12. 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.
15. 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
17. The Most
Common Causes of CKD
Glomerulonefritis
Penyakit ginjal herediter
Hipertensi
Uropathy obstruktif
Infeksi
Nefropati diabetik
18. The Most
Common Causes of CKD
Primary Diagnosis for Patients Who Start on Dialysis
Diabetes
50.1%
Hypertension
27%
Glomerulonephritis
13%
Other
10%
GlomerulonephritisOther
19. 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
22. 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
23.
24. 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
11805,900,00090
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.
25. 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
26. 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
27. STAGES OF CKDSTAGES OF CKD
NORMAL INCREASED RISK DAMAGE LOW GFR
RENAL FAILURE
CKD
DEATH
COMPLICATIONS
28. 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.
29. 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.
30. 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
34. 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
35. Cause of death in dialysis
patients
cardiac disease
CVA
withrawal of
RRT
malignancy
infection
others
unknown
36. Decisions in renal
replacement
• Pre-dialysis care
• Active treatment
- Peritoneal dialysis (PD)
- Haemodialysis (HD)
- Transplantation
• Conservative (non-dialytic) care. Symptom
management.
37. 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
38. 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
39. 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
40. 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.
45. 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
46. 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
