrocitarios o leucocitarios
• Ecografía para evaluar la estructura renal (forma, tamaño,
simetría y evidencia de obstrucción)
• Electrolitos en suero y en orina para evaluar desórdenes
tubulares renales
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
62. Evaluación de la TFG
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
63. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
64. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KIDNEY INTERNATIONAL SUPLEMENTS. VOL 3 | ISSUE 1 | JANUARY (1) 2013
Notes de l'éditeur
Los transversales solo toman una vez la cr y no durante 3 meses; roblema de ver si se queda cronico
Those
include the KDOQI guidelines in the United States, the CKD
National Institute for Health and Care Excellence (NICE) guidelines,
and the Australian Caring for Australasians with Renal Impairment
(CARI) guidelines. The KDOQI guidelines additionally recommend screening
those older than 65 years. Screening should consist of urinalysis,
a urine albumin or protein estimation (such as urine albumincreatinine
ratio [uACR]), and measurement of serum creatinine and
estimation of GFR (see Chapter 3), preferably by the CKD-EPI equation
(KDIGO 2012).
hereditary
nephropathy (such as autosomal dominant polycystic kidney disease
[ADPKD]) or acquired nephropathy (such as glomerulonephritis
[GN], diabetic nephropathy, or tubulointerstitial disease)
Edad mayor de 75, hombres en estudios en ratas, efectos de andrógenos, afroamericanos es la pob q mas esta en diálisis en usa
A diferencia de la AKI, en la ERC el daño es sotenudi, progresando a fibrosis y destrucción de la microarquitectura normal y su remmplazo por tej fibroso hecho de una matrix colagenosa, perdiendo las funciones
Afecta ppalmente el glomérulo, pero tmbn los tubulos y el intersticio, asi como los vasoso sanguíneos, histológicamente glomeruloesclerosisis, fibrosis túbulo intersticial y esclerosis vascular
Proceso
Rta inflamatoriainfiltración de células externas
Activación, proliferación y perdida de las cel intrínsecas renales (apoptosis o necrosis , mesangiolisis, podocitopenia)
Activación y proliferacipin de la Matriz Extracel, produciendo miofibrobalstos y fibroblastos
Deposito de MEC que reemplaxa la arwuitectura renal
Schematic representation showing the interaction of risk factors for chronic kidney disease (CKD) progression with pathophysi- ologic mechanisms that contribute to a vicious cycle of progressive nephron loss. Ang II, Angiotensin II; FSGS, focal segmental glomeruloscle- rosis; PGC, glomerular capillary hydraulic pressure; SNGFR, single-nephron glomerular filtration rate; TIF, tubulointerstitial fibrosis. endowment: dotacion
Las GN con inmunosupresión pueden parar o reversar, la ert puede ser reversible con trasplante
GFR is shown for men (Panel a) and women (Panel b) of various ages, with the GFR measured as the urinary clearance of inulin. The horizontal line indicates a GFR value of 60 ml/min/1.73 m2 , which is the threshold for the definition of CKD. Solid lines represent the mean value of GFR per decade of age, and dashed lines represent the value 1 SD from the mean value of GFR per decade of age. CKD, chronic kidney disease; GFR, glomerular filtration rate; SD, standard deviation. Adapted with permission from Wesson L.20 Physiology of the Human Kidney. Grune & Stratton: New York, 1969
AER: albumin excretion rate
ACR: albumin to creatinine ratio
t CKD is not a diagnosis in and of itself, and that the assignment of cause is important for prognostication and treatment.
AER: albumin excretion rate
ACR: albumin to creatinine ratio
Summary of continuous meta-analysis (adjusted RRs) for general population cohorts with ACR. Mortality is reported for general population cohorts assessing albuminuria as urine ACR. Kidney outcomes are reported for general population cohorts assessing albuminuria as either urine ACR or reagent strip. eGFR is expressed as a continuous variable. The three lines represent urine ACR of o30, 30-299 and Z300 mg/g (o3, 3-29, and Z30 mg/mmol, respectively) or reagent strip negative and trace, 1 þ positive, Z2 þ positive. All results are adjusted for covariates and compared to reference point of eGFR of 95 ml/min/1.73 m2 and ACR of o30 mg/g (o3 mg/mmol) or reagent strip negative (diamond). Each point represents the pooled RR from a meta-analysis. Solid circles indicate statistical significance compared to the reference point (P o0.05); triangles indicate non-significance. Red arrows indicate eGFR of 60 ml/min/1.73 m2 , threshold value of eGFR for the current definition of CKD. ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HR, hazard ratio; OR, odds ratio, RR, relative risk. Reprinted with permission from Macmillan Publishers Ltd: Kidney International. Levey AS, de Jong PE, Coresh J, et al. The definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report. Kidney Int 2011; 80: 17-2830; accessed http://www.nature.com/ki/journal/v80/n1/full/ki2010483a.html: Kidney International. Levey AS, de Jong PE, Coresh J, et al. The definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report. Kidney Int 2011; 80: 17-28
Figure 7 | Summary of categorical meta-analysis (adjusted RRs) for general population cohorts with ACR. Mortality is reported for general population cohorts assessing albuminuria as urine ACR. Kidney outcomes are reported for general population cohorts assessing albuminuria as either urine ACR or reagent strip. eGFR and albuminuria are expressed as categorical variables. All results are adjusted for covariates and compared to the reference cell (Ref). Each cell represents a pooled RR from a meta-analysis; bold numbers indicate statistical significance at P o0.05. Incidence rates per 1000 person-years for the reference cells are 7.0 for all-cause mortality, 4.5 for CVD mortality, 0.04 for kidney failure, 0.98 for AKI, and 2.02 for CKD progression. Colors reflect the ranking of adjusted RR. The point estimates for each cell were ranked from 1 to 28 (the lowest RR having rank number 1, and the highest number 28). The categories with a rank number 1-8 are green, rank numbers 9-14 are yellow, the rank numbers 15-21 are orange and the rank numbers 22-28 are colored red. (For the outcome of CKD progression, two cells with RR o1.0 are also green, leaving fewer cells as yellow, orange and red). ACR, albumin-to-creatinine ratio; AKI, acute kidney injury; CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; RR, relative risk. Reprinted with permission from Macmillan Publishers Ltd: Kidney International. Levey AS, de Jong PE, Coresh J, et al.30 The definition, classification, and prognosis of chronic kidney disease: a KDIGO controversies conference report. Kidney Int 2011; 80: 17-28; accessed http://www.nature.com/ki/journal/v80/n1/full/ki2010483a.html
AER: albumin excretion rate
ACR: albumin to creatinine ratio
PCR: protein to creatinine ratio
Abbreviations: AKI, acute kidney injury; BP, blood pressure; CVD, cardiovascular disease; GFR, glomerular filtration rate. Plus signs indicate the strength of the risk relationship between the CKD characteristic and the outcome: +, somewhat associated; ++, moderately associated; +++, strongly associated. *Note that the + designations refer to strength of relationship not strength of evidence to support, and are based on consensus overview by the Work Group members. Adapted with permission from Uhlig K, Levey AS.68 Developing guidelines for chronic kidney disease: we should include all of the outcomes. Ann Intern Med 2012; 156(8): 599-601
Evaluate the clinical context, including personal and family history, social and environmental factors, medications, physical examination, laboratory measures, imaging, and pathologic diagnosis to determine the causes of kidney disease. (Not Graded)
10-12 cm de largo
5-6 cm de ancho
Corteza: 1 cm de grosor
Many individuals found to have CKD will not have a primary kidney disease but kidney damage caused by diabetes mellitus, vascular disease, and hypertension. The issue for the clinician will be to decide whether the presence of these is a sufficient explanation and if not, to investigate further. The prevalence of other conditions will vary depending on region, age, and other factors
such as confirming a diagnosis of CKD, determining eligibility for kidney donation, or adjusting dosage of toxic drugs that are excreted by the kidneys.79 The choice of confirmatory test depends on the clinical circumstance and the availability of methods where the patient is treated.
creatinine generation by muscle and dietary intake, tubular creatinine secretion by organic anion transporters, and extrarenal creatinine elimination by the gastrointestinal tract
