A large number of epidemiological studies abroad display showing high prevalence of CKD , low awareness of the status quo . Our survey suggests some regional prevalence rate has reached over 10%. 18 districts and counties in Beijing permanent residents aged 18 or above ( 13925 ) conducted a survey , CKD prevalence of 13.0% , while the awareness of only 8.7%. Epidemiological studies in Guangzhou City of CKD in the general population , people over the age of 20 ( 6311 ) in CKD prevalence of 12.1% awareness rate was 9.6%. Shanghai community population ( 2554 ) of CKD prevalence was 11.8% , 8.2% awareness . People over the age of 18 in a village in Zhejiang Province in CKD prevalence of 13.1%. A study from Taiwan showed 12% CKD patients. Published in 2011 in China and Beijing Disease Prevention and Control Center to develop a multi-stage stratified sampling , 13 hospitals in the center of the 47,204 permanent residents aged 18 or above who carry out cross-sectional survey , CKD prevalence of 10.6% , 12.9% awareness . With the economy in rural areas, increased levels of albuminuria prevalence of a growing trend ; while the city is declining , which is the management of hypertension and diabetes are basically the same . In 1999 our country has entered the aging society, the elderly increased incidence of CKD , epidemiological investigation , PLA General Hospital , Beijing, community self-evaluation of healthy people , 65 people over the age of CKD Ⅲ prevalence rate of 26.13% over . Surveys have consistently shown that the elderly , hypertension, diabetes, and high cholesterol is an independent risk factor for CKD . Since the duration of occult CKD , early symptoms , the patient does not understand, the medical staff do not pay attention , awareness, early diagnosis and treatment rates low.
In China , if a 10% prevalence of CKD CKD analogy national number , which is 121 million cases , of which 1% if need dialysis , dialysis costs 100,000 yuan dollars per person per year , the annual cost of dialysis is 121 billion yuan RMB . Due to the rising prevalence and its corresponding treatment costs continue to rise, expect to spend the next decade due to the global cumulative result of dialysis and kidney transplantation will more than 1.1 trillion U.S. dollars . CKD longer duration, treatment expensive, would make the world unbearable burden, therefore , committed to the prevention of CKD is imperative .
Three , CKD etiology
According to incomplete statistics, China , chronic glomerulonephritis is still the first cause of CRF , but CRF -induced diabetes has risen to second place . In 1999, China hemodialysis patients remains the most common cause of glomerulonephritis ( 50% ) , followed by diabetic nephropathy ( 13.5% ) , hypertensive nephropathy ( 8.9% ) and polycystic kidney disease ( 2.7% ) . In addition, in different age and gender groups , causing a major cause of CRF are not the same . Secondary to hypertension , diabetes, atherosclerosis , such as kidney disease is a major hazard in elderly renal disease ; compared to less primary , acute renal disease and adults. Elderly men with prostate disorders resulting increase in the proportion of obstructive nephropathy . Middle-aged women with chronic urinary tract infections increased. According to the characteristics of our country , elderly patients renal interstitial tubular lesions are not uncommon , as some nephrotoxic antibiotics, antipyretic analgesics and herbs, abuse or overdose , resulting in renal interstitial fibrosis.
Fourth, the clinical features of CKD in elderly
CKD early signs and symptoms are nonspecific , such as fatigue , God, wilt , fatigue , anorexia , nausea , vomiting, and behind the yellow , dizziness, palpitations, skin itching , limb paresthesia , foot numbness. Advanced hypertension, heart failure , dyspnea , anemia, and other symptoms of psychosis , and often aqueous electrolyte acid-base balance disorders , and symptoms of each system .
CKD in the elderly and non- elderly clinical manifestations of the same . But these older more prominent .
1 more cardiovascular complications . Cardiovascular disease (CVD) is a common complication in patients with CKD is also the leading cause of death. In patients with serum creatinine ≥ 1.7mg/dl approximately 58% CRF patients died of CVD, CKD cardiovascular mortality is more than 15 times the general population , especially in the elderly . Cardiovascular complications include pericarditis , cardiomyopathy , heart failure , high blood pressure and heart damage caused by metabolic abnormalities .
2 . Poor nutritional status. Elderly intestinal mucosa, villous atrophy , digestion and absorption dysfunction , prone to malnutrition. Some statistics , China's death in hemodialysis patients than 1/3 cachexia .
3 anemia heavier. CRF anemia in elderly patients generally heavier, and often earlier onset of symptoms may be related to malnutrition , toxins greater impact on hematopoietic function and so on .
4 neurological symptoms common. Many elderly people with cerebral arteriosclerosis, cerebral blood flow decreased , insufficient blood supply to the brain , when the water , electrolyte imbalance, anemia and acidosis, nervous system prone .
Half of the terminal renal disease (ESRD) patients died from CVD, accounting for 25% of infections , cerebrovascular disease accounted for 6% , the three main causes of death are ESRD .
Six , renal function tests :
Elderly and ordinary people , inulin clearance GFR for determination is the gold standard is not applied in the clinical
( 1 ) serum creatinine (SCr) has been widely used in the evaluation of renal function , but its multiple confounding factors , low sensitivity , suitable for early detection of CKD , serum creatinine levels and age, gender and so on ; diet of meat, protein intake , gastrointestinal degradation and certain drugs ( spironolactone , cimetidine , etc. ) affect the renal tubular secretion of creatinine ; especially the older body lean , vegetarian , malnutrition, bedridden patients , reducing endogenous creatinine , serum creatinine is often low the actual level. While older GFR has dropped to 60 ml / min or less, but the muscle weight loss , Scr level does not rise significantly
( 2 ) blood urea nitrogen (BuN) when SCr increases blood BuN as secondary indicators of renal function , but its production rate is not constant , with the high-protein diet, tissue catabolism , glucocorticoids and bleeding will rise ; when liver disease and low protein decreased. Under normal circumstances, the blood BuN with Cr ratio was 10:1 ratio increased mostly prerenal factors , such as bleeding , dehydration, hypovolemia, cardiac dysfunction and tissue breakdown enhancement ; ratio decreased protein intake had seen less severe hepatic dysfunction .
( 3 ) creatinine clearance rate (Ccr) Ccr method previously used in the assessment of renal function , but the elderly cognitive dysfunction, enlarged prostate , incontinence , urine specimens specimens 24h error prone , poor reproducibility. And tubular secretion can cause renal Cr overestimated ( up to 10 % to 15% ) . Usually based on clinical SCr and Ccr roughly reflect changes in GFR , but its sensitivity is only 58% and 69%.
( 4 ) currently recommend some projections glomerular filtration rate (eGFR) or Ccr from SCr formula , which Cockcroft-Gault ( introduction of age, sex and weight parameters ) and MDRD ( introduction of age, gender and race parameters ) formula representatives, to increase the accuracy of eGFR . But the former formula established in the normal population , may be overestimated when evaluating CRF; while the latter was established in kidney disease patients with severe CRF application has good accuracy, but not for the elderly, children , pregnant women , normal and acute renal injury. CG formula in the assessment of renal function and perhaps better than the older MDRD formula , CG and MDRD formula for the probability of error formulas were 33 % and 50% ; while applying CG and MDRD formulas assessment formula elderly GFR, both deviations were 10% and 29 %. In recent years, other countries are in the MDRD formula developed on the basis of a new formula to estimate accurately the extent and the median offset significantly improve the situation for more than 80 years old, the deviation was significantly lower than the MDRD formula EPI formula.
Cockcroft-Gault formula:
Ccr (ml / min) = (140 - age (years )) × weight (kg) / 72 × SCr (mg / dl) ( F × 0.85))
MDRD formula:
eGFR (ml/min/1.73m2) = 186.3 × [SCr (umol / L) X0.0113] -1.154 × Age -0.203 ( F × 0.742)
CKD-epi formula:
eGFR (ml/min/1.73m2) = 141 × [SCr (mg / dl / 0.9 ( F × 0.7))-1.209X (0.993) Age ( F 1.0182 )
For our country , such as Ma Yingchun chronic kidney disease patients Fix MDRD equation , making it more suitable for Chinese people .
C-aGFR3 (ml/min/1.73m2) = 186 × [SCr (umol / L) X0.0113] -1.154 × Age -0.203 × (0.742 F ) × (1.233 Chinese people )
There is no strong evidence to prove what kind of formula is more suitable for the elderly. Both the MDRD formula , CG formula , or EPI equation derivation , were not involved in a large sample of the elderly population data , these formulas may appear large deviation in the elderly , and this bias will increase with age increases.
( 5 ) blood cystatin (Cystatin C) detection of endogenous cysteine protease inhibitor produced by a constant speed all nucleated cells from volume status , and drug interactions Inflammation affected. Cys C is considered to be superior to serum creatinine serum markers of an assessment of renal function in elderly patients with CKD .
It is worth noting , serum Cys C levels in patients with hyperthyroidism reduced ; coronary heart disease, infections, obesity and diabetes , asthma , cancer, hypothyroidism , steroid use , rheumatoid arthritis and other diseases seen increased serum Cys C levels , and can not use GFR decline to explain ; Cys C may be a causative factor involved in inflammatory atherosclerosis occurs development.
( 5 ) isotopes (ECT) is recognized as the gold standard method to detect GRF , which is more accurate than SCr and Ccr, and can be sub- renal judgment, in recent years, ECT measurement applications GRF has gradually increased, but its radioactive contamination , equipment and fees expensive and so greatly limiting the widespread clinical application .
GFR measured with ECT as the gold standard , the elderly population CKD3-5 period , CG formula , MDRD formula and corrected 24-hour creatinine clearance method were overestimated the level of GFR , inferred that the start time has renal replacement therapy in elderly may be delayed
In short , the presence of the elderly occurs with aging gradually decreased renal physiological phenomenon , the current method of assessment of renal function are ignored particularity in the elderly, a large sample of older people more clinical studies need to explore methods to assess renal function , suggested a number of ways a comprehensive assessment of renal function elderly , in order to improve its accuracy.
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