8/7/2018

CKD is Growing Globally at 8% Annually and Dialysis

Patient Population Doubled Since 2000

Stage 5 CKD Growth Drivers

CKD in Indonesia and Country Data
• Aging population
• No. 1 cause of CKD is diabetes

Its Management (40%–50%)

• No. 2 cause of CKD is hypertension
(20%–30%)

Mohammad Yogiantoro Asia Pacific

Data presented only for those countries from which relevant information
was available; “.” signifies data not reported. All rates are unadjusted.
Israel, Japan, and Taiwan are dialysis only. Percent change from 2004-2005
is not reported for countries whose reporting methods changed during
this period.

USRDS Annual Report 2008 and 2009

• Most Px CKD asymptomatic, until

developed ESRD
• Early detection  reduce incidence
(morbidity, mortality, cost)
• Etiology CKD in Indonesia :
– Glomerulonephritis (39.87%)
– Diabetic nephropathy (17.54%)
- Global prevalence of CKD : 11-13% (majority stage III)
- RRT : HD, CAPD, renal transplantation – Hypertension (15.72%)
- Incidence rate ESRD per million in Indonesia (2002- – Obstructive & infective (13.44%)
2006), increasing from 10.2 to 23.4
– Unknown (10.93%)
- 117,162 new case ESRD in USA (2013), incidence rate :
363 per million/year – Polycystic kidney disease (2.51%)

1
 8/7/2018

Distribution of dialysis centers and seven

geographic areas studied

• CKD growing rapidly, progression to ESRD

• 13 nephrology centers (questionnaire)
• Previous data  prevalence ESRD increased
• CAPD as alternative RRT
• High cost
• Covered by government health insurance
• Management approach should shifted from
treatment to prevention

Results: Of 9412 subjects recruited, 64.1% were female. Persistent RUMAH SAKIT
proteinuria was found in almost 3%. Systolic and diastolic hypertension was
found in 10%, isolated systolic hypertension in 4.8% and isolated diastolic
Dialysis in Indonesia
hypertension in 4.6%. CKD was found in 12.5% (CG), 8.6% (MDRD) or
7.5% (Chinese MDRD) of subjects with either hypertension, proteinuria  Belum ada data menyeluruh
and/or diabetes.
Proteinuria, systolic blood pressure and a history of diabetes mellitus  Indonesian Renal Registry (2015)
were independent predictors of impaired eGFR.  PERNEFRI & DEPKES
Obesity and smoking history were found in 32.5% and 19.8%,  Reporting rate : ~ 40%
respectively.  Hemodialysis, Peritoneal, CRRD, Hybrid

Conclusion: The present study showed a high prevalence of CKD in

representative urban and semi-urban areas and argues for screening
and treatment of all Indonesians, particularly those at an increased risk of PAGE 12 | Present situation of Dialysis in Indonesia

CKD

2
 8/7/2018

RUMAH SAKIT RUMAH SAKIT

Dialysis in Indonesia (IRR 2015) Dialysis in Indonesia (IRR 2015)

Cause Primary GN, 8% Etiology
4%
7%
Secondary
Nephropathy, 7%
Chronic
Pyelonephritis,
7%
89% Hypertension,
Other, 9% 44%

Unknown, 3%
Chronic Kidney Disease
Acute Kidney Failure
Diabetes, 22%
Acute on Chronic
PAGE 13 | Present situation of Dialysis in Indonesia PAGE 14 | Present situation of Dialysis in Indonesia

RUMAH SAKIT RUMAH SAKIT

Dialysis in Indonesia (IRR 2015) Dialysis in Indonesia (IRR 2015)

Vascular Access Type TIME FROM DIALYSIS TO DEATH
Cause of Death
80% 76% (MONTHS) IN 2015
70% > 36 mo Cardiovascular 44%
8%
60% 12 - 36 mo
14% < 3 mo Cerebrovascular 8%
50%
27%
40% GI Bleeding 3%
30%
Septicemia 16%
20%
13%
10% 3% 3% 4% other 29%
1%
0%
Vascular Access Type

Av Shunt Femoral Other

6 - 12 mo
33%
3 - 6 mo Majority Death : < 12 months;
18%
D/T Jugular D/T Subclavia2 D/T Femoral2 COD : Cardiovascular, Sepsis

PAGE 15 | Present situation of Dialysis in Indonesia PAGE 16 | Present situation of Dialysis in Indonesia

RUMAH SAKIT RUMAH SAKIT

Jaminan Kesehatan Nasional (JKN) Jaminan Kesehatan Nasional (JKN)

 1 Januari 2014 - now
 Kepesertaan
 1 Dec 2017: ~ 186 Juta (± 74%)

 Pengeluaran Penyakit Kronis -> Tinggi

 2016 : 21% Budget (~ USD 1.05 Billion)

PAGE 17 | Present situation of Dialysis in Indonesia PAGE 18 | Present situation of Dialysis in Indonesia

3
 8/7/2018

RUMAH SAKIT RUMAH SAKIT

Jaminan Kesehatan Nasional (JKN) Pembiayaan Pasien HD (IRR 2015)

Dialysis Cost Source
Out of Pocket Other
Private/Company 10% 1%
3%

National Health
Insurance
86%

National Health Insurance Private/Company Out of Pocket Other

PAGE 19 | Present situation of Dialysis in Indonesia PAGE 20 | Present situation of Dialysis in Indonesia

RUMAH SAKIT RUMAH SAKIT

Dialysis in Indonesia (IRR 2015) Dialysis (Jawa Timur)

Active vs New Patients
35000
National
Health 30000 Total 58 HD
Insurance
25000 Unit
20000

15000

10000
Dialysis : ~78.000 (28 HD Unit)
5000

0
2011 2012 2013 2014 2015
Active Patients 6951 9161 9396 11689 30554
New Patients 15353 19621 15128 17193 21050
Active Patients New Patients

Peningkatan Pasien Aktif HD Sejak BPJS Dimulai Populasi (2015) : 42 Juta Jiwa CKD : ~ 0,3%
PAGE 21 | Present situation of Dialysis in Indonesia PAGE 22 | Present situation of Dialysis in Indonesia

RUMAH SAKIT

Dialysis (Jawa Timur)

 Peningkatan pasien • CKD growing rapidly, progression to ESRD
 Meningkat 25 – 30% Sejak JKN • 13 nephrology centers (questionnaire)
 Akses Fakses Naik -> Deteksi lebih awal
• Previous data  prevalence ESRD increased
 Keterbatasan • CAPD as alternative RRT
 Unit Mesin HD : ~ 540 Units ( ~ 11% Nasional) • High cost
 SDM Khusus
• Covered by government health insurance
 Mayoritas pada rumah sakit
• Management approach should shifted from
treatment to prevention
Demand vs. Supply Discrepancy
PAGE 23 | Present situation of Dialysis in Indonesia

4
 8/7/2018

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Early treatment can make a The image part with relationship ID rId16 was
not found in the file.

difference
NEPHROLOGY AT A GLANCE

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100

No Treatment

Current Treatment

Early Treatment
GFR (mL/min/1.732)

10
Kidney Failure
0
4 7 9 11

130/80 mmHg
Time (years)

Treat the BP to Target Division of Nephrology and Hypertension - Departement of Internal Medicine
School of Medicine Airlangga University - Dr. Soetomo Teaching Hospital

Filtration, Reabsorption
and Secretion

Normal GFR 120 ml/min/1.73m2 In a day 210 L of water is filtered

Only 20% nephrons work at a time 2 L /day of urine is excreted

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How the Proteinuria

Induces Renal
Damage ?

5
 8/7/2018

Microalb/Proteinuria
Glomerular is early marker of kidney damage
Disease
Systemic
blood
pressure
DILTIAZEM
Urinary space
of Bowman’s
capsule

DILTIAZEM Tubulus

Albumin excretion increased by :

* Systemic or glomerular hypertension
* Reduced negative charge repulsion
on basement membrane
* Enlarge filtration pores
Fenestrated capillary
Urinary Excretion endothelium
Basement membrane
Protein Ephitelial cell
Lipids foot process

Complements Filtration of Albumin into urinary space

DILTIAZEM

Microalbuminuria: A Manifestation Progression of Renal Injury in

of Diffuse Endothelial Cell Injury Hypertension and CV Disease
Systemic Injured Endothelium Renal
Vasculature The image part with relationship ID rId7 was not found in the file.
Vasculature
The image part with relationship ID rId7 was not found in the file.

Cardiovascular Risk Factors

Age
Diabetes Proteinuria
Hypertension
Interstitial Albumin Smoking Renal Hyperfiltration Hypertension
Leak Absent nocturnal BP dipping injury
Salt sensitivity Fibrosis
Left ventricular hypertrophy
The image part with relationship ID rId7 was not found in the file.

Dyslipidemia Microalbuminuria
Central obesity
Insulin resistance
Elevated CRP

DILTIAZEM
Sympathetic dysfunction
Hyperuricemia
Retinopati

RENOPROTECTION EFFECT PREVEND Study

(Prevention of Renal and Vascular End Stage Disease)

DILTIAZEM 40,548 Individuals in the General Population

The image part with relationship ID rId4 was not found in the file.

Cardiovascular Death
25-50 100 > 100
• Renoprotection consist of :
Low protein diet + Keto.A
• BP lowering (125/75 mmHg)
– Decrease proteinuria ( negative )
– Decrease risk of fibrosis

Hillege et al.: Circulation 106:1777-1782, 2002

6
 8/7/2018

Proteinuria Is Also a Risk Factor Strength of MAU as a

for Progression of CKD Cardiovascular Risk
The image part with relationship ID rId3 was not found in the file.

50

• Modifiable risks
P<.001*
% With Doubling

40
of SCr or ESRD

30 – Blood sugar control (?)

20 – Lipid profile (OR 2.32)
10 – Hypertension (OR 3.2)
0
– Obesity (?OR 4 - 7)
<0.5 0.5-3.0 3.0-6.0 >6.0 – Smoking (OR 6.52)
Urine Protein (g/d)
*P-values are for comparison across the subgroups.
Jafar et al. Kidney Int. 2001;60:1131-1140. DILTIAZEM – Microalbuminuria (OR 10.02)

Risk Ratio +/- Risk Factor for CVD

2.5

1.5

0.5

DILTIAZEM DILTIAZEM

When Your
Kidneys Diabetes Hypertension

Failed….

Why detect CKD early?

Dialisis

Transplant

7
 8/7/2018

CKD is Growing Globally at 8% Annually and Dialysis

Patient Population Doubled Since 2000 Cardiovascular Risk Factors are the
Top 6 Leading Causes of Death
Stage 5 CKD Growth Drivers
Country Data
• Aging population
• No. 1 cause of CKD is diabetes
(40%–50%)
• No. 2 cause of CKD is hypertension
(20%–30%)

Asia Pacific
Data presented only for those countries from which relevant information
was available; “.” signifies data not reported. All rates are unadjusted.
Israel, Japan, and Taiwan are dialysis only. Percent change from 2004-2005
is not reported for countries whose reporting methods changed during
this period.

USRDS Annual Report 2008 and 2009

The image part with relationship ID rId3 was not found in the file.

Hipertenzija - samo dio višestrukog

Hypertension rizičnog sindroma sa teškim
Lifestyles, Fitness
and Rehabilitation posljedicama
• How can I tell if I have High Blood
Pressure?
– Usually NO SYMPTOMS!
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– “The Silent Killer”

– May have:
• Headache
• Blurry vision
• Chest Pain Treat the BP to Target
• Frequent urination at night

The image part with relationship ID rId13 was not found in the file.

Mosaic Genetic Environmental

2007

Haemodynamics
WHAT IS THE BLOOD
Renal
The image part with relationship ID rId3 was not found in the file.

PRESSURE TARGET
FROM TIME TO TIME?
Humoral BP Anatomical

Intrauterine

IN CKD
programming Adaptive

Endocrine Neural
48

8
 8/7/2018

What is the Optimal Blood Pressure in Adequate BP management delays the 

CKD? progression of CKD
MAP (mmHg)
95 98 101 104 107 110 113 116 119
0
r = 0.69; p < 0.05
-2
GFR (ml/min/year)

-4

-6 MAP = [(2 x diastolic)+systolic] / 3

-8

-10

-12 Mrs. Smith 160/95

Untreated HTN
-14 130/80 140/90
The image part with relationship ID rId4 was not found
in the file.

Diabetes Non-diabetes
Parving et al., Br Med J, 1989 Klahr et al., N Engl J Med, 1993
Viberti et al., JAMA, 1993 Maschio et al., N Engl J Med, 1996
If Rita’s blood pressure was consistently 
Hebert et al., Kidney Int, 1994 GISEN Group, Lancet, 1997 below target, the GFR loss per year would be 
Lebovitz et al., Kidney Int, 1994 reduced by 80%
Bakris et al., Kidney Int, 1996
Bakris et al., Hypertension, 1997
Bakris et al., Am J Kidney Dis, 2000 Treat the BP to Target
Bakris et al., Am J Kid Disease, 2000

Blood Pressure and ESRD in Men

16 Years Follow-Up Study of Subjects (MRFIT)

1. High blood pressure are a strong

/100,000/year
200independent risk factor for ESRD. 187.1
2. Interventions to prevent the disease need to
150emphasize the prevention and control of

100
both high-normal and high blood pressure.
96.1 140/90
130/80
50 43.6 The image part with relationship ID rId4 was not found in the file.

21.0
0
5.3 6.6 11.1
130/80
SBP <120 <129 <139 <159 <179 <209 >210 mmHg
DBP <80 <84 <90 <100 <110 <120 >120 mmHg Treat the BP to Target
Treat the
KlagBP
MJ et to
al. N Target
Engl J Med 1996;334, 13-18

Management of Hypertension in Patients With CKD

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/
130/80 130/80
APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood
Pressure in Adults

© American College of Cardiology Foundation and American Heart Association, Inc.

•Colors correspond to Class of Recommendation in Table 1.

•*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g
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rId13was
wasnot
notfound
foundininthe
thefile.
file. The image part with relationship ID rId13 was not found in the file.

The image part with relationship ID rId2

rId13was
wasnot
notfound
foundininthe
thefile.
file. The image part with relationship ID rId13 was not found in the file.

creatinine.
•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP
blood pressure; and CKD, chronic kidney disease.
.

9
 8/7/2018

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BP Thresholds for and Goals of Pharmacological Therapy in Patients

With Hypertension According to Clinical Conditions
BP
Interventions to Slow
CKD Progression
BP Goal,
Clinical Condition(s) Threshold,
mm Hg
mm Hg
General
Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80
No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized, ≥130 (SBP) <130 (SBP)
ambulatory, community-living adults)
Specific comorbidities
Diabetes mellitus ≥130/80 <130/80
Chronic kidney disease ≥130/80 <130/80 130/80
Chronic kidney disease after renal transplantation ≥130/80 <130/80
Heart failure ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
Secondary stroke prevention (lacunar) ≥130/80 <130/80
Peripheral arterial disease ≥130/80 <130/80

ASCVD indicates atherosclerotic cardiovascular The image part with relationship ID rId13 was not found in the file.

disease; BP, blood pressure; CVD, cardiovascular

The image part with relationship ID rId13 was not found in the file.

disease; and SBP, systolic blood pressure. Treat the BP to Target

Interventions to Slow CKD

Stages in Progression of Chronic Kidney Disease
Progression Treat and Therapeutic Strategies
130/80
Systemic Hypertension Hypertension
Treat the BP to TargetWeight loss Complications
1°Renal  Pgc  Dietary Protein
Disease  SNGFR
Treat the BP to Target
Mechanical Stress
Nephron Inhibit
Loss RAS Ang II Increased Kidney CKD
Normal Damage  GFR
risk failure death
Proteinuria
Macrophages
Treat Screening CKD risk Diagnosis Estimate Replacement
Fibroblasts  Proteinuria
Dyslipidaemia for CKD reduction; & treatment; progression; by dialysis
risk factors Screening for Rx. comorbid Rx. complications; & transplant
CKD conditions; Prepare for
New TGF-
Stop 2° FSGS Anti-inflammatory Cytokines
↓ progression replacement
Smoking and TIF Microalb
Anti-fibrotic CAMs
R/ Protein Diet + Ketoanalogue

Progressive Kidney Damage:

INTERACTION OF HYPERTENSION,
Risk Factors and Pathophysiology PROTEINURIA and GFR LOSS
Kidney Injury2
Risk Factors1
Proteinuria > 1.5 g/24 hr Reduction in nephron mass
Hypertension 1 Proteinuria
Protein to Creatinine ratio > 1 g/g
Glomerular capillary hypertension
Hypertension
 Glomerular permeability 2
Type of underlying kidney disease to macromolecules 3 4
6
African American race 5
Male gender  Filtration of plasma
Obesity  Systemic
blood pressure Glomerular Tubular
Diabetes mellitus (DM) or family Proteinuria Proteins 8
injury injury
history of DM
Hyperlipidemia Excessive tubular protein reabsorption
Smoking
Tubulointerstitial inflammation 7 9
High protein diet
Hyperphosphatemia Kidney Scarring
Metabolic acidosis
1. Huether SE, Pathophysiology,4th Edition, 2002, Chapter 35, 1191-1216
2. Pisoni R, Primer on Kidney Disease,3rd edition, 2001, Chapter 58, 385-396
GFR loss
Treat the BP to Target Treat the BP to Target
Hebert, et al. KI 2001:59;121-1226

10
 8/7/2018

The image part with relationship ID rId16 was not found in the file.

Early treatment can make a The image part with relationship ID rId16 was
not found in the file.

difference

The image part with relationship ID rId3 was not found in the file.

100

No Treatment

Current Treatment

Early Treatment
GFR (mL/min/1.732)

10

0
Kidney Failure

4 7 9 11
DILTIAZEM
130/80 mmHg Time (years)

Treat the BP to Target

Differential Effects of CCB Therapy

Type 2 Diabetics With Nephropathy
10 SBP DBP 100 D 24 h proteinuira

Proteinuria reduction vs baseline

BP reduction vs baseline (mmHg)

0 0

-10 -100

(mg/day)
-20 -200

* *
-30 -300

-40 -400
*
-50 * -500

*
Nifedipine (n = 10) *p<0.05
Diltiazem (n = 11)

Smith et al. Kidney Int. 1998;54:889-896.

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Diltiazem & ACE-I Combination Early treatment can make a

difference
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not found in the file.

Type 2 Diabetics –Microalbuminuria

300 Initial
2 Year Follow-Up The image part with relationship ID rId3 was not found in the file.

100

250 No Treatment

Current Treatment
UAE (mg/24 hrs)

200 p < 0.05 Early Treatment

GFR (mL/min/1.732)

150

100
DILTIAZEM
50 10
Kidney Failure
0
4 7 9 11

0 130/80 mmHg Time (years)

Captopril (n=17) Captopril + Diltiazem (n=11)

Pèrez-Maraver M, et al. (EASD) Meeting 2001; Abstract: 1056. Treat the BP to Target

11
 8/7/2018

THE ATHEROSCLEROTIC
SYNDROME
Y o g i a n t o r o

Clinical manifestations of insulin resistance Natural History of Type 2 Diabetes

R/ Metformin Type 2 diabetes and

glycemic disorders
Atherosclerosis

Dyslipidemia
DM Atherosclerotic Hypertension
Insulin
resistance – Low HDL
– Small, dense LDL
Visceral Glucotoxicity – Hypertriglyceridemia
Obesity Lipotoxicity Hypertension
M o h a m m a d

 Adiponectin Endothelial dysfunction/

inflammation (hsCRP) Micro Angiopathy Macro Angiopathy
Time (yrs) 0 5 20 30
Micro Alb. Prot. Uria BP increase CVD CKD HD
Impaired thrombolysis Creatinin increase
 PAI-1 Risk Factors 2nd Prevention
st
3rd Prevention
1 Prevention

Treat the BP to Target Courtesy of Selwyn AP, Weissman PN.

Treat the BP to Target

I FEEL FINE Adipose Tissue is the Largest Endocrine Organ

It Promotes Endothel Disfunction (CVD)
Cardiovascular Risk visfatin
QS 4:29 “Janganlah kamu membunuh dirimu,  Factors
Age
sesungguhnya Allah Maha Penyayang terhadapmu” Diabetes
Hypertension
Smoking
Absent nocturnal BP
dipping

TREAT the BP TO TARGET
Salt sensitivity
Left ventricular
hypertrophy
Dyslipidemia
Central obesity
Insulin resistance
Elevated CRP
Sympathetic
dysfunction
Hyperuricemia
AJP-Heart Circ Physiol, 2005.-

12
 8/7/2018

I FEEL FINE
ICU
Unstable A
Atherosclerosis Thrombosis angina C
MI
S
TREAT the BP TO TARGET Ischemic 1st & 2nd Prevention
stroke/TIA

130/80 Diabetic
TREAT the BP TO TARGET
nephropathy

130/80

3rd Prevention

How to halt the progressivity of the

atherosclerosis syndrome?
I FEEL FINE HD
I Feel Fine
1st & 2nd Prevention

TREAT the BP TO TARGET
130/80
TREAT the BP TO TARGET
130/80

1st & 2nd Prevention 3rd Prevention

1st & 2nd Prevention 3rd Prevention

I FEEL FINE Let this not happen please!

Unstable A
Atherosclerosis Thrombosis angina C
MI
S
Ischemic
stroke/TIA

Diabetic
130/80 nephropathy

Cardiovascular
death

Normal ESRD

13
 8/7/2018

Kidney damage Polycystic Kidneys

Benign
Nephrosclerosis:

Leathery Granularity
due to minute scarring

KERUSAKAN GINJAL
Batu / Obstruksi Contracted Kidneys

Contracted smooth kidney

PENGKERUTAN PEMBENGKAKAN
( FIBROSIS ) ( HIDRONEFROSIS )
Scarred kidney –cut section

End Stage Renal Disease WHAT IS RENOPRECTION?

PCKD with ESRD

Chronic Contracted Kidney

14
 8/7/2018

Stages in Progression of Chronic Kidney Disease

and Therapeutic Strategies Microalbuminuria: A Manifestation
of Diffuse Endothelial Cell Injury
Complications Injured Endothelium
Systemic Renal
Normoalbuminuria Microalbuminuria Macroalbuminuria
Vasculature Vasculature

Increased  GFR Kidney CKD

Normal Damage Cardiovascular Risk Factors
risk failure death
Age
Diabetes
Screening CKD risk Diagnosis Estimate Replacement Hypertension
for CKD reduction; & treatment; progression; by dialysis Interstitial Albumin Smoking
risk factors Screening for Rx. comorbid Rx. complications; & transplant Leak Absent nocturnal BP dipping
CKD conditions; Prepare for Salt sensitivity
↓ progression replacement Left ventricular hypertrophy
Dyslipidemia Microalbuminuria
Vascular Lesion Permiability↑ Citokyn Vasoconstriction Trombosis Central obesity
& Remodelling Microalb & Macroalb Inflammation HTN
Insulin resistance
Elevated CRP

Treat the BP to Target

ATHEROSCLEROSIS
Sympathetic dysfunction
Hyperuricemia

CVD
Retinopati

Progression of Renal Injury in

RENOPROTECTION EFFECT
Hypertension and CV Disease

• Renoprotection consist of :
Proteinuria Low protein diet + Keto.A
Renal Hyperfiltration Hypertension
injury • BP lowering (125/75 mmHg)
Fibrosis
– Decrease proteinuria ( negative )
– Decrease risk of fibrosis

Treat the BP to Target

Treat the BP to Target

Interventions to Slow CKD

INTERACTION OF HYPERTENSION,
PROTEINURIA and GFR LOSS Progression Treat
Systemic Hypertension Hypertension

Hypertension 1 Proteinuria
1°Renal
Treat the BP to Target
 Pgc
Weight loss
 Dietary Protein
2 Disease  SNGFR
3 4
6
5 Mechanical Stress
Nephron Inhibit
Glomerular Tubular Loss RAS Ang II
8
injury injury Proteinuria
Macrophages
Treat
7 Fibroblasts  Proteinuria
9 Dyslipidaemia

New TGF-
Stop 2° FSGS Anti-inflammatory
GFR loss Smoking and TIF
Cytokines
Anti-fibrotic
Treat the BP to Target
Hebert, et al. KI 2001:59;121-1226
CAMs

15
 8/7/2018

Adequate BP management delays the  Pathophysiology of progression

progression of CKD HILIR
HULU
Cardiovascular Risk Factors
Age
Diabetes
Hypertension
Hypertension
Smoking Syndrome
Absent nocturnal BP dipping
Atherosclerosis
Salt sensitivity Outcome
Syndrome
Left ventricular hypertrophy
Dyslipidemia
Central obesity
Insulin resistance
Elevated CRP
Sympathetic dysfunction
Hyperuricemia
160/95

The image part with relationship ID rId4 was not found

in the file.

Area of Trial End Point

If Rita’s blood pressure was consistently 
below target, the GFR loss per year would be 
Risk Risk
reduced by 80%
Factors Treat the BP to Target
Reduction
Treat the BP to Target Bakris et al., Am J Kid Disease, 2000

Stages in Progression of Chronic Kidney Disease Natural History of Type 2 Diabetes

and Therapeutic Strategies
Complications
HILIR DM Atherosclerotic Hypertension
Treat the BP to Target
Increased Kidney CKD
Normal Damage  GFR
risk failure death

Screening CKD risk Diagnosis Estimate Replacement Micro Angiopathy Macro Angiopathy
Time (yrs) 0 5 20 30
for CKD reduction; & treatment; progression; by dialysis
Micro Alb. Prot. Uria BP increase
risk factors Screening for Rx. comorbid Rx. complications; & transplant CVD CKD HD
Creatinin increase
CKD conditions; Prepare for
↓ progression replacement Risk Factors 2nd Prevention 3rd Prevention
st
1 Prevention
Microalb
HULU R/ Protein Diet + Ketoanalogue HULU Treat the BP to Target HILIR

III. Assessment of the overall cardiovascular risk TARGET HIDUP SEHAT

Search for target organ damage 1. Tekanan Darah >60 thn 150/90 mmHg
Cerebrovascular disease
2. Tekanan Darah <60 thn
HULU - transient ischemic attacks
- ischemic or hemorrhagic stroke
• Tidak ada komplikasi 140/90 mmHg
- vascular dementia • DM positif 130/80 mmHg
Hypertensive retinopathy
Left ventricular dysfunction • CKD positif 130/80 mmHg
Left ventricular hypertrophy
Coronary artery disease
• Mikroalbuminuria positif 130/80 mmHg
- myocardial infarction
- angina pectoris
3. DM                                     A1C  6,5 – 7,0
- congestive heart failure 4. LDL Kolesterol <70
Chronic kidney disease
- hypertensive nephropathy (GFR < 60 5. Asam Urat <7,0
ml/min/1.73 m2)
Treat the BP to Target - albuminuria 6. Mikroalbuminuria Negatif
Peripheral artery disease

BP 130/80 - intermittent claudication 7. EGFR   (kreatinin 0,9‐1,2)         >60%

- ankle brachial index < 0.9
mmHg 8. Lingkar Perut wanita < 80 cm, Laki‐laki <90 cm
HILIR 9. Hb antara 10‐11 gr%

16
 8/7/2018

CONCLUSION
Protection, Prevention, and 
Regression the Progressivity of  HILIR
Atherosclerotic Syndrome  140/90
Dominited by :
130/80
Treat the BP to Target

hulu AKIBAT

CONCLUSION CONCLUSION
Protection, Prevention, and  Protection, Prevention, and 
Regression the Progressivity of  Regression the Progressivity of 
Atherosclerotic Syndrome  Atherosclerotic Syndrome 
Dominited by : Dominited by :

HULU Treat the Risk Factors HILIR Treat the Organ Damage

Treat the BP to Target Treat the BP to Target

What’s new in CKD? Stages of Chronic Kidney Disease

(K/DOQI Guidelines 2002)
Blood Pressure Targets
GFR
Stage Description (mL/min/1.73 m2)
What Old New 1 Kidney damage with normal or  > 90
Blood Pressure People with >1g proteinuria/ day – People with CKD - should GFR
Targets BP target 125/75 mmHg maintain a BP consistently 2 Kidney damage with mild  GFR 60 – 89
below 140/90 mmHg
People with CKD (or other
conditions) – BP target 130/80 People with diabetes or 3 Moderate  GFR 30 – 59
mmHg microalbuminuria should
maintain a BP consistently 4 Severe  GFR 15 – 29
All other conditions – BP target below 130/80 mmHg
140/90 mmHg
5 Kidney failure < 15 or dialysis
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
tests or imaging studies

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What’s new in CKD? staging schema

Staging of Chronic Kidney Disease Albuminuria Stage
Normal Microalbuminuria Macroalbuminuria
Old New Rationale GFR GFR (urine ACR mg/mmol) (urine ACR mg/mmol) (urine ACR mg/mmol)
CKD Determined Determined by kidney Recommended by all Stage (mL/min/1.73m2) Male: < 2.5 Male: 2.5-25 Male: > 25
Female: < 3.5 Female: 3.5-35 Female: > 35
staging by eGFR function (eGFR) and the Australian and
system level of albuminuria in all international Not CKD unless
1 ≥90
stages of CKD guidelines and is a haematuria, structural
better indicator of 2 60-89
or pathological
abnormalities present
overall risk
3a 45-59
Stage 3 Stage 3 CKD Divided into More accurately
CKD (eGFR 30-59 Stage 3a (eGFR 45-59 reflects risk
3b 30-44
mL/min/1.73m2 mL/min/1.73m2) stratification
) Stage 3b (eGFR 30-44 4 15-29
mL/min/1.73m2)
5 <15 or on dialysis

Using the new CKD staging schema
CKD Staging system and Action plan
‘CKD Management in General Practice’ booklet 
has colour‐coded action plans for overall risk of 
“PreCKD” Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
• Progression of CKD
• Cardiovascular events
GFR
≥90
Normal mL/min/ with risk ≥90 60-89 30-59 16-29 <15
1.73m2 factors
Low At increased Kidney Mild ↓ Moderate ↓ Severe ↓ Kidney
risk for damage with Failiure
Description Kidney normal or
Moderate damage increased
GFR
Screening Diagnosis and Estimate Evaluate and Prepare for Replacement
High CKD risk treatment Progression treat RRT therapy for
Action reduction Slow complications indications
Plan* progression
Treat
Comorbidities
CV risk
reduction
MORE SEVERE
* Includes actions from preceding stages KDOQI

STAGES OF CHRONIC KIDNEY DISEASE : CLINICAL PRESENTATIONS

CKD Staging system and Action plan STAGE DESCRIPTION GFR RANGE Clinical Presentations *
(mL/min/1,73m2)
At increased risk ≥ 60 CKD Risk Factors
(without markers of damage)
“PreCKD” Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 1 Kidney damage ≥ 90 Markers of damage
with normal or ↑ GFR (Nephrotic syndrome,
Nephritic syndrome

GFR
≥90 Tubular syndromes
Urinary tract sympatoms
mL/min/ with risk ≥90 60-89 30-59 16-29 <15 Asympmtomatic urinalysis abnormalities
Asymtomatic radiologic abnormalities
1.73m2 factors Hypertension due to kidney disease
At increased Kidney Mild ↓ Moderate ↓ Severe ↓ Kidney
2 Kidney damage 60 – 89 Mild complications
risk for damage with Failiure with mild ↓ GFR
Description Kidney normal or
damage increased 3 Moderate ↓ GFR 30 – 59 Moderate complications
GFR
4 Severe ↓ GFR 15 – 29 Severe complications
Screening Diagnosis and Estimate Evaluate and Prepare for Replacement
CKD risk treatment Progression treat RRT therapy for 5 Kidney Failure < 15 Uremia
Action reduction Slow complications indications (or dialysis) Cardiovascular disease
Plan* progression
Treat * Includes presentations from preceding stage. Chronic kidney disease is dfined as either kidney
Comorbidities damage or GFR < 60 mL/min/1,73 m2 for 3 months. Kidney damage is defined as pathologic
CV risk abnormalities or markers of damage, including adnormalities in blood or urine or tests or imaging
reduction
studies
* Includes actions from preceding stages KDOQI

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Risk factors for the development, progression,
and complications of CKD
Risk factor Definition
Development Increases susceptibility to
kidney damage
Directly initiates kidney
damage
Risk factors for the development, progression,
and complications of CKD
Risk factor Definition
Complications Accelerate the onset or
recurrence of CVD
Increase morbidity and
mortality in kidney failure
The Adherence Continuum
Non-compliant pill irregularly pill regularly
8/7/2018
Risk factors for the development, progression,
and complications of CKD
Examples Risk factor Definition Examples
Older age, family history of Progression Worsens kidney damage Higher level of proteinuria
CKD, US racial or ethnic or accelerates GFR
minority status, low income, decline
reduced kidney mass, Increases the risk of Factors related to
hyperfiltration states complications of hypertension, anaemia,
Diabetes, high blood decreased GFR malnutrition, bone and
pressure, obesity, mineral disorders,
dyslipidaemia, autoimmune neuropathy, drugs and
diseases, infections, procedure with kidney or
stones, obstruction, systemic toxicity
neoplasia, recovery from
acute injury
CKD Intervention: Clinical Action Plan
Stage 1-2 Stage 3 Stage 4 Stage 5
Examples GFR >60 30-59 15-29 <15
BP<130/80 mm Hg, ACEI/ARB
Traditional CVD risk
Glycemic control
factors, non-traditional
‘CKD-related’ risk factors CVD risk reduction:
Dyslipidemia management,
Late referral, dialysis Tobacco cessation
factors, comorbid Avoid NSAIDS/Contrast
conditions
Anemia
Nutrition
Renal bone disease
Vascular access &
Transplantation
ACEI = Angiotensin Converting Enzyme Inhibitor ARB = Angiotensin Receptor Blocker
pill + behavior change
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