Klasifikasi hipertensi pada kehamilan : Gestational hypertension Hypertension chronic in pregnancy Preeclampsia Superimposed preeclampsia

Gestational hypertension Normotensi hamil hipertensi partus - normotensi Hypertension chronic in pregnancy Hipertensi hamil hipertensi partus hipertensi Preeclampsia Normotensi n- hamil hipertensi proteniuri partus normotensi Superimposed preeclampsia Hipertensi hamil hipertensi- proteinuri partus hipertensi

CHRONI C KIDNEY DISEASE

Definition of Chronic Kidney Disease

Criteria
1. Kidney damage for 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either : Pathological abnormalities, or Markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests 2. GFR < 60 mL/min/1.73 m2 for 3 months, with or without kidney damage
Am J Kidney Dis 2002 ; 39 (suppl 1) : S18.

The Relationship of Blood Urea Nitrogen (BUN) or Serum Creatinine Concentration to Glomerular Filtration Rate.

oken lines indicate that there is a family of curves rather than a single one for all p

Prevalence of GFR Catagory

Stage Description
At increased risk

GFR
(mL/min/1.73m2)

PREVALENCE
(%)

90 (with CKD risk factors) 90 60-89 30-59 15-29 < 15 (or dialysis) 3.3 3.0 4.3 0.2 0.1

1 2 3 4 5

Kidney damage with normal or

GFR GFR

Kidney damage with mild Moderate Severe

GFR

GFR

Kidney failure

NHANES III 1988-1994, U.S. Adults

Methods of Glomerular Filtration Rate (GFR) Measurement

Inulin Clearance Alternative Filtration Markers
125

I-Iothalamate,

51

Cr-EDTA,

99m

Tc-DTPA and

non-radioactive iohexol Plasma Creatinine Creatinine Clearance Predictive Creatinine Clearance (the Cockroft-Gault Formula)

Creatinine Clearance

Ccr =

Ucr x V Pcr

Pcr = Plasma concentration of creatinine Ucr = Urine concentration of creatinine V = Urine flow rate

V:

24 hr collection Over night collection Time collection

Cockcroft Gault Formula

Estimated creatinine clearence (Ccr) with respect age, gender and body weight

Men
Ccr =

(140-age)(weight) 72 Pcr (mg/dl)

1.23 (140-age)(weight) or Ccr = Pcr (mol/L)

Women
Ccr = (140-age)(weight) 85 Pcr (mg/dl) 1.04 (140-age)(weight) or Ccr = Pcr (mol/L)

Age years Weight Kg Pcr plasma creatinine The formula estimates Ccr in obese patients and those on a low protein diet

EXAMPLES
Patient 1 : In a 68 years old dibetic female weighing 50 kg with a plasma creatinine level of 5.0 mg/dl the creatinine clearance would be: (140-68) x 50 x 0.85 -------------------------- = 8.5 ml/minute 72 x 5.0 This woman is ready to start maintenance dialysis Patient 2 : A 30 year old 70 kg male with with a plasma creatinine value of 5.0 mg/dl has, by the formula, a creatinine clearance of 21 ml/minute and does not yet require dialysis therapy

Evaluation and Treatment

Patients with chronic kidney disease should be evaluated to determine :
Diagnosis (type of kidney disease) Comorbid conditions Severity, assessed by level of kidney function Complications, related to level of kidney functions Risk for loss of kidney function Risk for cardiovascular disease

Am J Kidney Dis 2002 ; 39 (suppl 1) : S2

Evaluation and Treatment

Treatment of chronic kidney disease should include :
Spesific therapy, based on diagnosis Evaluation and management of co-morbid conditions Slowing the loss of kidney function Prevention and treatment of cardiovascular disease Prevention and treatment of complications of decreased kidney function Preparation for kidney failure and kidney replacement therapy Replacement of kidney function by dialysis and transplantation, if sign and symptoms of uremia are present

Am J Kidney Dis 2002 ; 39 (suppl 1) : S24

Individuals at increased risk for CKD should be tested at the time of a health evaluations to determine if they have CKD.
Diabetes Hypertension Autoimmune diseases Systemic infections Exposure to drugs or procedures associated with acute decline in kidney function Recovery from acute kidney failure Age > 60 years Family history of kidney disease Reduced kidney mass (includes kidney donors and transplant recipients)

Measurements should included :

Serum creatinine for estimation of GFR Assessment of proteinuria Urinary sediment of urine dipstick for red blood cells and white blood cells

Progression of renal disease :

A irreversible decline in GFR because of structural damage to the renal vasculature, tubules or interstitium.

Definitions of Progression, Remission, and Regression of Proteinuric Chronic Nephropathy

Variable
Proteinuria

Progression
1g/24 h

Remission
< 1g/ 24 h

Regression
< 0.3g / 24 h

Glomerular filtration rate

Declining Worsering

Stable

Increasing

Renal structural changes

Stable

Improving

Ruggenenti P, et al. Lancet 2001 ; 357 : 1602

Pivotal role of glomerular hypertension in the initiation and progression of structural injury
Systemic Hypertension Primary Renal Disease Renal Ablation Aging Diabetes Mellitus Dietary Factor

GLOMERULAR HYPERTENSION

ENDOTHELIAL INJURY
Release of vasoactive factors Vascular lipid deposition Intracapillary throbosis

MESANGIAL INJURY
Accumulation of macromolecules Matrix production Cell proliteration

EPITHELIAL INJURY Proteinuria

Permeability to water

GLOMERULAR SCLEROSIS
Brenner B M

THE MECHANISM OF PROGRESSION OF CHRONIC KIDNEY DISEASE

1. HYPERTENSION 2. PROTEINURIA 3. ANGIOTENSIN-II 4. HYPERGLYCEMIA. 5. PROTEIN INTAKE 6. SODIUM INTAKE 7. WATER INTAKE 8. HYPERLIPIDEMIA 9. SMOKING 10. NSAID 11. ANEMIA 12. HYPERINSULINEMIA 13. HOMOCYSTEINEMIA 14. HYPERPHOSPHATEMIA 15. POTASSIUM DEPLETION 16. HYPERCOAGULATION 17. GENDER = LEVEL 1 = LEVEL 2 = LEVEL 3

Hebert LA, et al : Kidney Int 2001; 59 : 80

Aims of Dietary protein restriction :

To slow the progression of kidney disease
Minimize accumulation of uremic toxins Preserve protein nutritional status (GFR mL/min) :
>50 25 50 <25 : No restriction recommended : 0.6 to 0.75 g/kgBW : 0.6 g/kgBW : 0.8 g of protein add 1 g of protein/g of proteinuria HD : 1.2 g/kgBW

Nephrotic patients

ADEQUACY OF HD (1)
Outcome for patients on HD is also related to the dosage of dialysis received. Adequate HD is a dialysis regimen, consistently delivered, that maximizes well-being for an individual patient. Urea clearance is the basis for all measurements of dialysis dose in current usage. Three methods for the calculation of urea removal: Formal Urea Kinetic Modeling (UKM) The Calculation of Kt/V from urea reduction The Urea Reduction Ratio

ADEQUACY OF HD (2)
DOQI recommends that Kt/V > 1.3 These recommendations are based on thrice weekly dialysis; twice weekly dialysis cannot be adequate unless there is substantial residual renal function (glomerular filtration rate 5 10 ml/min). A URR > 65% is equivalent to Kt/V > 1.2 DOQI recommends a target of 70% (equivalent to Kt/V of 1.3)

Goals for renoprotection approach in CKD patient (1)

BP control <130/80 mm Hg Many patients will need two or more antihypertensive drugs Reduction of proteinuria <0.5 g/day or ratio of protein to creatinine on spot urine collection <200mg/g Considered a BP-independent goal Dual blockade with ACE inhibitors and ARBs may exert an additional benefit HbA1C <7% in diabetics Smoking cessation Lipid-lowering therapy Total cholesterol <175mg/dl and LDL cholesterol <100mg/dl Anti-platelet therapy Control of calcium-phosphorus product <55 mg/dl Control of anemia >12 g/dl

Goals for renoprotection approach in CKD patient (2) Antihypertensive therapy First step, ACE inhibitor or ARB Second step, diuretic In stage 3, loop diuretic Third step, CCB or BB Fourth step, BB or CCB if not used before. Consider other alternatives such as alpha blocker or centrally acting drugs.

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