Chronic Organ Dysfunction

Ver.1: 2015713
Ver.2: 2016420
Ver.32017527
Ver.420171108

COPD

ACS
COPD






COPDCKDetc



65707550
Multimorbidity
6565%8582

Multimorbidity



Managing patients with multimorbidity in primary care. BMJ.
2015



AS
COPDCKD
DNAR

!?



AIDS

DPC

Common

Common Disease


Common Disease

Common disease

Common

TOP50



,. 2000
Common Disease


2.0
COPD 1.4

1.3

ACS

COPD


35.7 28.5%
19.5 15.5%
12.5 9.9%
12.4 9.9%
5.9 4.8%
5.2 4.2%
2.9 2.3%
2.5 2.0%
COPD 1.7 1.4%
1.6 1.3%
25.3 20.2%


11.1%

45 45

7 7

5% 22%
5%
VTE/PTE 4%
COPD 4%
4%
DKA 5% 12%
4%
AIHA/ITP 3%
5% 5%
2% 4%
1%
1%
307/151147/263/


CHFCOPDLCCKD

 Common Disease

DPC


Chronic Organ Dysfunction

CHDChronic Heart Disease

CPDChronic Pulmonary Disease
COPD
CLDChronic Liver Disease
NAFLD/NASH
CKDChronic Kidney Disease
DMHT
CBDChronic Brain Disease



At risk Basal Clinical Discomfort / End

change symptom decompensated stage
stageA Stage B Stage C Stage D

CHD AHA)

Stage Stage Stage~

CPD GOLD

Child A Child B Child C

C
CLD
Stage1 Stage23A Stage3B Stage45 ESKD

CKD CKD HD

MCI AD

CBD FAST1~3 FAST4~6 FAST7



Stage
Stage

!!

Stage1

Stage

orICU
OK ACP

 MultimorbidityCOD
7


#1.
#2.
#3.
#4. OA
#5.
#6.
#7.
#8.
#9.
#10.

CKD:G5A2+DM

AHA stageBHFpEFOMI

OA
ADFAST4/KP

ADLQOL
ACP!?



Stage
StageCOD
StageStage1
 Common Disease






Common Disease


Common disease

Generalist masters

20162 Vol.98 No.2



!




http://www.zaitakuiryo-yuumizaidan.com/data/file/data1_20110516101021.pdf


Common Disease




ACCCC/A


 At risk





COD






Basal Change

COD

 Clinical symptom

a
a

Stage2



Discomfort/Discompensated






RAS

ACP


Endstage

ACP
DPC




SPSSICF



2015127
https://www.igaku-shoin.co.jp/paperDetail.do?id=PA03153_01
 Multimorbidity

QOL, etc.

Managing patients with multimorbidity in primary care. BMJ. 2015

http://cmj.publishers.fm/


 Illness Trajectory

Patterns of Functional Decline at the End of Life. JAMA. 2003;289(18):2387-2392



 COD
CHF SHFM
CPD BODE index
CLD MELD, CLIP score
CKD CRIB
CBD FAST, MRI, ADEPT

http://www.zaitakuiryo-yuumizaidan.com/data/file/data1_20110516101021.pdf
 SHFM

Seattle Heart Failure Model

https://depts.washington.edu/shfm/
 COPD BODE index
(FEV)
(6)
(MRC)
BMI)

10
34

The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in
Chronic Obstructive Pulmonary Disease
NEJM Volume 350:1005-1012 March 4, 2004 Number 10
 CLIP score

Discrimination Value of the New Western Prognostic System (CLIP Score) for Hepatocellular Carcinoma in
662Japanese Patients. (HEPATOLOGY 2001; 34:529-534. http://www.skh.org.tw/gi/activity/CLIP.pdf
 CKD CRIB

Prediction of ESRD and Death Among People With CKD: The Chronic Renal Impairment in
Birmingham (CRIB) Prospective Cohort Study. Am J Kidney Dis. Dec 2010; 56(6-2): 10821094.
StageK/DOQI (Kidney Disease Outcomes Quality Initiative)


ADL



Palliative
Prognostic
Score


(Stage1~2)

Stage3
Stage4
Stage5


Generalist masters.


 Multimorbidity

QOL

STARTSTOPP/BEERS
Managing patients with multimorbidity in primary care. BMJ. 2015
http://cmj.publishers.fm/
 Coordination
Refer
Collateral referral

Interval referral

Cross referral

Sprit referral

GERD

Coordination
Kurt C. Stange. A science of Connectedness. Ann Fam Med 2009 7 387-394

System holarchy
(Hierarchy of holons



QOL
!

ABCDE+III+QRST
Infection :
Ion & fluid:

Insulin & nutrition

QOLADL()
()
()
()