Gagal ginjal

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Gagal ginjal

  1. 1. Dr. Eddy Susatyo, SpPD FinaSIM RSU dr. Sutrasno Rembang Gangguan sistem urologi fokus gagal ginjal
  2. 2. STRUCTURE OF THE KIDNEYS
  3. 3. Chronic Kidney Disease ?
  4. 4. Definition of CKD • Kidney damage for >3 months – Defined by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR) • Reduced GFR for >3 months • New staging for chronic kidney disease (CKD) is primarily based on kidney function. National Kidney Foundation (NKF). Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.
  5. 5. Prevalence of CKD
  6. 6. How About the Function of Renal ?
  7. 7. Fungsi ginjal Regulasi volume cairan tubuh Regulasi keseimbangan elektrolit Regulasi keseimbangan asam basa Regulasi tekanan darah (RAAS) Ekskresi sampah metabolik Regulasi erithropoesis Metabolisme vit D Sintesis prostaglandin
  8. 8. ADH Angiotensin II Ang II Adrenal Aldosteron Kidney Na+ excretion H2O excretion Angiotensin I Angiotensinogen Renin Brain Lung Hepar RAAS
  9. 9. The Most Common Causes of CKD Glomerulonefritis Penyakit ginjal herediter Hipertensi Uropathy obstruktif Infeksi Nefropati diabetik
  10. 10. The Most Common Causes of CKD Primary Diagnosis for Patients Who Start on Dialysis Diabetes 50.1% Hypertension 27% Glomerulonephritis 13% Other 10% GlomerulonephritisOther
  11. 11. Hipertrofi sel renal Ggn konstentrasi urin Penurunan GFR CKD Ggn fs ekskresi Ggn fs non ekskresi Pe↓ ekskr ion H Pe↓ ekskr PO4 Pe↓ ekskr kalium Pe↓ eksr sisa metab Pe↑ Reabs Na Ggn Imun ↓ prod eritropoetin Pe↓ abs Ca Ggn Reproduksi
  12. 12. JENIS PEMERIKSAAN PENUNJANG • Urinalisis • Evaluasi Fungsi Ginjal • Evaluasi Serologis • Pemeriksaan Radiologis • Biopsi Ginjal
  13. 13. Equations for Estimating GFR Abbreviated MDRD Study Equation GFR (mL/min/1.73 m2 ) = 186.3 X SCr -1.154 X Age-0.203 X 0.742 (if female) X 1.210 (if African American) MDRD = Modification of Diet in Renal Disease; Ccr = creatinine clearance. Levey et al. Ann Intern Med. 2003;139:137-147. Cockcroft-Gault Equation Ccr = (mL/min) (140 – Age) X Weight in kg 72 X SCr = 0.85 if female
  14. 14. CKD Progresses in Stages Defined by Kidney Function: GFR 20 Million People With CKD (1 in 9 adults) in the United States, Many More at Risk 70 (145-160 by 2010)* 300,000<15Kidney failure5 80400,00015-29Severe decr in GFR4 15207,600,00030-59Mod dec. in GFR3 10605,300,00060-89Mild decr. in GFR2 11805,900,00090 Kidney damage normal incr. GFR 1 Patients/ NephrologistPrevalenceGFRDescription CKD Stage *Estimated maximal load of kidney failure patients/nephrologist. Adapted from NKF. Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.; Coresh et al. Am J Kidney Dis. 2003;41:1-12; and Wish. Nephrol News Issues. 1999;13:23, 27, 53.
  15. 15. Clinical Features – CKD 3-5 • Unintentional weight loss • Nausea, vomiting General ill feeling • Fatigue; Headache; Frequent hiccups • Generalized itching (pruritus) • Increased or decreased urine output • Need to urinate at night, polyuria • Easy bruising or bleeding
  16. 16. Clinical Features – CKD 3-5 • Blood in the vomit or in stools • Decreased alertness; Muscle cramps • Seizures; Agitation; Hypertension • Peripheral sensory neuropathy • Breath fetor; Loss of appetite; • Uremic frost on the skin • Uremic pericarditis, CHF
  17. 17. STAGES OF CKDSTAGES OF CKD NORMAL INCREASED RISK DAMAGE LOW GFR RENAL FAILURE CKD DEATH COMPLICATIONS
  18. 18. Considerations for Patients with CKD? • CVD • Anemia • Altered bone & mineral metabolism Complications • Higher level of proteinuria • Higher BP • Poor glycemic control • Smoking • Hyperlipidemia • Drug use • Diabetes • Hypertension • Older age • Family history of CKD • Racial or ethnic minority • Other: low income, minimal education, kidney-mass reduction, known kidney disease Progression Factors Susceptibility Risk Factors Levey et al. Ann Intern Med. 2003;139:137-147. USRDS. 1999 Annual Data Report. Available at: www.usrds.org.
  19. 19. What Are Progression Factors for CKD? • Elevated creatinine may indicate CKD, but not all creatinine elevation is irreversible • Key progression factors include – Elevated blood pressure (BP) – Proteinuria – Poorly controlled glucose in patients with diabetes – Excess protein intake. – NSAIDs, contrast, aminoglycosides, other Levey et al. Ann Intern Med. 2003;139:137-147.
  20. 20. 15.7 29.5 32.3 84.0 67.6 61.6 0.3 2.9 6.1 0 20 40 60 80 100 No Events ESRD Death 2-year Follow-Up of Medicare Patients: Focus on Diabetes, CKD or Both CKD identified as ICD-9-CM diagnosis code, includes CKD from diabetes, hypertension, obstructive uropathy, and other diagnosis codes reported on USRDS ESRD registration forms. ESRD = end-stage renal disease; DM = diabetes mellitus; ICD-9-CM = International Statistical Classification of Diseases, 9th Revision, Clinical Modification. Collins et al. Kidney Int. 2003;64(suppl 87):S24-S31. + DM, - CKD - DM, +CKD + DM, + CKD Medical Cohort
  21. 21. LVH Increases With CKD Progression eGFR (mL/min/1.73 meGFR (mL/min/1.73 m22 ))11 eGFR = estimated glomerular filtration rate.eGFR = estimated glomerular filtration rate. 1. Levin et al.1. Levin et al. Am J Kidney DisAm J Kidney Dis. 1999;34:125-134.. 1999;34:125-134. 2. Foley et al.2. Foley et al. J Nephrol.J Nephrol. 1998;11:239-245.1998;11:239-245. 00 2020 4040 6060 8080 50-7550-75 25-5025-50 DialysisDialysis StartStart LVHatBaseline(%)LVHatBaseline(%) <25<25
  22. 22. Anemia Rates Increase as Levels of CKD Severity Progress 20 8 17 43 8 15 62 15 10 14 9 5 0 20 40 60 80 100 <2 2-2.9 3-3.9 ≥4 Creatinine (mg/dL) AnemiaPrevalence(%) Hgb = hemoglobin. Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513. Chronic Kidney Disease (CKD) Progression Hgb Values 11-12 g/dL 10-11 g/dL <10 g/dL
  23. 23. Specific Interventions for Complications of CKD Adequate energy intake 11-12 g/dL LDL-C <100 mg/dL (70?) TG <150 mg/dL HDL-C >40 mg/dL CKD stage 3 = 35-70 pg/mL 4 = 70-110 pg/mL < 130/80 mm Hg preprandial glucose 90-125 mg/dL A1C <7% Target Goals Dietary modification Reach Hgb goal Maintain lipids to target PTH control BP control Glycemic control Intervention Dyslipidemia Anemia Malnutrition Secondary HPT Hypertension Diabetes Complication A1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone; LDL-C = low-densityA1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone; LDL-C = low-density lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density lipoprotein cholesterol; Hgb = hemoglobin.lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density lipoprotein cholesterol; Hgb = hemoglobin.
  24. 24. Summary: Clinical Actions for Progressive Stages of CKD *Actions for each progressive stage of CKD also include all the actions for prior stages. NKF. Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266. Kidney replacement if uremia present<15 or dialysisKidney failure5 Prepare for kidney replacement Evaluate and treat complications 15-29Severe ↓ GFR4 Evaluate and treat complications *All actions for prior stages 30-59Moderate ↓ GFR3 Estimate progression *All actions for prior stages 60-89 Kidney damage with mild ↓ GFR 2 Diagnose and treat comorbid conditions Address progression factors Reduce/control CVD risk factors ≥90 Kidney damage with normal or ↑ GFR 1 Evaluate for CKD Reduce/control CKD risk factors ≥90 with CKD risk factors At increased riskRisk Action* GFR (mL/min/1.73 m2 )Description CKD Stage
  25. 25. Cause of death in dialysis patients cardiac disease CVA withrawal of RRT malignancy infection others unknown
  26. 26. Decisions in renal replacement • Pre-dialysis care • Active treatment - Peritoneal dialysis (PD) - Haemodialysis (HD) - Transplantation • Conservative (non-dialytic) care. Symptom management.
  27. 27. Penatalaksanaan CKD Ditujukan untuk mengurangi gejala klinik , mencegah komplikasi , mencegah progresifitas CKD, mempersiapkan initiasi dialisis Uremia : diit protein 0,6 – 0,8 gr / kg bb / hari Hiperkalemia : diit rendah kalium ; 60 – 80 meq/hari Asidosis metabolik : diit rendah protein / fosfat; HCO3 Stop rokok Kontrol lipid ( preparat statin ) HbA1C < 7 % Hipertensi Anemia Osteodistrofi renal Komplikasi kardiovaskuler
  28. 28. How Do We Know if a Patient is Adequately Dialyzed? K/DOQI Guidelines Define Adequate Dialysis as: • KT/V = 1.2 or greater • URR = 65% or greater
  29. 29. URR% - Urea Reduction Ratio : the percentage of urea removed during the treatment KT/V : Formula utilizing dialyzer urea clearance, treatment time and total body fluid
  30. 30. Example URR Initial (predialysis) urea level: 50 mg/dL The postdialysis urea level: 15 mg/dL The amount of urea removed: 50 mg/dL–15 mg/dL = 35mg/dL URR% = Ur pre – Ur post x 100% Ur Pre 35/50 = 70/100 = 70%  Recommended a minimum URR of 65 percent.  The URR is usually measured only a month.
  31. 31. How About Acute kidney injury in Sepsis ?
  32. 32. Critical ill patient potentially AKI
  33. 33. AKI in ICU  5 –25% Mortality AKI 40-80%
  34. 34. RIFLE criteria for Acute Renal Dysfunction Risk Injury Failure Loss ESRD Abrupt (1-7 days) decrease (> 25%) in GFR or Scr x 1.5 Sustained (> 24 hrs) ARF ~ earliest time point for provision of RRT Irreversible ARF or persistent ARF > 4 wks ESRD > 3 months Non-Oliguria Oliguria UO < .5/ml/kg/h x 24 hr Anuria x 12 hrs UO < 0.5/ml/kg/h x 12 hr ?? Decreased UO relative to the fluid input UO < 0.5/ml/kg/h x 6hr Adjusted creat or GFR decrease> 50% or Scr x 2 Adjusted creat or GFR decrease > 75% Scr x 3 or Scr > 4mg% When acute > 0.5mg% Specificity
  35. 35. Klasifikasi/staging AKI modifikasi RIFLE Stadium kriteria kreatinin kriteria urin output 1. Risk serum kreatinin meningkat > 0,3 mg/dl atau meningkat lebih dari 150-200 % dari awal < 0,5ml/kg per jam untuk >6jam 2. Injury serum kreatinin meningkat sampai > 200% sampai 300% dari data awal < 0,5 ml/kg per jam untuk 12 jam 3. Failure serum kreatinin meningkat > 300%, (serum kreatinin > 4mg/dl dengan peningkatan akut 0,5mg/dl, indikasi untuk renal replacement therapy <0,3 ml/kg per jam x 24 jam atau anuria x 12 jam Mehta RL. Nephrology Self Assesment Program , Vol 6, No 5, Sept 2007 Loss Persistent renal failure for >4 weeks ESRD Persistent renal failure for >3 months Murray PT, Palevsky PM. Nephrology Self Assesment Program , Vol 6, No 5, Sept 2007
  36. 36. Sepsis Ischemic insult Nephrotoxic insult Complement activationEndotoxin releaseIschemia-reperfusion Cellular activation (PMN, endothelial cells…) Arachidonic acid metabolities Proteases Chemokines Platelet activating factor ↑ Serum creatinine Oxygen free radicals Nitric oxide Heat shock proteins Endothelins Acute kidney injury↑ Urinary KIM-1, NAG ↓ Urine output ↓ GFR Anti-inflamatory mediators Pro-inflamatory mediators - + Pathogenic mechanism of sepsis related acute kidney injury
  37. 37. (1) Vasoconstriction Renin-angiotensin endothelin PGI2 NO (2) Obstruction by casts (3) Tubular backleak Ischemia Nephrotoxins Tubular damage (proximal tubules and ascending thick limb) (5) ? Direct glomerular effect GFR Oliguria Tubular fluid flow Intratubular pressure Possible pathogenetic mechanisms in ATN. (4) Interstitial inflammation
  38. 38. Effects of ischemia on renal tubules in the pathogenesis of ischemic AKI Schrier et al, J Clin Invest 2004, 114:5-14
  39. 39. Renal protection, there is damage before any symptom MAP> 65 mmHg CVP 8-12 mmHg (no ventilator) 12-15 mmHg (ventilator) Urine > 0,5ml/BW/hour SaO2 >70% Koloid ,albumin ? Renal Protection
  40. 40. Intensive insulin therapy ↓ sepsis by 45% Blood glucose 80-110 mg/dl ↓ morbidity and mortality Mechanism : ↑ bacterial phagocytosis and antiapoptotic effect of insulin Tight control of blood glucose

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