This document describes a case of chronic kidney disease in a 21-year old man. Over 5 years, his serum creatinine level gradually increased from 0.5 mg/dL to 1.81 mg/dL, indicating progressive loss of kidney function. He was treated with steroids and immunosuppressants but continued to experience relapses of nephrotic syndrome. On his latest examination, lab tests showed further kidney dysfunction with a serum creatinine of 1.29 mg/dL. Despite refusing dialysis, he died shortly after from complications of his kidney disease. The document outlines factors related to managing chronic kidney disease, including monitoring for anemia, acidosis, mineral abnormalities, and nutrition.

1. Chronic Kidney Disease
Syafrizal Nasution and Oke Rina
H.Adam Malik Hospital

2. Case
 AE is a 21 year-old man with nephrotic
syndrome. He complains of mild fatigue but
is otherwise asymptomatic. Five years
before he complain anasarca edema and
proteinuria.
 Doctor had trial steroid and proteinuria (-)
but relaps again
 On physical examination:
 Weight 40 kg with BP 120/80 mm Hg

3. Labs
 Five years ago, his serum Cr: 0.5 mg/dL
 Three years ago, his serum Cr: 0.9 mg/dL
 One year ago, sCr: 1.81 mg/dL

4. Lab Data
 CBC (January 2011)
 Hb 15.9
 WBC 19.35
 HCT 45.4
 PLTs 329
 Urine: protein (++),
eritrosit (-), cast
granular
 SMA-7
 Ureum 33
 Cr: 1.29
 Renal ultrasound: …?

5. Calculations
 Cockcroft-Gault
 Men: CrCl (mL/min) = (140 - age) x wt (kg)
 SCr x 0.81
 Women: multiply by 0.85
 MDRD
 GFR (mL/min per 1.73 m2) = 186 x (SCr x 0.0113)-1.154 x
(age)-0.203 x (0.742 if female) x (1.12 if African-American)

6. Back to the case…
 History medications: (five years ago)
 Predvison
 Captopril
 Cyclosporin A
 History medication : (three years ago)
 Metil prednisolon
 Captopril
 Cellcept

7. Metabolic changes with CKD
 Hemoglobin/hematocrit 
 Bicarbonate 
 Calcium
 Phosphate 
 PTH 
 Triglycerides 

8. Metabolic changes…
 Monitor and treat biochemical abnormalities
 Anemia
 Metabolic acidosis
 Mineral metabolism
 Dyslipidemia
 Nutrition

9. Metabolic acidosis
 Muscle catabolism
 Metabolic bone disease
 Sodium bicarbonate
 Maintain serum bicarbonate > 22 meq/L
 0.5-1.0 meq/kg per day
 Watch for sodium loading
 Volume expansion
 HTN

10. NEJM 2000; 342(20): 1478-83
Mineral metabolism
 Calcium and phosphate metabolism
abnormalities associated with:
 Renal osteodystrophy
 Calciphylaxis and vascular calcification
 14 of 16 ESRD/HD pts (20-30 yrs) had
calcification on CT scan
 3 of 60 in the control group

11. Nutrition
 Think about uremia
 Catabolic state
 Anorexia
 Decreased protein intake
 Consider assistance with a renal dietician

12. Follow-up Visit
 Two weeks later, the patient returns and
complains of fatique and hematemesis
 His BP today is 159/75 mm Hg
 He refused dialysis  go back to his home
 He died 10 days after came home in another
hospital

13. New laboratories (dari Adam
Malik)
 Hb
 Leuco
 Ureum: ?
 Creat:?

14. Evaluation for CKD
 Blood
 CBC with diff
 SMA-7 with Ca2+ and
phosphorous
 PTH
 HBA1c
 LFTs and FLP
 Uric acid and Fe2+
studies
 Urine
 Urinalysis with
microscopy
 Spot urine for
microalbumin
 24-urine collection for
protein and creatinine
 Ultrasound

15. Key points
 The serum creatinine level is not enough!
 Target BP for CKD
 <130/80 mm Hg
 <125/75 mm Hg in proteinuria
 HTN and proteinuria are the two most
important modifiable risk factors for
progressive CKD