Chronic Kidney Disease:

Tufts-New England Medical CenterNational Kidney Foundation

Definition of CKDStructural or functional abnormalities of the kidneys for >3 months, as manifested by either:

Kidney damage, with or without decreased GFR, as defined by markers of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests2. GFR 3 month with or without kidney damage

CKD Risk FactorsDiabetes MellitusHypertensionCardiovascular DiseaseObesityMetabolic SyndromeAcute Kidney InjuryMalignancyKidney StonesAutoimmune diseasesNephrotoxics like NSAIDS

Etiologi of CKDDiabetic Kidney DiseaseGlomerular diseases (autoimmune diseases, systemic infections, drugs, neoplasia)Vascular diseases (renal artery disease, hypertension, microangiopathy)Tubulointerstitial diseases (urinary tract infection, stones, obstruction, drug toxicity)Cystic diseases (polycystic kidney disease)Diseases in the transplant (Allograft nephropathy, drug toxicity, recurrent diseases, transplant glomerulopathy)

Prevalence of CKD and Estimated Number of Adults with CKD in the US (NHANES 88-94)*Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two measurements.

StageDescriptionGFR (ml/min/1.73 m2)Prevalence*N (1000s)%1Kidney Damage with Normal or GFR 905,9003.32Kidney Damage with Mild GFR60-895,3003.03Moderate GFR30-597,6004.34Severe GFR15-294000.25Kidney Failure< 15 or Dialysis3000.1

Prevalence of Abnormalities at each level of GFR*>140/90 or antihypertensive medicationp-trend < 0.001 for each abnormality

Chart2

77542485.94

73131862.40.03

355422.30

16622.62.50.06

Hypertension

Hemoglobin < 12.0 g/dL

Unable to walk 1/4 mile

Serum albumin < 3.5 g/dL

Serum calcium < 8.5 mg/dL

Serum phosphorus > 4.5 mg/dL

Estimated GFR (ml/min/1.73 m2)

Proportion of population (%)

Chart1

77542485.94

73131862.40.03

355422.30

16622.62.50.06

Hypertension*

Hemoglobin < 12.0 g/dL

Unable to walk 1/4 mile

Serum albumin < 3.5 g/dL

Serum calcium < 8.5 mg/dL

Serum phosphorus > 4.5 mg/dL

Estimated GFR (ml/min/1.73 m2)

Proportion of population (%)

Sheet1

15-2930-5960-8990+

HTN77733516

Hgb 4.5 mg/dL

Estimated GFR (ml/min/1.73 m2)

Proportion of population (%)

Sheet2

Sheet3

Estimated prevalence of selected abnormalities, by category of estimated GFR, among participants age 20 years and older in NHANES III, 1988-1994. These estimates are not adjusted for age, the mean of which is 33 years higher at an estimated GFR of 15-29 than at an estimated GFR of 90-150 ml/min/1.73 m2.

Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD

Stage

Description

GFR

Evaluation

Management

At increased risk

Test for CKD

Risk factor management

1

Kidney damage with normal or ( GFR

>90

Diagnosis

Comorbid conditions

CVD and CVD risk factors

Specific therapy, based on diagnosis

Management of comorbid conditions

Treatment of CVD and CVD risk factors

2

Kidney damage with mild ( GFR

60-89

Rate of progression

Slowing rate of loss of kidney function 1

3

Moderate ( GFR

30-59

Complications

Prevention and treatment of complications

4

Severe ( GFR

15-29

Preparation for kidney replacement therapy

Referral to Nephrologist

5

Kidney Failure

CKD deathStages in Progression of Chronic Kidney Disease and Therapeutic StrategiesComplicationsScreening for CKD risk factorsCKD risk reduction; Screening for CKDDiagnosis & treatment; Treat comorbid conditions; Slow progressionEstimate progression; Treat complications; Prepare for replacementReplacement by dialysis & transplantNormalIncreased riskKidney failureDamage GFR

CKD - ManagementDiagnostic work up to decide underlying etiologyTreatment of Hypertension and DyslipidemiaTreatment of AnemiaTreatment of HyperphosphatemiaAvoidance of Dehydration & Nephrotoxic agentsProper Dosing of DrugsPreparation for Renal Replacement Therapy

Definition of ESRD vs Kidney FailureESRD defined term that indicates chronic treatment by dialysis or transplantation

Kidney Failure: GFR < 15 ml/min/1.73 m2 or on dialysis.

Abnormal Sodium-Water metabolismEdema, HypertensionAbnormal Acid-base abnormalitiesMetabolic Acidosis due to uremia Abnormal hematopoesisAnemia of CKDCardiovascular AbnormalitiesLVH, CAD, Diastolic DysfunctionAbnormal Calcium-Phosphorus metabolismHyperphosphatemia, pruritus, arthralgiaHyperparathyroidismRenal Osteodystrophy

CKD - Manifestations

Importance of Proteinuria in CKD

Interpretation

Explanation

Marker of kidney damage

Spot urine albumin-to-creatinine ratio >30 mg/g or spot urine total protein-to-creatinine ratio >200 mg/g for >3 months defines CKD

Clue to the type (diagnosis) of CKD

Spot urine total protein-to-creatinine ratio >500-1000 mg/g suggests diabetic kidney disease, glomerular diseases, or transplant glomerulopathy.

Risk factor for adverse outcomes

Higher proteinuria predicts faster progression of kidney disease and increased risk of CVD.

Effect modifier for interventions

Strict blood pressure control and ACE inhibitors are more effective in slowing kidney disease progression in patients with higher baseline proteinuria.

Hypothesized surrogate outcomes and target for interventions

If validated, then lowering proteinuria would be a goal of therapy.

Akut kidney injuryHB normalOliguric typeNon oliguric type (30-60%) prognosis lebih baikUmumnya reversibleMortalitas tinggi: 40-60%

Penyebab AKIPre-renal : Hypovolemic, hypotensi, dehydrasi, syokRenal (Intrinsic renal failure) ATN (acute tubular nephrosis) or VMN (vascular membrane nephrosis)Post-renal : obstruksi, batu, prostat, trauma, keganasan.

AnamnesisRiwayat tindakan / operasiHipotensi shockHipertensi (accelerated / malignant)DrugsRenal disease

Clinical Course of AKIOnset Phase : oliguria, ureum creatinin meningkat, gangguan elektrolit

Oliguric Phase : fluid overload, edema ankle/pulmo, hyperkalemia cardiac, arythmia, hyponatremia, acidosis, kussmaul respiration.

Acute uremic syndromeCVS : hipertensi, arythmia, CHF, pericarditisGastroinstestinal : anorexia, nausea, vomithing, diarhea, bleeding, pancreatitisCNS : cunfussion, twitching, asterixis, soporosus comaHemopoetic system : bleeding, anemia

Management of AKIPhase oliguri : cairan

RRTPreparation for Renal Replacement TherapyEducation for Options of Dialysis & Renal Transplantation for Renal ReplacementHemodialysis Vs Peritoneal DialysisTimely placement of vascular access or PD catheter.

Integrated Renal Replacement Therapy

RRTIndications (Absolute):Uncontrolled hyperkalemia and acidosisUncontrollable hypervolemia (pulmonary edema)Pericarditissomnolence (advanced encephalopathy)Bleeding diathesisIndications (Relative):Nausea, vomiting and poor nutritionMetabolic acidosisLethargy and MalaiseWorsening kidney function

CKD - RRTTransplantation:Graft survival better with living donor kidneys.Immunosuppresion is almost always a must.

CKD - RRTTransplantation:Diseases like FSGS may reccur early in the transplanted kidney.Increased risk for infection, cardiovascular disease.Contraindications:Malignancy (recent or metastatic)Current infectionSevere extra renal diseaseActive use of illicit drugs(narcotics,stimulant,depressant,hallucinogens)

HD VS PDKeunggulanDilakukan dalah waktu lebih singkatLebih efisien terhadap pengeluaran zat-zat BM rendahTerjadi sosialisasi di senter dialisis

Kelemahan Membutuhkan heparinMembutuhkan vascular accessGangguan hemodinamikPengendalian tekanan darah yang lebih sulitDibutuhkan disiplin diet dan jadwal pengobatan yang teratur

KeunggulanKimia darah lebih stabilHematocrite lebih tinggiPengendalian tekanan darah lebih mudahCairan dialisat sebagai sumber nutrisi, pada penderita DM, insulin bisa diberikan intraperitoneal

KelemahanPeritonitisObesitasHiperglikemiMalnutrisi / protein lossHerniaBack pain