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肾性贫血诊断与治疗中国专家共识(2014_修订版)课件_1

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性贫血 诊断 治疗 中国 专家 共识 2014 修订版 课件 _1
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Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾性贫血诊断与治疗中国专家 共识 2014 修订版 解读 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2014肾性贫血的专家共识 肾性贫血的发病率及危害 肾性贫血的治疗现状 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 58 98 2 贫血的发生率 22 37 45 4 85 1 98 2 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial VEN PM010 01 11 2008 Ludwig H Strasser K Semin Oncol 2001 28 Suppl 8 7 14 人体多个器官均受到贫血的影响 心血管系统 心动过速 乏力 左室肥厚 中枢神经系统 情绪变化 认知功能变化 消化道 不规律的肠道运动 免疫系统 免疫缺陷 肾脏功能 灌注减低 液体潴留 肌肉骨骼系统 肌肉无力 生殖系统 月经不调 性欲缺乏 4 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial DOPPS Hb和住院危险性之间的关系 Pisoni RL et al AJKD 44 1 94 111 2004 住院的相对危险度 p 0 0001p 0 05p 0 77 Ref 血红蛋白 g dl p 0 001 n 435 n 2484 n 1994 n 1789 n 1296 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 贫血导致CKD患者的生存率降低 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial CKD 贫血 临床事件和 死亡率显著上升 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 贫血是CKD常见的并发症 1 贫血可加重CKD的进展2 贫血可导致CKD患者心脑血管事 件发生率增加 3 贫血导致CKD患者死亡率 增加 生存率降低 4 贫血的危害 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2014肾性贫血的专家共识 肾性贫血的发病率及危害 肾性贫血的治疗现状 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 接受治疗的CKD患者Hb达标率低 2010 Shanghai Dialysis Registry Report 仅有34 22 的 患者Hb达标 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 绝大部分CKD患者的贫血没有得到治疗 Am J Kid Dis 2001 38 803 812 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2014肾性贫血的专家共识 肾性贫血的发病率及危害 肾性贫血的治疗现状 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾肾性贫贫血诊诊断与治疗疗中国专专 家共识识 2014 修订订版 中国医师协会肾脏内科医师分会于 2014 年 5 月启动了肾性贫血诊断和 治疗的专家共识修订工作 旨在为 我国 CKD 患者贫血的规范化诊断和 治疗提供指导性建议 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2014 修订订版 1 慢性肾脏病患者贫血的诊断和评估 2 铁剂治疗 3 红细胞生成刺激剂 FSAs 治疗 4 输血治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾性贫血是指由各类肾脏疾病造成促红细胞 生成素 EPO 的相对或者绝对不足导致的贫 血 以及尿毒症患者血浆中的一些毒性物质 通过干扰红细胞的生成和代谢而导致的贫血 肾性贫血的定义 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 酌情考虑居住地海拔高度对血红蛋白的影响 海平面水平地区 年龄大于等于15岁 成年非妊娠女性 120g L 贫血的诊断标准 男性 130g L 成年妊娠女性 110g L Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 每6个月测量血红蛋白1次 无贫血病史 CKD1 3期 CKD4 5期 未透析 CKD5期和 透析 每年测量血红蛋白1次 评估贫血的频率 每3个月测量血红蛋白1次 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 有贫血病史 CKD3 5期 未透析 CKD5期腹膜 透析 CKD5期血 透患者 评估贫血的频率 至少每月测量血红蛋白1次 至少每3个月测量血红蛋白1次 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 网织红细胞计 数 维生素 B12 叶酸 骨髓穿刺 粪便 隐血等项目 铁储备和铁利用指 标 全血细胞计数 CBC 贫血 评估贫血的实验室指标 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial KDOQI指南建议从早期关注和 治疗CKD贫血 NKF K DOQI 2006 2007 UPDATE 不需要进一步评 估和治疗 ESA治疗贫血 纠正患者缺铁 Yes Yes 所有CKD患者 检测Hb 1次 年 男性 13 5g dL 女性 29 pg cell 接受稳定 ESAs 治疗的 CKD 患者 未接受 ESAs 治 疗的 CKD 3 5 期非透析患者以及未接受 ESAs 治疗的 维持性血液透析患者 应每 3 个月监测铁状态 1 次 调整 ESAs 剂量时 有出血存在时 静脉铁剂治疗后监 测疗效时 有其他导致铁状态改变的情况 如合并炎性 感染未控制时 需增加监测铁的频率 1 铁状态的评价及监测频率 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 铁剂治 疗指征 2 铁剂治疗指征 对于对于未接受铁剂或 ESAs 治疗 的成年 CKD 贫血患者 转铁蛋白 饱和度 TSAT 30 且铁蛋白 500 ug L 则推荐尝试使用静脉 铁剂治疗 在 CKD 非透析患者中 或可尝试 进行为期 1 3 个月的口服铁剂治疗 若无效可以改用静脉铁剂治疗 A Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 铁剂治 疗指征 B 对于已接受 ESAs 治疗但尚未接受铁 剂治疗的成年 CKD 贫血患者 若需 要提高血红蛋白水平或希望减少 ESAs 剂量 且转铁蛋白饱和度 TSAT 30 铁蛋白 500 ug L 则 推荐尝试使用静脉铁剂治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial SF 500 ug L 原则上不常规应用静脉 补铁治疗 若排除了急性期炎症 高 剂量 ESAs 仍不能改善贫血时 可试 用铁剂治疗 铁剂治 疗指征 C Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 非透析患者及腹膜 透析患者可先试用 口服途径补铁 或 根据铁缺乏状态直 接应用静脉铁剂治 疗 血液透析患者应优 先选择静脉途径补 铁 口服补铁 剂量为 200 mg d 1 3 个 月后再次评价铁状 态 如果铁状态 血红蛋白没有达到 目标值 每周 ESAs 100 150 IU kg 体质量治疗 条件下 或口服 铁剂不能耐受者 推荐改用静脉途径 补铁 3 铁剂的用法和剂量 血液透析患者应常规采 用静脉补铁 1 个疗程剂量 常为 1000 mg 一个疗程 完成后 如SF 500ug L 和 TSAT 30 可再重复一 个疗程 静脉途径铁剂维持性治 疗 当铁状态达标后 应 用铁剂的剂量和时间间隔 应根据患者对铁剂的反应 铁状态 血红 蛋白水平 ESAs 用量 ESAs 反应 及近期并发症等情况调整 推荐 100 mg 每 1 2 周 1 次 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 如果患者 TSAT 50 和 或 血清铁蛋白 800 ug L 应停止静脉补铁 3 个月 随后 重复检测铁指标以决定静脉补铁是否恢复 当 TSAT 和血清铁蛋白分别降至 50 和 800 ug L 时 可考虑恢复静脉补铁 但每 周剂量需减少 1 3 1 2 3 铁剂的用法和剂量 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 给予初始剂量静脉铁剂治疗时 输注 60 min 内应对患者进 行监护 需配有复苏设备及药 物 有受过专业培训的医护人 员对其严重不良反应进行评估 4 铁剂治疗注意事项 给予初始剂量静脉铁剂治疗时 输注 60 min 内应对患者进 行监护 需配有复苏设备及药 物 有受过专业培训的医护人 员对其严重不良反应进行评估 有全身活动性感染时 禁用静 脉铁剂治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 治疗前准备 接受 ESAs 治疗前 应权衡因减少输血和缓解贫血相关症状 带来的利与弊 三 红细红细 胞生成刺激剂剂 ESAs 治疗疗 对于 CKD 合并活动性恶性肿瘤患者 应用 ESAs 治疗时应提高警惕 尤 其是以治愈为目的的活动性恶性肿瘤患者及既往有卒中史的患者 接受 ESAs 治疗疗之前 应处应处 理好各种导导致贫贫血的可逆性因素 接受 ESAs 治疗前 应权衡因减少输血和缓解贫血相关症状带 来的利与弊 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 ESAs治疗时机 成人透析患者血红蛋白下降速度比非透析患者快 建议血红蛋白 100 g L 时即开始 ESAs 治疗 2 血红蛋白 100 g L 的部分肾性贫血患者可以个体 化使用 ESAs 治疗以改善部分患者的生活质量 3 血红蛋白 100g L 的非透析成人 CKD 患者 个体 化权衡和决策是否应用 ESAs 1 血红蛋白 130 g L 以上 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 4 ESAs剂量及用量调整 Content Title Content Title CKD透析和非透析患者初始计量 50 100 IU kg 每 周3次或 10000 IU 每周1次 静脉或皮下 治疗的目标是每月Hb上升10 20 g L 避免1月内Hb 增幅超过 20 g L 初始治疗阶段每月至少监测Hb1次 维持治疗期间非透 析患者每3月监测1次 透析患者每月监测1次 应应根据患者的Hb水平 Hb变变化速度 目前 ESAs 的 使用剂剂量以及临临床情况等多种因素调调整 ESAs 剂剂量 推荐在 ESAs 治疗疗 1 个月后再调调整剂剂量 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Hb未达目标值 增加剂量 20iu kg 每周3次 或1000iu 每2周3次 Hb接近130g L时 剂量降低约25 血红蛋白持续升高 应暂停 给药直到血红蛋白开始下降 然后将剂量降低约 25 后重新 开始给药 任意2 周内血红蛋白 水平升高超过 10 g L 应将剂量降低约 25 剂量调整 当 需要下调血红蛋白水平时 应减少 ESAs 剂量 但没必要 停止给药 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 5 ESAs用药途径 非透析患者和腹 膜透析患者 建议采用皮下注射 途径给药 静脉或皮下注射方式 皮下注射可以减少药 物的用量 血液滤过或血液透 析患者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 按照患者体质量计算的适量 ESAs 治疗1个月后 血红蛋 白水平与基线值相比无增加 初始 ESAs 治疗 反应低下 获得性 ESAs 反 应低下 稳定剂量的 ESAs 治疗后 为 维持Hb稳定需要两次增加 ESAs 剂量且增加的剂量超过 稳定剂量的 50 6 ESAs 低反应应性原因及处处理 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial ESAs 低反应性的原因 铁缺乏 铝中毒 脾亢 PRCA 透析不充 分 SHPT 纤维性骨炎 ACEI ARB 炎性疾病 慢性失血 肿瘤 营养不良 溶血 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 评估患者 ESAs 低反应性的类型 针对 ESAs 低反应性的特定原 因进行治疗 对纠正原发病因后仍存在 ESAs 治疗低反 应性的患者 建议采用个体化方案进行治疗 并评估血红蛋白下降 继续 ESAs 治疗 和输血治疗的风险 对初始和获得性治疗反应低下患者 最大剂 量不应高于初始剂量或稳定剂量 基于体质 量计算 的 2 倍 处 理 6 ESAs 低反应应性原因及处处理 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 需要输注红细胞才可 维持血红蛋白水平 确诊必须有EPO抗体检测 阳性的证据 以及骨髓象 检查结果的支持 血小板和白细胞计数正 常 且网织红细胞绝对 计数小于 10 000 ul 血红蛋白以每周 5 一 10 g L 的速度快速下降 PRCA 6 ESAs抗体介导导的 PRCA 的处处理 重组人促红细胞生成素治疗超过 8 周并出现下述情况 治疗 凡疑似或确诊的患者均应停用任何促红细胞生成素制剂 可应用免疫 抑制剂 雄激素 大剂量静脉丙种球蛋白治疗 必要时输血 最有效的治疗 是肾移植 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 透析通 路血栓 癫痫 高血压 高钾血 症 高钙血 症 肌痛及 输液样 反应 ESAs 7 ESAs 不良反应 ESAs 促红细胞生成素治疗还可导致内膜增生和随后的血管 狭窄 深静脉血栓 皮疹 心悸 过敏反应 虹膜炎 样反应 脱发等症状 但发生率很低 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 原 则 适合器官移 植的患者 在病情允许 的情况下应 避免输注红 细胞 以减 少发生同种 致敏的风险 四 输血治疗 对于肾性贫 血治疗 在 病情允许的 情况下应尽 量避免输注 红细胞 减 少输血反应 的风险 1 输血原则 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 输血适应症及注意事项 已出现贫血相关症状及体征的严重贫血者 如急性失血致血流动力学不稳定者 手术失血需要补充血容量者 伴慢性失血的 ESAs 不敏感患者 原则 确定贫血的性质及纠正的可 能性 使可纠正的贫血得到相应的治 疗 确定通过红细胞成分输血可以 减轻相应症状及体征 如果输注红细 胞不能逆转症状及体征 则不要输血 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 慢性贫血输血 指针 ESAs 治疗无效 如血红蛋白病 骨髓衰竭 ESAs 耐药 ESAs 治疗的风险超过其治疗获益 不能仅根据血红蛋白的变化来判断非急性贫血 CKD 患者是否需要输血治疗 而应根据贫血所 导致的症状来判断 2 输血适应症及注意事项 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 注意事项 血红蛋白 100 g L 时 不推荐输血 患者血红蛋白 70 g L 需要提高血液携氧能力时 应考虑输血 因红细胞破坏过多 丢失或生成障碍引起的慢性贫血 血 红蛋白 100 次 min 活动后心率 120 次 min 或 出现奔马律时可考虑输血 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 高危患者 年龄 65 岁 合并心血管和 或 呼吸 道疾病患者 对贫血耐受性差 血红蛋白 80 g L 时可考虑输血治疗 紧急情况下 当输注红细胞的利大于弊时 可考虑输 注红细胞治疗 包括 需要快速纠正贫血来稳定患者全身情况时 如 急性出血 不 稳定性冠心病 术前需要快速纠正 血红蛋白水平时 2 输血适应症及注意事项 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 溶血反应 急性肺损伤 过敏反应 枸橼酸盐中毒和高钾血症 移植物抗宿主病 3 输血相关风险 发热反应 疾病传播和血液污染 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial
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