【｢越馬南向、腎糖傳奇｣ 國際慢性腎臟病研討會】 2020 International Symposium of Chronic Kidney Disease 感染症相關之慢性腎臟病概述 Chronic Kidney Disease-Associated with Infectious Diseases: An Overview 曾偉誠 臺北榮民總醫院 腎臟科

Infection-induced kidney disease is a major concern for clinicians. Timely diagnosis and treatment of infection can halt or attenuate the kidney damage inflicted by infection. Infection can result in chronic kidney disease by either direct invasion or indirectly by immune-mediated injury. Certain bacteria, mycobacteria, virus, fungus and protozoa have been implicated in the causes of infection-induced kidney diseases. Although bacterial and protozal infection usually result in acute kidney injury, a significant portion of survivors displays persistent reduced renal function. On the other hand, infection-associated glomerulonephritis constitutes an important disease entity. Hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus, dengue virus and hanta virus can induce glomerulopathy and affect hundreds of millions of people worldwide. With the advent of the latest nucleos(t)ide analogue and direct-acting antivirals, the threat of HBV- and HCV-related kidney diseases are decreasing. Furthermore, emergence of novel infections has cultivated in uncertain diagnostic challenge and resultant kidney damage. The latest coronavirus disease 2019 (COVID-19) has become a worldwide pandemic and results in various kinds of kidney diseases. To sum up, evolution in medicine leads to cure of many infectious diseases but several incurable infections and newly emerging pathogens remain a major healthcare threat. Early detection and aggressive treatment of infections may limit the extent of infection-related renal injury. Proper referral and follow-up is imperative to identify those with high risk of progressive renal diseases.

【｢越馬南向、腎糖傳奇｣ 國際慢性腎臟病研討會】 2020 International Symposium of Chronic Kidney Disease 感染相關之慢性腎臟病-越南現況 The current status of chronic kidney disease in Vietnam Ha Phan Hai An Hanoi Medical University, Hanoi, Vietnam Vietnam is a South-East Asian nation part of ASEAN, with a population of 96.2 million (2019). Vietnam has survived long years of war, though proclaimed independent since 1945, the nation still had to fight for its freedom until 1975. After the reunification of Northern and Southern Vietnam and successful reforms, the country is enjoying outstanding economic growth rates. But come with this are many challenges including pollution, inadequate social welfare… Due to inadequate funding the country is in shortage of health professionals especially nurses, midwives, and hospital beds. Since the early 90’s, the disease pattern in Vietnam has changed, with a progressive reduction in the number of communicable cases, enabled by intensified vaccination programs, better hygiene and foreign assistance. The top causes of death were non-communicable diseases and death due to traffic accident-related injuries. Chronic kidney disease was not documented in this list until 2017. Diabetes and diabetic kidney disease are on the rise, causing heavy burden for the health system and population. Urinary tract infections and other urological problems are commonly seen at late stage, when kidney function has severely been impaired. The education for preventing recurrence of stones is not adequately provided. But the Government has been active in promoting healthy lifestyles, facilitating access to service for diabetes patients and improving collaboration among different levels of health care providers. Hepatitis B infection rate has decreased remarkably since 2003, as the expanded vaccination program included vaccine against Hepatitis B for neonates and infants. Health promotion programs have been implemented for community awareness and behavioral changes to prevent viral Hepatitis C and other blood-born infections. Hepatitis C is still common in Hemodialysis centers. The life expectancy of Vietnamese people is expanding, but a lot of efforts are still required to ensure adequate health care for Vietnamese people.

【｢越馬南向、腎糖傳奇｣ 國際慢性腎臟病研討會】 2020 International Symposium of Chronic Kidney Disease 糖尿病腎臟病之多元照護綜論 Multi-disciplinary Care for Diabetic Kidney Disease: An Overview 黎思源 臺北榮民總醫院 腎臟科

About 30 years ago, Gerald Reaven, often referred to as the "father of insulin resistance," hypothesized that the inability of the body to process insulin normally led to Type 2 diabetes and cardiovascular disease. He also pointed out that certain medical conditions that increase the risk for heart disease, such as high triglycerides, high blood pressure, and elevated blood sugar caused by an inability of insulin to do its job, or insulin resistance. He referred to this condition as metabolic syndrome.

The kidneys remove waste, help regulate blood pressure, in part by controlling sodium levels in the blood, balance fluids and direct the production of red blood cells — We believed they were not directly affected by insulin resistance. New evidence suggests insulin could also have distinct actions in kidney tissue that regulate growth, hypertrophy, as well as microcirculatory and fibrotic pathways which, in turn, impact glomerular filtration, including that governed by tubuloglomerular feedback. However, in clinical practice, it is hard to discern the distinct effects of excess circulating insulin and impaired insulin actions, as exist in the insulin resistance individual, meanwhile, it is also difficult to dissect insulin resistance in the level of individual organ from the traditional HOMA-IR based whole body manner.

In this section, we take a look of DKD in a new perspective, digging out the vary basic pathophysiology of DKD from animal models and clinical samples. We’ll have a journey starting from the basic cell energy metabolism, through physiological changes after insulin resistance in different nephron segments, to the latest theories of metabolic kidney disease, and hopefully, pointing out some ongoing promising treatment strategies.

【｢越馬南向、腎糖傳奇｣ 國際慢性腎臟病研討會】 2020 International Symposium of Chronic Kidney Disease 糖尿病腎臟病-馬來西亞現況 The current status of diabetic kidney disease in Malaysia Dr.Sunita Bavanandan Department of Nephrology, Hospital Kuala Lumpur, Malaysia As Malaysia continues to make socioeconomic progress as a nation, disease patterns and burdens have been changing to reflect changes in the lifestyle and dietary patterns of its population. Diabetes in Malaysia has become increasingly problematic along with other co-morbidities or complications of diabetes such as hypertension, heart disease, stroke and chronic kidney disease. National Health and Morbidity Surveys have shown an alarming increase in the prevalence of diabetes in Malaysia over the past decade, i.e. from 11.6% in 2006 to 18.3% in 2019.1 Population ageing, urbanisation and rising prevalence of overweight and obesity are important contributors to this increasing prevalence of diabetes. Diabetic kidney disease (DKD) defined as presence of proteinuria with eGFR > 60 ml/min/1.73m2 or a GFR < 60 ml/min/1.73m2 occurs in as many as 14.6% of patients attending Malaysian government primary healthcare clinics.2 In secondary and tertiary healthcare clinics, moderately increased albuminuria is present in 34.4.% while another 33.5% have severely increased albuminuria.3 Malaysia ranks among the countries with the highest proportion of ESKD due to diabetes4 with a rising incidence of new dialysis patients with diabetes mellitus from 44% in 2000 to 69% in 20185. There is a clear need for primary prevention of diabetes as well as control of the complication rates of existing diabetic patients. At the primary healthcare care level, various programmes and activities have been initiated in late 1990s and early 2000s, including development of local clinical practice guidelines on diabetes management. The National Diabetes Registry (NDR) helps monitor the quality of care among patients living with diabetes and provide surveillance for diabetic complications and co-morbidities. Unfortunately it is limited to patients who are managed in primary healthcare facilities in the public sector. In 2018, a National Strategic Action Plan for Chronic Kidney Disease (ACT-KID) was incorporated into the National Strategic Plan on Non-communicable Diseases (NSP-NCD) to tackle the growing burden of non-communicable diseases in Malaysia. This action plan involves multiple stakeholders in primary care, public health, nephrology, professional societies and non-governmental organisations. It aims to improve all levels of CKD care from prevention and early detection to the other end of the spectrum, i.e kidney replacement therapy (KRT). Key measures used for evaluation of efficacy are mostly focused on the care of patients with DKD because of the recognition that diabetes is the major cause of ESKD, diabetic patients on KRT tend to have poorer outcomes6 and consume more resources than nondiabetic counterparts7. References : 1. Institute for Public Health (IPH), National Institutes of Health, Ministry of Health Malaysia.2020.National Health and Morbidity Survey(NHMS) 2019:Vol. I : NCDs – Non-Communicable Diseases:Risk Factors and other Health Problems 2. Unpublished data, Malaysian National Diabetes Registry 3.Mohamad M et al. DiabCare 2013: A cross-sectional study of hospital based diabetes care delivery and prevention of diabetes related complications in Malaysia. Med J Malaysia 2016; 71(4):177-185

4. United States Renal Data System 2018 Annual Data Report, vol.2 ESRD, Chapter 11: International Comparisons 5. Ong LM, Goh BL (Eds) Twenty Sixth Report of the Malaysian Dialysis and Transplant Registry 2018, Kuala Lumpur 2020 6. BL Goh, LM Ong, YN Lim, (Eds) Twenty Fourth Report of the Malaysian Dialysis and Transplant Registry 2016, Kuala Lumpur 2017 7.Yang WC, Hwang SJ, Chiang SS et al, The impact of diabetes on economic costs in dialysis patients : experiences in Taiwan. Diabetes Res Clin Pract. 2001 Nov;54 Suppl 1:S47-54

【｢越馬南向、腎糖傳奇｣ 國際慢性腎臟病研討會】 2020 International Symposium of Chronic Kidney Disease 急性腎損傷如何影響慢性腎臟病之進展 How Acute Kidney Injury Affects Chronic Kidney Disease Progression 黃道民 台大醫院 腎臟科 台灣至於世界先進國家，慢性腎臟病造成對個人、國家健康體系的影響隨著醫療的進步日漸重要。其中探索慢性腎臟病風險因子中，急性腎損傷是重要的一環。急性腎損傷依其原

因、患者共病症及急性疾病狀態有不同的表現及預後，然而急性腎損傷的發生在慢性腎臟病

的進展是重要的危險因子之一。這樣的急性腎病至慢性腎臟病的進展，提供我們在介入治療

的機會之窗。腎臟科醫師在此一過程耽任重要角色，在目前實證上如何介入治療，減少進展

到慢性腎臟病造成未來進入末期腎病變或改善相關心血管疾病預後是重要工作。本講次以實

證及臨床觀察回答目前的證據及未來展望。 關鍵字：急性腎損傷、慢性腎臟病

【｢越馬南向、腎糖傳奇｣ 國際慢性腎臟病研討會】 2020 International Symposium of Chronic Kidney Disease 急性腎損傷之後續追蹤、照護與預後 After Acute Kidney Injury: Follow-up, Care, and Outcome 林志慶 臺北榮民總醫院 腎臟科

Acute kidney injury (AKI) greatly affects the prognosis of hospitalized patients where some may require temporary or even permanent renal replacement therapy. Although prevention is the best strategy, the proper care and follow-up after the occurrence of AKI is another key to reduce complications. When AKI occurs, the first step is to stop all nephrotoxic drugs that may cause it and remove the possible risk factors that may contribute to it. Careful evaluation of fluid status and control of hemodynamic stability may eliminate ischemic injury to the kidneys and preserve renal perfusion. The correct staging and identification of the cause of AKI can guide clinicians in making a prognosis and providing a corresponding treatment. Clinical care including nutritional support, glycemic control, blood pressure management, and statin use for hyperlipidemia are all indispensable parts of the ideal treatment for AKI. During the recovery process, there should be an understanding of the natural course of the disease in that AKI may lead to the development of chronic kidney disease. In patients who suffer from renal failure and are in need of renal replacement therapy, potential indicators of the recovery of renal function should be noted early on and renal replacement therapy may be discontinued based on clinical indications. The role of renin-angiotensin-aldosterone system (RAAS) blockers in post-AKI care is a double-edged sword linked to increased survival and long-term renal protection but also increased risk of hospitalization and hyperkalemia. More evidence are needed to support the new or continuous use of RAAS blockers in post-AKI care, especially in patients with hypertension and cardiovascular comorbidities. The current management of AKI is mainly supportive and there is no universal therapy to treat it. The efforts to clarify the effects of appropriate medical treatment and the optimization of post-AKI care can help clinicians to improve the prognosis of patients.