Gangguan sistem urologi

fokus gagal ginjal

Dr. Eddy Susatyo, SpPD FinaSIM

RSU dr. Sutrasno
Rembang

STRUCTURE OF THE KIDNEYS

Chronic Kidney Disease ?

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.

Prevalence of CKD

How About the Function of Renal ?

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

Brain

ADH

Renin
Angiotensin II
Lung

Kidney
Ang II

Angiotensin I

Adrenal

Angiotensinogen
Hepar

Na+ excretion
H2O excretion

Aldosteron

RAAS

The Most
Common Causes of CKD
Glomerulonefritis
Penyakit ginjal

herediter
Hipertensi
Uropathy obstruktif
Infeksi
Nefropati diabetik

The Most
Common Causes of CKD
Other
Other
10%

Diabetes
50.1%

Glomerulonephritis
Glomerulonephritis
13%

Hypertension
27%

Primary Diagnosis for Patients Who Start on

Dialysis

Pe Reabs Na
Hipertrofi sel
renal

Pe eksr sisa
metab

Ggn
konstentrasi
urin
Penurunan
GFR

Pe ekskr
kalium
Ggn fs
ekskresi

Pe ekskr PO4
Pe ekskr ion
H

CKD

Ggn
Reproduksi
Ggn fs non
ekskresi

Ggn Imun
prod
eritropoetin
Pe abs Ca

JENIS PEMERIKSAAN
PENUNJANG
Urinalisis
Evaluasi Fungsi Ginjal
Evaluasi Serologis
Pemeriksaan Radiologis
Biopsi Ginjal

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)
Cockcroft-Gault Equation

Ccr =
(mL/min)

(140 Age) X Weight in kg

72 X SCr

MDRD = Modification of Diet in Renal Disease; C cr = creatinine clearance.

Levey et al. Ann Intern Med. 2003;139:137-147.

= 0.85 if female

CKD Progresses in Stages Defined by

Kidney Function: GFR
CKD
Stage

Description

GFR

Prevalence

Patients/
Nephrologist

Kidney damage
normal incr. GFR

90

5,900,000

1180

Mild decr. in GFR

60-89

5,300,000

1060

Mod dec. in GFR

30-59

7,600,000

1520

Severe decr in GFR

15-29

400,000

80

Kidney failure

<15

300,000

70 (145-160
by 2010)*

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. 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.

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

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

STAGES OF CKD

NORMAL

INCREASED RISK

COMPLICATIONS

CKD
DEATH

DAMAGE

LOW GFR

RENAL FAILURE

Considerations for Patients with CKD?

Susceptibility
Risk Factors
Diabetes
Hypertension
Older age

Progression
Factors
Higher level of
proteinuria
Higher BP

Family history of CKD

Poor glycemic
control

Racial or ethnic
minority

Smoking
Hyperlipidemia

Other: low income,

Drug use
minimal education,
kidney-mass
reduction, known
Levey
et al. Anndisease
Intern Med. 2003;139:137-147.
kidney
USRDS. 1999 Annual Data Report. Available at: www.usrds.org.

Complications
CVD
Anemia
Altered bone &
mineral
metabolism

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.

2-year Follow-Up of Medicare Patients: Focus

on Diabetes, CKD or Both
100

No Events
ESRD
Death

80
60

61.6

67.6
84.0

40

6.1

2.9
20
0

15.7
+ DM,
- CKD

0.3

29.5
- DM,
+CKD

32.3
+ DM,
+ CKD

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. 2003;64(suppl 87):S24-S31.

LVH Increases With CKD Progression

LVH at Baseline (%)

80
60
40
20
0
50-75

25-50
<25
eGFR (mL/min/1.73 m2)1

eGFR = estimated glomerular filtration rate.

1. Levin et al. Am J Kidney Dis.
Dis. 1999;34:125-134.
2. Foley et al. J Nephrol. 1998;11:239-245.

Dialysis
Start

Anemia Rates Increase as Levels of CKD

Severity Progress
Anemia Prevalence (%)

100
10

80

Hgb Values

15

60

15
8

40

17
9
5

20

14

<2

62
43

20

2-2.9

3-3.9

Creatinine (mg/dL)
Chronic Kidney Disease (CKD) Progression
Hgb = hemoglobin.
Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.

11-12 g/dL
10-11 g/dL
<10 g/dL

Specific Interventions for Complications

of CKD
Complicatio Intervention
n
Diabetes
Glycemic control
Hypertension
BP control
Secondary HPT PTH control
Dyslipidemia

Maintain lipids to
target

Anemia
Malnutrition

Reach Hgb goal

Dietary
modification

Target Goals
preprandial glucose 90125 mg/dL
A1C <7%
< 130/80 mm Hg
CKD stage
3 = 35-70
pg/mL
4 = 70-110
LDL-C <100 mg/dL
(70?)
pg/mL
TG <150 mg/dL
HDL-C >40 mg/dL
11-12 g/dL
Adequate energy intake

A1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone;

LDL-C = low-density lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density
lipoprotein cholesterol; Hgb = hemoglobin.

Summary: Clinical Actions for Progressive

Stages of CKD
CKD
Stag
e
Risk

Descripti
on

At increased
risk

GFR

(mL/min/1.73
m2)

Action*

90 with
CKD risk factors

Evaluate for CKD

Reduce/control CKD risk
factors
Diagnose and treat comorbid
conditions
Address progression factors
Reduce/control CVD risk
factors
Estimate progression
*All actions for prior stages

Kidney damage
with normal
or GFR

90

Kidney damage
with mild GFR

60-89

Moderate
GFR

30-59

Severe GFR

15-29

Kidney failure

<15 or dialysis

Evaluate and treat

complications
*All actions for prior stages
Prepare for kidney
replacement
Evaluate and treat
Kidney
replacement if uremia
complications
present

*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.

Cause of death in dialysis

patients
unknown
cardiac disease
others

infection

CVA
malignancy

withrawal of
RRT

Decisions in renal
replacement
Pre-dialysis care
Active treatment
- Peritoneal dialysis (PD)
- Haemodialysis (HD)
- Transplantation
Conservative (non-dialytic) care.
Symptom management.

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

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

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

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.

How About
Acute kidney injury in Sepsis ?

Critical ill patient potentially AKI

AKI in ICU 5 25%

Mortality AKI 40-80%

RIFLE criteria for Acute Renal Dysfunction

Oliguria

Abrupt (1-7 days)

Decreased UO relative to
decrease (> 25%) in GFR or
the fluid input
Scr x 1.5
UO < 0.5/ml/kg/h x 6hr
Sustained (> 24 hrs)

Risk
Injury

Adjusted creat or GFR

decrease> 50% or
Scr x 2

Failure
Loss
ESRD

UO < 0.5/ml/kg/h
x 12 hr ??

Adjusted creat or GFR

UO < .5/ml/kg/h
decrease > 75%
Scr x 3 or Scr > 4mg% x 24 hr
When acute > 0.5mg% Anuria x 12 hrs

Irreversible ARF or persistent

ARF > 4 wks
ESRD > 3 months

Specificity

Non-Oliguria

ARF ~ earliest
time point for
provision of RRT

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

Sepsis
Ischemic insult
Nephrotoxic insult

Ischemia-reperfusion

Endotoxin release

Pro-inflamatory
mediators

+
-

Anti-inflamatory
mediators

Oxygen free radicals

Nitric oxide
Heat shock proteins

Arachidonic acid
metabolities

Cellular activation
(PMN, endothelial cells)

Endothelins
Urinary KIM-1, NAG

Complement activation

Proteases
Chemokines
Platelet activating factor

Acute kidney injury

Serum creatinine

Urine output GFR

Pathogenic mechanism of sepsis related acute kidney injury

Possible pathogenetic mechanisms in ATN.

Tubular damage
(proximal tubules and
ascending thick limb)

Ischemia
Nephrotoxins

(1)
Vasoconstriction
Renin-angiotensin
endothelin
PGI2
NO

(5)
? Direct glomerular
effect

(2)
Obstruction
by casts

Intratubular
pressure

GFR

(3)
Tubular
backleak

(4)
Interstitial
inflammation

Tubular
fluid flow

Oliguria

Effects of ischemia on renal tubules in

the pathogenesis of ischemic AKI

Schrier et al, J Clin Invest 2004, 114:5-14

Renal Protection
Renal protection, there is damage before any symptom
MAP> 65 mmHg
CVP 8-12 mmHg (no ventilator)
12-15 mmHg (ventilator)
Urine > 0,5ml/BW/hour
SaO2 >70%
Koloid ,albumin ?

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