1. Gangguan sistem urologi fokus gagal ginjal
Dr. Eddy Susatyo, SpPD FinaSIM
RSU dr. Sutrasno
Rembang

2. STRUCTURE OF THE KIDNEYS

11. Chronic Kidney Disease ?

12. 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.

13. Prevalence of CKD

14. How About the Function of Renal ?

15. 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

16. RAAS Brain ADH Renin Angiotensin II Kidney Na+ excretion H2O excretion
Lung
Ang II
Angiotensin I
Adrenal
Angiotensinogen
Aldosteron
RAAS
Hepar

17. The Most Common Causes of CKD
Glomerulonefritis
Penyakit ginjal herediter
Hipertensi
Uropathy obstruktif
Infeksi
Nefropati diabetik

18. The Most Common Causes of CKD
Diabetes
50.1%
Hypertension
27%
Glomerulonephritis
13%
Other
10%
Other
Glomerulonephritis
Primary Diagnosis for Patients Who Start on Dialysis

19. 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

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

22. Equations for Estimating GFR
Abbreviated MDRD Study Equation
GFR (mL/min/1.73 m2) = X SCr X Age X (if female) X (if African American)
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. 2003;139:

24. CKD Progresses in Stages Defined by Kidney Function: GFR
300,000
<15
Kidney failure 5 80
400,000
15-29
Severe decr in GFR 4
1520
7,600,000
30-59
Mod dec. in GFR 3
1060
5,300,000
60-89
Mild decr. in GFR 2
1180
5,900,000
90
Kidney damage normal incr. GFR 1
Patients/ Nephrologist
Prevalence
GFR
Description
CKD Stage
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.

25. 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

26. 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

27. STAGES OF CKD COMPLICATIONS CKD DEATH INCREASED RISK NORMAL DAMAGE
LOW GFR
RENAL FAILURE
CKD
DEATH
COMPLICATIONS

28. Considerations for Patients with CKD?
CVD
Anemia
Altered bone & mineral metabolism
Complications
Higher level of proteinuria
Higher BP
Poor glycemic control
Smoking
Hyperlipidemia
Drug use
Diabetes
Hypertension
Older age
Family history of CKD
Racial or ethnic minority
Other: low income, minimal education, kidney-mass reduction, known kidney disease
Progression Factors
Susceptibility Risk Factors
Levey et al. Ann Intern Med. 2003;139:
USRDS Annual Data Report. Available at:

29. 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:

30. 2-year Follow-Up of Medicare Patients: Focus on Diabetes, CKD or Both
+ DM, - CKD
- DM, +CKD
+ 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.

31. LVH Increases With CKD Progression
LVH at Baseline (%)‏ 80 60 40 20
50-75
25-50
<25
Dialysis Start
eGFR (mL/min/1.73 m2)1
eGFR = estimated glomerular filtration rate.
1. Levin et al. Am J Kidney Dis. 1999;34:
2. Foley et al. J Nephrol. 1998;11:

32. Anemia Rates Increase as Levels of CKD Severity Progress
100
Anemia Prevalence (%)‏ 62 15 10
Hgb Values 80
11-12 g/dL 43 8 15
10-11 g/dL 60
<10 g/dL 40 20 8 17 14 9 5 20
<2
2-2.9
3-3.9 ≥4
Creatinine (mg/dL)‏
Chronic Kidney Disease (CKD) Progression
Hgb = hemoglobin.
Kausz et al. Dis Manage Health Outcomes. 2002;10:

33. Specific Interventions for Complications of CKD
Adequate energy intake
11-12 g/dL
LDL-C <100 mg/dL (70?) TG <150 mg/dL HDL-C >40 mg/dL
CKD stage 3 = pg/mL = pg/mL
< 130/80 mm Hg
preprandial glucose mg/dL A1C <7%
Target Goals
Dietary modification
Reach Hgb goal
Maintain lipids to target
PTH control
BP control
Glycemic control
Intervention
Dyslipidemia
Anemia
Malnutrition
Secondary HPT
Hypertension
Diabetes
Complication
A1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone; LDL-C = low-density lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density lipoprotein cholesterol; Hgb = hemoglobin.

34. Summary: Clinical Actions for Progressive Stages of CKD
Kidney replacement if uremia present
<15 or dialysis
Kidney failure 5
Prepare for kidney replacement
Evaluate and treat complications
15-29
Severe  GFR 4
*All actions for prior stages
30-59
Moderate  GFR 3
Estimate progression
60-89
Kidney damage with mild  GFR 2
Diagnose and treat comorbid conditions
Address progression factors
Reduce/control CVD risk factors
90
Kidney damage with normal or  GFR 1
Evaluate for CKD
Reduce/control CKD risk factors
90 with CKD risk factors
At increased risk
Risk
Action*
GFR (mL/min/1.73 m2)‏
Description
CKD Stage
*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.

35. Cause of death in dialysis patients

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

37. Penatalaksanaan CKD Uremia : diit protein 0,6 – 0,8 gr / kg bb / hari
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

38. 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

39. 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

40. Example URR URR% = Ur pre – Ur post x 100% Ur Pre 35/50 = 70/100 = 70%
Initial (predialysis) urea level: 50 mg/dL
The postdialysis urea level: 15 mg/dL
The amount of urea removed: 50 mg/dL–15 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.

41. Acute kidney injury in Sepsis ?
How About
Acute kidney injury in Sepsis ?

42. Critical ill patient potentially AKI

43. AKI in ICU  5 –25%
Mortality AKI 40-80%

46. < 0,5ml/kg per jam untuk >6jam
Klasifikasi/staging AKI modifikasi RIFLE
Stadium
kriteria kreatinin
kriteria urin output 1.
Risk
serum kreatinin meningkat > 0,3 mg/dl atau meningkat lebih dari % 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

47. Ischemia-reperfusion Complement activation (PMN, endothelial cells…)
Sepsis
Ischemic insult
Nephrotoxic insult
Ischemia-reperfusion
Endotoxin release
Complement activation +
Pro-inflamatory
mediators
Anti-inflamatory
mediators -
Oxygen free radicals
Arachidonic acid
metabolities
Cellular activation
(PMN, endothelial cells…)
Nitric oxide
Proteases
Heat shock proteins
Chemokines
Endothelins
Platelet activating factor
 Urinary KIM-1, NAG
Acute kidney injury
 Serum creatinine
 Urine output
 GFR
Pathogenic mechanism of sepsis related acute kidney injury

49. Schrier et al, J Clin Invest 2004, 114:5-14
Effects of ischemia on renal tubules in the pathogenesis of ischemic AKI
Schrier et al, J Clin Invest 2004, 114:5-14

50. 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 ?

51. Tight control of blood glucose
Intensive insulin therapy  sepsis by 45%
Blood glucose mg/dl  morbidity and mortality
Mechanism :  bacterial phagocytosis and antiapoptotic effect of insulin

52. Matur Nuwun