Kanpo-Maseterです。
今週のMayo Clin Procは比較的そそった内容だったのでチェックしてみました。Primary careをやっている自分としてもこうゆう知識は確認も含めて大事と思います。
The Top 10 Things nephrologists with every primary care physician knew [Mayo Clin Proc 2009;84:180-186]
http://www.mayoclinicproceedings.com/content/84/2/180.abstract
1 ■ A "Normal" serum creatinine level may not be normal
The interpretation of serum creatinicne level also depends on muscle mass, age, sex, height, and limb amputation.
2 ■ Know the medications that spuriously elevate the serum creatinine level.
ST 合剤とH2-blocker cimetidine （タガメット）はcreatinieのsecretionを減少させる２つのcommonなdrugである。base lineから0.4 to 0.5mg/dlほど上げる。
Famotidine (ガスター) and ranitidine （ザンタック）can likewise cause an increase but to a lesser degree. BUNの上昇も伴うcreatinineの上昇はGFRの低下を意味する。
3 ■ Patients with decreased GFR or proteinuria should be evaluated to determine the cause; positive urine dipstick test results for protein should be followed up with a spot urine protein to urine creatinine ratio.
Alb/Creatiniteはmicroalbuminuriaの検出に役立つ
TP/Creatinine≧1.0は注意である。
TP/Creatinine≧1.0の場合、CKDへ進展するリスクは高い。Glomerular diseaseの検索は、、、diabetes, CVD (SLEなど), Malignancy (MM),Infections (HIV, Syphilis, HBV, HCV), NSAIDS, Solid tumors (membranous glomerulophatyとの関連あり).
4 ■ In patients with early-stage CKD, peiodic evaluation and intervention are appropriate to slow the progression of renal disease and avoid its complications
ACE-Is and ARBs may slow the progression of CKD, especially in patients with proteinuria. They may also reduce angiotensin II-mediated cell proliferation and fibrosis. その他、アスピリン81mg/dayの投与やLDL-Cを100mg/dl以下を目標に。
5 ■ Do not automatically discontinue an ACEI or ARB solely because of a
small increase in the serum creatinine or potassium level.
*Creatinineは20%-30%程度の上昇はOKだが、それ以上の上昇がないかどうかを確認すべき。
*5.5mEq/L以上のpotassiumは注意。特にスピロノラクトンとの併用の有無のチェック。
6 ■ Anemia in patients with CKD should be treated with erythrocyte-stimulating agents such as recombinant human erythropoietin but should not
be overtreated.
As much, the National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) guideline for the treatement of anemia of CKD recommends that the hemoglobin target should be between 11 and 12 g/dl (to convert to g/L, multiply by 10) and should not exceed 13g/dl.[Am J Kidney Dis 2007;50:471-530]
7 ■ Phosphate-COntaining Bowel preparations should be used with causion
CKD
CKDやCHFやNSAIDSやdiuretics投与患者はphosphate nephropathyのリスクが
あるのでガイドラインではpolyethylen glycolを薦めている
8 ■ Patients with severe CKD should avoid magnesium-or Aluminum-containing oral preparations.
Concominant use of citrate-containing preparations and aluminum-containing oral preparations is potentially hazardous because it can lead to acute aluminum toxicity.
severe CKDでは制酸剤は注意。（まーろ○○など） Chronic aluminum toxicity has been linked to sporadic Alzheimer disease and other
neurodegenerative disorders, however, this link is highly controversial.
9 ■ Although most patients with hypertension should not be screened for secondary hypertension, certain clinical clues may suggest the presence of an underlyin g cause that, when addressed, may resolve or improve the patient's hypertension.
Primary care clinicでは95%がprimary or essential hypertension
5%がsecondary cause.
Hypokalemia: aldosteronismのclueになる
Headaches, palpitations, and seats: pheochromocytomaのclueに。
Moon facies and/or striae: Cushing
History of snoring in an obese patients: OSAS
Hypothyroidism
Hyperparathyroidism
など。
Worsening blood pressure or renal function on initiation of an ACEI or ARB may also suggest renal artery stenosis.
10 ■ In patients with recurrent stone disease, an in depth metabolic evaluation is needed to identify and treat modifiable risk factor, thereby preventing further episodes and/or promoting stone dissolution.
The 10-year recurrence rates after a first calcium oxalate stone can be as high as 50% without treatment.
■One additional point: CYclosporine and Tacrolimus, Drugs commonly used in patients with renal allografts, have many drug-drug interactions.
Reduced cyclosporine levels: rifampin, phenytoin, carbamazepine
Increase cyclosporine levels: verapamil, diltiazem, erythromycin
Simvastatin(リポバス)との併用でstatin-induced rhabdomyolysisなど。
今週のMayo Clin Procは比較的そそった内容だったのでチェックしてみました。Primary careをやっている自分としてもこうゆう知識は確認も含めて大事と思います。
The Top 10 Things nephrologists with every primary care physician knew [Mayo Clin Proc 2009;84:180-186]
http://www.mayoclinicproceedings.com/content/84/2/180.abstract1 ■ A "Normal" serum creatinine level may not be normal
The interpretation of serum creatinicne level also depends on muscle mass, age, sex, height, and limb amputation.
2 ■ Know the medications that spuriously elevate the serum creatinine level.
ST 合剤とH2-blocker cimetidine （タガメット）はcreatinieのsecretionを減少させる２つのcommonなdrugである。base lineから0.4 to 0.5mg/dlほど上げる。
Famotidine (ガスター) and ranitidine （ザンタック）can likewise cause an increase but to a lesser degree. BUNの上昇も伴うcreatinineの上昇はGFRの低下を意味する。
3 ■ Patients with decreased GFR or proteinuria should be evaluated to determine the cause; positive urine dipstick test results for protein should be followed up with a spot urine protein to urine creatinine ratio.
Alb/Creatiniteはmicroalbuminuriaの検出に役立つ
TP/Creatinine≧1.0は注意である。
TP/Creatinine≧1.0の場合、CKDへ進展するリスクは高い。Glomerular diseaseの検索は、、、diabetes, CVD (SLEなど), Malignancy (MM),Infections (HIV, Syphilis, HBV, HCV), NSAIDS, Solid tumors (membranous glomerulophatyとの関連あり).
4 ■ In patients with early-stage CKD, peiodic evaluation and intervention are appropriate to slow the progression of renal disease and avoid its complications
ACE-Is and ARBs may slow the progression of CKD, especially in patients with proteinuria. They may also reduce angiotensin II-mediated cell proliferation and fibrosis. その他、アスピリン81mg/dayの投与やLDL-Cを100mg/dl以下を目標に。
5 ■ Do not automatically discontinue an ACEI or ARB solely because of a
small increase in the serum creatinine or potassium level.
*Creatinineは20%-30%程度の上昇はOKだが、それ以上の上昇がないかどうかを確認すべき。
*5.5mEq/L以上のpotassiumは注意。特にスピロノラクトンとの併用の有無のチェック。
6 ■ Anemia in patients with CKD should be treated with erythrocyte-stimulating agents such as recombinant human erythropoietin but should not
be overtreated.
As much, the National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) guideline for the treatement of anemia of CKD recommends that the hemoglobin target should be between 11 and 12 g/dl (to convert to g/L, multiply by 10) and should not exceed 13g/dl.[Am J Kidney Dis 2007;50:471-530]
7 ■ Phosphate-COntaining Bowel preparations should be used with causion
CKD
CKDやCHFやNSAIDSやdiuretics投与患者はphosphate nephropathyのリスクが
あるのでガイドラインではpolyethylen glycolを薦めている
8 ■ Patients with severe CKD should avoid magnesium-or Aluminum-containing oral preparations.
Concominant use of citrate-containing preparations and aluminum-containing oral preparations is potentially hazardous because it can lead to acute aluminum toxicity.
severe CKDでは制酸剤は注意。（まーろ○○など） Chronic aluminum toxicity has been linked to sporadic Alzheimer disease and other
neurodegenerative disorders, however, this link is highly controversial.
9 ■ Although most patients with hypertension should not be screened for secondary hypertension, certain clinical clues may suggest the presence of an underlyin g cause that, when addressed, may resolve or improve the patient's hypertension.
Primary care clinicでは95%がprimary or essential hypertension
5%がsecondary cause.
Hypokalemia: aldosteronismのclueになる
Headaches, palpitations, and seats: pheochromocytomaのclueに。
Moon facies and/or striae: Cushing
History of snoring in an obese patients: OSAS
Hypothyroidism
Hyperparathyroidism
など。
Worsening blood pressure or renal function on initiation of an ACEI or ARB may also suggest renal artery stenosis.
10 ■ In patients with recurrent stone disease, an in depth metabolic evaluation is needed to identify and treat modifiable risk factor, thereby preventing further episodes and/or promoting stone dissolution.
The 10-year recurrence rates after a first calcium oxalate stone can be as high as 50% without treatment.
■One additional point: CYclosporine and Tacrolimus, Drugs commonly used in patients with renal allografts, have many drug-drug interactions.
Reduced cyclosporine levels: rifampin, phenytoin, carbamazepine
Increase cyclosporine levels: verapamil, diltiazem, erythromycin
Simvastatin(リポバス)との併用でstatin-induced rhabdomyolysisなど。
