Chronic Kidney Disease

Rensa, MD Departement of Internal Medicine Udayana University / Sanglah Hospital

Physiological Review

FUN GSI G INJA L Fungsi utama ginjal adalah : mempertahankan keseimbangan internal (milieu interiour) Yg dipertahankan adalah : - keseimbangan air - keseimbangan elektrolit

organ ekskresi

- keseimbangan asam-basa - keseimbangan metabolisme ----- mensekresikan hormon

MEKANISM E FUNGSI

GIN JA L

Fungsi ginjal dilaksanakan melalui mekanisme : 1. filtrasi

(penyaringan)

2. reabsorbsi

(penyerapan kembali)

3. sekresi

(produksi bahan tertentu)

4. ekskresi

(mengeluarkan bahan tertentu)

HORM ON- HORMON YG DIHASI LK AN G INJAL 1. Erythropoitin - berfungsi utk ”membentuk ” darah 2. Renin - berfungsi untuk mengatur tekanan darah 3. Calcitriol - berfungsi utk metabolisme mineral (calsium & fosfat) 4. Prostaglandin - ikut berfungsi mengatur tekanan darah

EVALUASI FUNGSI GINJAL • yang bisa dievaluasi hanyalah fungsi filtrasinya saja • dengan mengukur Laju Filtrasi Glomerulus (LFG) Laju Filtrasi Glomerulus adalah : Jumlah darah yang dpt difiltrasi oleh ginjal dalam waktu satu menit • pada orang yang luas peermukaan tubuhnya 1,73 m2 (satuannya: ml/menit/1,73m2) • pengukuran dilakukan secara tidak langsung

NILAI N ORMAL Tergantung pada : • jenis kelamin • umur • berat badan/luas pemukaan tubuh Umur

Laki

Perempuan

20 th

117 – 170

104 – 158

50 th

96 – 138

90 – 130

70 th

70 – 110

70 – 114

Hamil

20% lbh banyak

Berkurang ± 1% setiap tahun, di atas umur 30 th

Teknik e valua si fun gsi g inja l • LFG dievaluasi secara tidak langsung dengan mengukur clearance (bersihan) bahan tertentu • Clearance adalah: jumlah ’bahan tertentu” yang dapat difiltrasi oleh ginjal dalam satu satuan waktu (ml/mnt) • ”Bahan tertentu” yg dipakai adalah : • bahan radioaktif • inulin • kreatinin

Yang paling baik adalah inulin, tapi yang paling mudah dan praktis adalah kreatinin, sehingga LFG diukur dengan Test Klirens Kreatinin (Cliearance Creatinin Test =CCT) Jadi : CCT ∞ LFG

Men ge valu as i C CT di lak uk an d eng an : 1. Mengukur : Dengan jalan mengukur; kadar kreatinin urin (U), volume urine /menit (V) dan kadar kreatinin plasma (P) Kemudian dimasukkan dalam rumus Van Slyke

CCT =

UXV -------------------- ml/mnt P

2. Menghitung : Dengan mengukur, kreatinin plasma (P), berat badan (BB), umur (U) Kemudian dimasukkan dalam rumus Cockroft - Gault

CCT =

Catatan : pada

(140 – U ) X BB -------------------------- ml/mnt 72 X P

 : X 85%

Deraj at fun gs i gin jal di ses uaik an den ga n CC T Deraja

Kelainan struktur dlm

CCT

t

3 bl (ada/tidak)

1

ada

≥ 90 ml/mnt

2

ada/tidak

60 - 89

3

ada/tidak

ml/mnt 30 – 59 ml/mnt

4

ada/tidak

15 – 29 ml/mnt

5

ada/tidak

< 15 ml/mnt

Gejala gangguan fungsi ginjal : 1. Anemia 2. Hipertensi 3. Edema 4. Peningkatan kadar ureum&kreatinin plasma 5. Asidosis

Definition CKD is a group of kidney disease with specification : • Chronic

: more than 3 months

• Progressive : become worst time to time • Persistent

: can not completely remission

Definisi  Pe

faal / struktur ginjal yang lebih dari 3 bln yang bersifat menetap dan progresif

Criteria : • Kidney damage for ≥ 3 month • structural and functional abnormality • with or without decreased Glomerular Filration Rate (GFR) • manifest by either abnormality of : • pathology • blood composition • urine composition • imaging trest 3. GFR < 60 ml/min for 3 month, with or without kidney damage

Explanation : • Structural abnormality e.g. single kidney, kidney/ureter stone, cystic kidney, Prostate hypertrophy, etc • GFR : calculated by Cockroft-Gault Formula • Blood composition e.g. ureum, creatinin • Urine composition e.g. proteinuria, haematura • Imaging e.g. BNO (plain photo abdomen), USG etc

Ter masu k kelai nan str uktur gin jal an tar a lain : • Kelainan makroskopik / mikroskopik urin • Kelainan anatomis traktus urinarius • Kelainan ukuran atau jumlah ginjal • Hidronefrosis • Batu traktus urinarius

Kidney disease ≥ 3 month :

GFR (Cockroft Gault)

< 60 ml/mnt/1.73 m2 - CKD

≥ 60 ml/mnt/1.73 m2

Kidney damage (-) - normal

Kidney damage (+) - CKD

ETIOLOGY OF CKD Etiology of CKD are : 3. Diabetes Mellitus 4. Chronic Glomerulonephritis 5. Chronic Pyelonephritis 6. Hypertension 7. Urinary tract stone 8. Obstruction (tumor, prostate) 9. Immunological disease (SLE) 10. Congenital (polycystic kidney) 11. Malignancy 12. Others : • pregnancy • chronic liver disease

Etiology of CKD: (another version)  Diabetes Mellitus  Non-Diabetes Mellitus:     

Glomerular (e.g. Autoimmune dis, neoplasia) Vascular (e.g.Hypertension) Tubulo-intersititial ( UTI, Renal stone, drugs) Cystic Transplantation (e.g.chronic host-rejection)

Anamnesis   

Urine volume Frequency of micturition Urine appearance and colour



Pain:  in loins, back, abdomen, suprapubic area?  Constant or intermittent?  Related to micturition?



Nonspecific symptoms, including:  Fatigue  Nausea-vomiting  Weight loss  Pallor  Oedema  Dyspneu on effort (associated with heart failure)

Physical Examination Hypertension  Anemia  Edema  Sign of complications e.g. heart hypertrophy, Ascites 

1. Gejala Neurologik - lelah - sakit kepala - kejang – kejang - neuropati perifer 2. Gastro intestinal - mual, muntah, diare - singultus, stomatitis 3. Kulit kering - Pruritus

Akibat menumpuknya toksin uremik, berupa : fosfat, ion hidrogen, urea dan kreatinin, phenol, indol, guanidin, hormon paratiroid, oksalat, homosistein.

Patophysiology of hypertension in CKD 2. -Sodium retention - fail of the kidney for excreted water and sodium

2. Acceleration of Renin Angiotensin System - increased secretion of renin

Ischemic Kidney

Angiotensinogen (produced by liver) Renin (produced by kidney

Angiotensin I

Angiotensin Converting Enzyme (ACE) Suprarenal cortex

Angiotensin II

Aldosteron Renin Angiotensin Aldosterone System

PATHOPHYSIOLOGY OF ANEMIA IN CKD 3. Erythropoitin insufficiency - decreased of erythropoitin secreted by the kidney 6. Iron deficiency - chronic bleeding - low intake 3. Others - haemolysis / decreased of erythrocyte live spend - depressed of bone marrow by uraemic substances

Patients with chronic kidney disease should be evaluated to determine: 2. Diagnosis (type of kidney disease) 3. Comorbid conditions; 4. Severity; assessed by level of kidney function; 5. Complications, related to level of kidney function; 6. Risk for loss of kidney function; 7. Risk for cardiovascular disease

COMPLICATION OF CKD 1. Cardiac diseases - coronary artery disease - congestive hearth disease - acute left hearth failure 2. Metabolic acidosis 9. Electrolyte imbalance - hyper / hypokalemia - hyper / hyponatremia 4. Renal osteodystrophy (renal bone disease)

IMPORTANT !!

Treatment for chronic kidney disease should include: 2. Specific therapy, based on diagnosis 3. Evaluation and management of comorbid conditions; 4. Slowing the loss of kidney function 5. Prevention and treatment of cardiovascular disease; 6. Prevention and treatment of complications of decreased kidney function 7. Preparation for kidney failure and kidney replacement therapy; 8. Replacement of kidney function by dialysis and transplantation, if signs and symptoms of uremia are present

STAGES OF CKD: A CLINICAL ACTION PLAN Stage

Description

GFR

Actions*

(mL/min/1.73

I

Kidney damage

m2)

≥ 90

with normal or ↑

Treatment of comorbid

GFR II

Kidney damage

Diagnosis and treatment. conditions, Slowing

60-89

progression, CVD risk Estimating progression reduction

with mild ↓ GFR III

Moderate ↓ GFR

30-59

Evaluating and treating

IV

Severe ↓ GFR

15-29

complications Preparation for kidney replacement therapy

V

Kidney failure

< 15 or

Replacement (if uremia

dialysis

present)

Chronic Kidney Disease is defined as either kidney damage or GFR < 60 mL/min/1.73 m2 for ≥ 3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies

Ko nse rvatif

Dialisis Aktif

Transplantasi

1 . Menghilangkan faktor-faktor yang reversibel 2. Mengendalikan faktor-faktor yang ireversibel 3. Nutrisi dan keseimbangan cairan 4. Mengatasi komplikasi 5. Mencegah pemberian obat nefrotoksik 6. Mengatasi keluhan

✏ diet :

kalori 35-40 kkal/kg bb/hari protein 0,8 – 1 gr/kg bb/hari

✏ air : masuk = 500 cc + produksi urin/24 jam ✏ Elektrolit :

- rendah garam - rendah kalium (buah-buahan)

RESUME TERAPI NUTRISI PADA PENDERITA GGK PREDIALISIS Kalori • Jumlah • Jenis Protein • Jumlah • Jenis

Karbohidrat: • Jumlah

Elektrolit

: 30-35 kcal/kg bb/hari : 20-25% dalam bentuk lipid

: 0.8-1.0 g/kg bb/hari : Kombinasi asam amino esensial (AAE) dan asam amino non esensial (AANE)

: melengkapi kebutuhan kalori - rata-rata 6-8 g / kg bb / hari : Natrium 70 meq/L Kalium : dibatasi Fosfat 500 - 600 mg/hari

Resume of Nutritional Requirement of Dialytic Patients

Protein

1-1.4

Energy

35

g/kg/day kcal/kg/day

Water

600-700

Sodium

65-100

cc + urine output during previous 25 hours mEq/day

Potassium

40-70

mEq/day

Calcium

1000

mg/day

800-1000

mg/day

Phosphorus Iron Vitamins

600

mg/day as ferrous sulphate Water-soluble vitamins which are lost during dialysis