Dr. Eddy Susatyo, SpPD FinaSIM

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Gangguan sistem urologifokus gagal ginjal

• Dr. Eddy Susatyo, SpPD FinaSIM
• RSU dr. Sutrasno
• Rembang

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STRUCTURE OF THE KIDNEYS
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Chronic Kidney Disease ?
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Definition of CKD

• Kidney damage for gt3 months
• Defined by structural or functional abnormalities
  of the kidney, with or without decreased
  glomerular filtration rate (GFR)?
• Reduced GFR for gt3 months
• New staging for chronic kidney disease (CKD) is
  primarily based on kidney function.

National Kidney Foundation (NKF). Am J Kidney
Dis. 200239(2 suppl 1)S1-S266.
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Prevalence of CKD
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How About the Function of Renal ?
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• 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

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Brain
ADH
Renin
Angiotensin II
Kidney Na excretion H2O excretion
Lung
Ang II
Angiotensin I
Adrenal
Angiotensinogen
Aldosteron
RAAS
Hepar
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The Most Common Causes of CKD

• Glomerulonefritis
• Penyakit ginjal herediter
• Hipertensi
• Uropathy obstruktif
• Infeksi
• Nefropati diabetik

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The Most Common Causes of CKD
Glomerulonephritis
Other
Primary Diagnosis for Patients Who Start on
Dialysis
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Pe? Reabs Na
Hipertrofi sel renal
Pe? eksr sisa metab
Ggn konstentrasi urin
Pe? ekskr kalium
Penurunan GFR
Ggn fs ekskresi
Pe? ekskr PO4
Pe? ekskr ion H
CKD
Ggn Reproduksi
Ggn Imun
Ggn fs non ekskresi
? prod eritropoetin
Pe? abs Ca
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JENIS PEMERIKSAAN PENUNJANG

• Urinalisis
• Evaluasi Fungsi Ginjal
• Evaluasi Serologis
• Pemeriksaan Radiologis
• Biopsi Ginjal

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Equations for Estimating GFR
Cockcroft-Gault Equation
(140 Age) X Weight in kg
Ccr (mL/min)?
0.85 if female
72 X SCr
MDRD Modification of Diet in Renal Disease Ccr
creatinine clearance. Levey et al. Ann Intern
Med. 2003139137-147.
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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
Estimated maximal load of kidney failure
patients/nephrologist.Adapted from NKF. Am J
Kidney Dis. 200239(2 suppl 1)S1-S266. Coresh
et al. Am J Kidney Dis. 2003411-12 and Wish.
Nephrol News Issues. 19991323, 27, 53.
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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

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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

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STAGES OF CKD
INCREASED RISK
NORMAL
DAMAGE
LOW GFR
RENAL FAILURE
CKD DEATH
COMPLICATIONS
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Considerations for Patients with CKD?
Levey et al. Ann Intern Med. 2003139137-147.
USRDS. 1999 Annual Data Report. Available at
www.usrds.org.
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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. 2003139137-147.
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2-year Follow-Up of Medicare Patients Focus on
Diabetes, CKD or Both
Medical Cohort
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.
200364(suppl 87)S24-S31.
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LVH Increases With CKD Progression
LVH at Baseline ()?
80
60
40
20
0
50-75
25-50
Dialysis Start
lt25
eGFR (mL/min/1.73 m2)1
eGFR estimated glomerular filtration rate. 1.
Levin et al. Am J Kidney Dis. 199934125-134. 2.
Foley et al. J Nephrol. 199811239-245.
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Anemia Rates Increase as Levels of CKD Severity
Progress
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Anemia Prevalence ()?
Hgb Values
80
11-12 g/dL
10-11 g/dL
60
lt10 g/dL
40
20
0
lt2
2-2.9
3-3.9
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Creatinine (mg/dL)?
Chronic Kidney Disease (CKD) Progression
Hgb hemoglobin. Kausz et al. Dis Manage Health
Outcomes. 200210505-513.
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Specific Interventions for Complications of CKD
A1C glycosylated hemoglobin HPT
hyperparathyroidism PTH parathyroid hormone
LDL-C low-density lipoprotein cholesterol TG
triglycerides HDL-C high-density lipoprotein
cholesterol Hgb hemoglobin.
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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. 200239(2 suppl 1)S1-S266.

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Cause of death in dialysis patients
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Decisions in renal replacement

• Pre-dialysis care
• Active treatment- Peritoneal dialysis (PD)-
  Haemodialysis (HD)- Transplantation
• Conservative (non-dialytic) care. Symptom
  management.

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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 lt 7
Hipertensi Anemia Osteodistrofi
renal Komplikasi kardiovaskuler
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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

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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
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• Example URR
• Initial (predialysis) urea level 50 mg/dL
• The postdialysis urea level 15 mg/dL
• The amount of urea removed 50 mg/dL15 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.

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How About Acute kidney injury in Sepsis ?
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Critical ill patient potentially AKI
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AKI in ICU ? 5 25 Mortality AKI 40-80
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Klasifikasi/staging AKI modifikasi RIFLE
Stadium kriteria kreatinin kriteria urin output
1. Risk serum kreatinin meningkat gt 0,3 mg/dl atau meningkat lebih dari 150-200 dari awal lt 0,5ml/kg per jam untuk gt6jam
2. Injury serum kreatinin meningkat sampai gt 200 sampai 300 dari data awal lt 0,5 ml/kg per jam untuk 12 jam
3. Failure serum kreatinin meningkat gt 300, (serum kreatinin gt 4mg/dl dengan peningkatan akut 0,5mg/dl, indikasi untuk renal replacement therapy lt0,3 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 gt4 weeks
ESRD Persistent renal failure for gt3 months
Murray PT, Palevsky PM. Nephrology Self Assesment
Program , Vol 6, No 5, Sept 2007
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Sepsis Ischemic insult Nephrotoxic insult
Complement activation
Endotoxin release
Ischemia-reperfusion

Anti-inflamatory mediators
Pro-inflamatory mediators
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Arachidonic acid metabolities
Oxygen free radicals
Cellular activation (PMN, endothelial cells)
Proteases
Nitric oxide
Chemokines
Heat shock proteins
Platelet activating factor
Endothelins
? Serum creatinine
? Urinary KIM-1, NAG
Acute kidney injury
? GFR
? Urine output
Pathogenic mechanism of sepsis related acute
kidney injury
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Effects of ischemia on renal tubules in the
pathogenesis of ischemic AKI
Schrier et al, J Clin Invest 2004, 1145-14
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Renal Protection
Renal protection, there is damage before any
symptom MAPgt 65 mmHg CVP 8-12 mmHg (no
ventilator) 12-15 mmHg (ventilator) Urine gt
0,5ml/BW/hour SaO2 gt70 Koloid ,albumin ?
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Tight control of blood glucose
Intensive insulin therapy ? sepsis by 45 Blood
glucose 80-110 mg/dl ? morbidity and
mortality Mechanism ? bacterial phagocytosis
and antiapoptotic effect of insulin
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Matur Nuwun