1. Defining Optimal Care of CKD : ( CV Risk management … …) NTUH Quality Wins 洪冠予醫師 2009/10/18

2. Q1. What’s the Mission of this talk ? … … 孟子見梁惠王 : 王 : 『叟，不遠千里而來，亦將有以利吾國乎 ? 』 孟子 : 『王何必曰利，亦有仁義而已矣。』

3. (n=2,434, CAD 18.9%)

4. DM, HT, and Hyperlipidemia associated with increased CKD risk AVD : Athrosclerotic vascular disease Adjusted for age, sex, region, coronary artery disease, cerebrovascular accident, transient ischemic attack, and peripheral vascular disease Kuo HW et al. AJKD, 49:46-55, 2007

5. All-cause mortality attributable to CKD:a prospective cohort study (462,293 adults) in Taiwan (Lancet. 2008 Jun 28;371(9631):2173-82)

6. Mortality Risks for All Causes and CV Diseases and Reduced GFR in a Middle-aged Working Population in Taiwan (AJKD 2008 Aug 14. [Epub ahead of print])

7. 標竿學習 … … Q2. 貴院的 CKD 衛教計畫 ， 重點項目為 : # Who ? # What ? # When ? # How ? 腎臟病防治的重點是什麼 ?

8. Kidney protection: a key target in the management of patients with diabetes (J Hypertens 2009 May;27(suppl 1):S15–S18) Microalbuminuria LVH arteriopathy Overt CVD, Advanced CKD, or both.

9. 【 RAA Dual Blockade for Cardiorenal Protection: An Update 】 Am J Kidney Dis 2009 Feb; 332-345

10. Am J Med (2008 Apr);121: 265-71

11. vs Renin Concentration (PRC) vs Renin Activity (PRA) Am J Med (2008 Apr);121: 265-71

12. 標竿學習 … … Q3. 貴院 CKD 病人 CVD 現況與醫療計畫為何 ? # 1 # 2 CKDHDPD (+) (-) By what standard ? ARBACEICCBβ-blocker 滿意 尚可 不好

13. Kidney protection: a key target in the management of patients with diabetes (J Hypertens 2009 May;27(suppl 1):S15–S18)

14. (NEJM 2002,April 11) 糖尿病腎病變的整合照顧

15. (AURORA, NEJM 2009;360:1395-407)

16. Q4. Is Statin beneficial for CKD? [AJKD 2009; 53(5):723-5] [NEJM 2009; 360:1455-7]

17. Staging of CKD BMJ 2006; 333: 733-7

18. Mortality Risks for All Causes and CV Diseases and Reduced GFR in a Middle-aged Working Population in Taiwan (AJKD 2008 Aug 14. [Epub ahead of print])

19. (Am J Cardiol 2008;102:1668 –73) (GFR <60 /min) (GFR <50 /min)

20. Q5. 結構面 : Def. of Critical CKD Stage ?

21. Kidney Dysfunction as a CV Risk Factor Arch Intern Med 2008;168(6):617-624

22. Q6. From CKD to CVD: same mechanism ? CV risk Oxidative Stress Traditional Risk Factors Inflammation Insulin resistance (metabolic syndrome)

23. Insulin Resistance, Adiponectin and Chronic Inflammation in Dialysis (HD & PD) Patients (Huang JW, Hung KY, et al. AJKD 2004;43:1047-55)

24. [Chiang CK, et al. Am J Nephrol 2009;29:392-397]

26. [NEJM 2008; 359:2195-2207] Implications of the Jupiter Trial ?

27. Fetuin-A, insulin resistance in non-diabetic HD Patients Chronic inflammation, Insulin resistance in DM HD Patients (Hung KY, et al. Diabetes Care 2007;30:3-7) (Hung KY, et al. Eur J Endocrin 2009;160:1-9)

28. Q7. Will you prescribe Cardio-protective agents for your CKD patients ? 1.Yes, always 2.Often 3.Seldom 4.No, never

29. Q8. Risk management: “Frequency and items of measurement” ? CKD Staging Serum [Cre] UAE I II III IV V

30. Q9. From CKD to CVD: mechanism ? CV risk Oxidative Stress Inflammation Insulin Resistance Traditional Risk Factors JASN 2008;19:1065–70