Disease
Fungsi Ginjal
Description
GFR (mL/min/1.73
m2)
90
60-89
Moderate GFR
30-59
Severe GFR
15-29
Kidney failure
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.
Pathophysiology(1)
Glomerulosclerosis
prolonged increased glomerular capillary
pressure leads to continuous cycle of nephron
destruction
Pathophysiology(2)
Cockcroft-Gault
Formula
to estimating GFR
Where
Where k=0.4,
k=0.4, Ht
Ht in
in cm
cm and
and SScrcr in
in mg/dL
mg/dL and
and
measured
measured by
by enzymatic
enzymatic methodology
methodology
Proteinuria
Etiology
Male gender
Proteinuria
Black Race
Dyslipidemia
Genotype
Hyperuricemia
Hypertension
Smoking
.Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race
USRDS ADR, 2007
CLINICAL PRESENTATION
Poor growth.
Clinical features
Symptoms
Fatigue
Dyspnoea
Pleuritic pain
Ankle Swelling
Restless legs
Nausea, anorexiavomiting
Diarrhoea
Pruritus
Reduced concentration
Bone pain
Impotence/ infertility
Menorrhagia
Signs
Pallor
^ BP
Cardiomegaly
Pleural effussion
Pericarditis
Retinopathy
Prox myopathy
Periph neuropathy
Late: Aryythmias,
encephalopathy, seizures,
coma
Uremic state
anorexia
nausea,
vomiting
growth retardation
platelate dysfunction
pericardial disease
peripheral neuropathy
central nervous system
abnormalities ranging from loss of
concentration and lethargy to
seizures, coma and death.
COMPLICATIONS OF CKD
Renal Osteodystrophy
Anemia
Hypertension
Dyslipidemia
Endocrine abnormalities
Growth impairment
Metabolic acidosis
CKD 3 :
Ammonium excretion begins to fall.
Reduction in titratable acid excretion
(primarily as phosphate).
Decreased bicarbonate reabsorption.
Body utilizes bone to buffer the excess
hydrogen ions.
Renal Osteodystrophy:
Anemia
Consequences of Anemia in
CKD
Reduced oxygen delivery to tissues
Decrease in Hgb compensated by increased
cardiac output
Progressive cardiac damage and progressive renal
damage1
Increased mortality risk2
Reduced quality of life (QOL)3
Fatigue
Diminished exercise capacity
Reduced cognitive function
Left ventricular hypertrophy (LVH)4
Silverberg et al. Blood Purif. 2003;21:124-130. 2. Collins et al. Semin Nephrol. 2000;20:345-. 1
349; 3. The US Recombinant Human Erythropoietin Study Group. Am J Kidney Dis. 1991;18:50.59; 4. Levin. Semin Dial. 2003;16:101-105
The Johns Hopkins University School of 2005
Hypertension
Volume expansion
Activation of the renin-angiotensin
system.
May be due to medications used to treat
the underlying renal disease.
can be present in the earliest stages of
CKD and its prevalence increases with
progressive declines in GFR..
Endocrine Dysfunction:
Gonadal hormones
Delayed puberty ( average delay 2.5 years)
In males, reduced levels of free testosterone,
dihydrotestosterone, adrenal androgens, and increases LH & FSH
Postpubertal females low estrogen, elevated LH and FSH, and
loss of the LH pulsatile pattern. These disturbances result in
anovulation
Neurodevelopment
Treatment of CKD
Patients in stage 1 to 4
Reduce risk factors for progression
(hypertension, diabetes)
Provide interventions that delay progression
Hyperkalemia:
Metabolic acidosis:
guidelines by the K/DOQI working group are to maintain the serum
bicarbonate level at or above 22 mEq/L
Sodium bicarbonate is started at 1-2 meq/kg/d
Renal osteodystrophy :
Low phosphate diet.
Administration of phosphate binders.
Vitamine D replacement therapy
Hypertension:
The K/DOQI guidelines recommend a target blood pressure of less
than 90th percentile for age, gender, and height, or less than
120/80 mmHg, whichever is lower.
Non pharmacologic therapy
Pharmacological therapy: diuretics, ACE inhibirors, ARBs
Management Anemia
Treatment of anemia
K/DOQI guidelines recommend a target Hb between 11 and 12
g/dL, FDA recommend a Hb of 10-12
Iron therapy: targeted to maintain a TSAT 20 percent and serum
ferritin 100 ng/dL
Iron status should be monitored every 1-3 mon.
Erythropoiesis stimulating agent
initial EPO dose in older children not receiving dialysis is 80 to 120
u/kg per week
RENAL REPLACEMENT
THERAPY
CKD - RRT
Indications (Absolute):
Indications (Relative):
CKD - RRT
Transplantation:
Preemptive transplant carries both patient and
graft survival advantage.
Graft survival better with living donor kidneys.
Immunosuppresion is almost always a must.
Hemodialysis System
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