Chronic Kidney Disease

Rensa, MDRensa, MDDepartement of Internal MedicineDepartement of Internal Medicine

Udayana University / Sanglah HospitalUdayana University / Sanglah Hospital

Physiological ReviewPhysiological Review

FUNGSI GINJALFUNGSI GINJAL

Fungsi utama ginjal adalah :Fungsi utama ginjal adalah :

mempertahankan keseimbangan internal (mempertahankan keseimbangan internal (mmilieu ilieu

interiourinteriour))

Yg dipertahankan adalah :Yg dipertahankan adalah :

- keseimbangan - keseimbangan airair

- keseimbangan - keseimbangan elektrolitelektrolit organ ekskresi organ ekskresi

- keseimbangan - keseimbangan asam-basaasam-basa

- keseimbangan - keseimbangan metabolismemetabolisme ----- mensekresikan ----- mensekresikan

hormon hormon

MEKANISME FUNGSI GINJALMEKANISME FUNGSI GINJAL

Fungsi ginjal dilaksanakan melalui mekanisme :Fungsi ginjal dilaksanakan melalui mekanisme :

1. 1. filtrasifiltrasi (penyaringan)(penyaringan)

2. 2. reabsorbsireabsorbsi (penyerapan kembali)(penyerapan kembali)

3. 3. sekresisekresi (produksi bahan tertentu)(produksi bahan tertentu)

4. 4. ekskresiekskresi (mengeluarkan bahan tertentu)(mengeluarkan bahan tertentu)

HORMON-HORMON YG DIHASILKAN GINJALHORMON-HORMON YG DIHASILKAN GINJAL

1.1. ErythropoitinErythropoitin

- - berfungsi utk ”membentuk ” darahberfungsi utk ”membentuk ” darah

2. 2. ReninRenin

- - berfungsi untuk mengatur tekanan darahberfungsi untuk mengatur tekanan darah

3. 3. CalcitriolCalcitriol

- - berfungsi utk metabolisme mineral (calsium & fosfat)berfungsi utk metabolisme mineral (calsium & fosfat)

4. 4. ProstaglandinProstaglandin

- - ikut berfungsi mengatur tekanan darahikut berfungsi mengatur tekanan darah

EVALUASI FUNGSI GINJALEVALUASI FUNGSI GINJAL

• yang bisa dievaluasi hanyalah yang bisa dievaluasi hanyalah fungsi fungsi

filtrasinya sajafiltrasinya saja

• dengan mengukur Laju Filtrasi Glomerulus dengan mengukur Laju Filtrasi Glomerulus

(LFG)(LFG)

Laju Filtrasi GlomerulusLaju Filtrasi Glomerulus adalah : adalah :

Jumlah darah yang dpt difiltrasi oleh ginjal Jumlah darah yang dpt difiltrasi oleh ginjal

dalam waktu satu menitdalam waktu satu menit

• pada orang yang luas peermukaan tubuhnya pada orang yang luas peermukaan tubuhnya

1,73 m2 (satuannya: ml/menit/1,73m2)1,73 m2 (satuannya: ml/menit/1,73m2)

• pengukuran dilakukan secara pengukuran dilakukan secara tidak langsungtidak langsung

(mempergunakann rumus)(mempergunakann rumus)

NILAI NORMALNILAI NORMAL

Tergantung pada :Tergantung pada :

• jenis kelaminjenis kelamin

• umurumur

• berat badan/luas pemukaan tubuhberat badan/luas pemukaan tubuh

UmurUmur LakiLaki PerempuanPerempuan

20 th20 th 117 – 170 117 – 170 104 – 158104 – 158

50 th50 th 96 – 13896 – 138 90 – 13090 – 130

70 th70 th 70 – 11070 – 110 70 – 114 70 – 114

HamilHamil 20% lbh banyak20% lbh banyak

Berkurang Berkurang 1% setiap tahun, di atas umur 30 th 1% setiap tahun, di atas umur 30 th

Teknik evaluasi fungsi ginjalTeknik evaluasi fungsi ginjal

• LFG dievaluasi secara tidak langsung dengan LFG dievaluasi secara tidak langsung dengan

mengukur mengukur clearanceclearance (bersihan) (bersihan) bahan tertentubahan tertentu

• ClearanceClearance adalah: jumlah ’bahan tertentu” yang adalah: jumlah ’bahan tertentu” yang

dapat difiltrasi oleh ginjal dalam satu satuan dapat difiltrasi oleh ginjal dalam satu satuan

waktu (ml/mnt)waktu (ml/mnt)

• ””Bahan tertentu” yg dipakai adalah :Bahan tertentu” yg dipakai adalah :

• bahan radioaktifbahan radioaktif

• inulininulin

• kreatininkreatinin

Yang paling baik adalah Yang paling baik adalah inulininulin, tapi yang paling , tapi yang paling

mudah dan praktis adalah kreatinin, sehingga mudah dan praktis adalah kreatinin, sehingga

LFG diukur dengan LFG diukur dengan Test Klirens KreatininTest Klirens Kreatinin

(Cliearance Creatinin Test =CCT)(Cliearance Creatinin Test =CCT)

Jadi : CCT Jadi : CCT LFG LFG

Mengevaluasi CCT dilakukan dengan :Mengevaluasi CCT dilakukan dengan :1. Mengukur :1. Mengukur : Dengan jalan mengukur; kadar kreatinin urin (U), Dengan jalan mengukur; kadar kreatinin urin (U), volume urine /menit (V) dan kadar kreatinin plasma (P) volume urine /menit (V) dan kadar kreatinin plasma (P) Kemudian dimasukkan dalam Kemudian dimasukkan dalam rumus rumus Van SlykeVan Slyke

U X VU X VCCT = -------------------- ml/mntCCT = -------------------- ml/mnt

PP

2. Menghitung :2. Menghitung : Dengan mengukur, kreatinin plasma (P), berat badan (BB), umur (U)Dengan mengukur, kreatinin plasma (P), berat badan (BB), umur (U) Kemudian dimasukkan dalam Kemudian dimasukkan dalam rumus rumus Cockroft - GaultCockroft - Gault

(140 – U ) X BB(140 – U ) X BBCCT = -------------------------- ml/mntCCT = -------------------------- ml/mnt

72 X P72 X P

Catatan : pada Catatan : pada :: X 85% X 85%

Derajat fungsi ginjal disesuaikan dengan CCT

DerajaDeraja

t t

Kelainan struktur dlm Kelainan struktur dlm

3 bl (ada/tidak) 3 bl (ada/tidak)

CCTCCT

11 adaada 90 ml/mnt90 ml/mnt

22 ada/tidakada/tidak 60 - 89 60 - 89

ml/mntml/mnt

33 ada/tidakada/tidak 30 – 59 ml/mnt30 – 59 ml/mnt

44 ada/tidakada/tidak 15 – 29 ml/mnt15 – 29 ml/mnt

55 ada/tidakada/tidak < 15 ml/mnt< 15 ml/mnt

Gejala gangguan fungsi ginjal :Gejala gangguan fungsi ginjal :

1. Anemia1. Anemia

2. 2. HipertensiHipertensi

3. Edema3. Edema

4. 4. Peningkatan kadar ureum&kreatinin Peningkatan kadar ureum&kreatinin

plasmaplasma

5. Asidosis5. Asidosis

CKD is a group of kidney disease with CKD is a group of kidney disease with

specification :specification :

• ChronicChronic : more than : more than 3 months3 months

• ProgressiveProgressive : become worst time to time : become worst time to time

• PersistentPersistent : can not completely remission : can not completely remission

Definition

DefinisiDefinisi

Pe Pe faal / struktur ginjal yang faal / struktur ginjal yang

lebih dari 3 bln yang bersifat lebih dari 3 bln yang bersifat menetap dan progresifmenetap dan progresif

Criteria :Criteria :1.1. Kidney damage for Kidney damage for 3 month 3 month

• structural and functional abnormalitystructural and functional abnormality

• with or without decreased Glomerular Filration with or without decreased Glomerular Filration

Rate (GFR)Rate (GFR)

• manifest by either abnormality of :manifest by either abnormality of :

• pathologypathology

• blood compositionblood composition

• urine compositionurine composition

• imaging trestimaging trest

2.2. GFR < 60 ml/min for 3 month, with or without kidney GFR < 60 ml/min for 3 month, with or without kidney

damagedamage

Explanation :Explanation :

• Structural abnormality e.g. single kidney, Structural abnormality e.g. single kidney,

kidney/ureter stone, cystic kidney, kidney/ureter stone, cystic kidney,

Prostate hypertrophy, etcProstate hypertrophy, etc

• GFR : calculated by Cockroft-Gault FormulaGFR : calculated by Cockroft-Gault Formula

• Blood composition e.g. ureum, creatininBlood composition e.g. ureum, creatinin

• Urine composition e.g. proteinuria, haematuraUrine composition e.g. proteinuria, haematura

• Imaging e.g. BNO (plain photo abdomen), USG etcImaging e.g. BNO (plain photo abdomen), USG etc

Termasuk kelainan struktur ginjal antara lain :Termasuk kelainan struktur ginjal antara lain :

• Kelainan makroskopik / mikroskopik urinKelainan makroskopik / mikroskopik urin

• Kelainan anatomis traktus urinariusKelainan anatomis traktus urinarius

• Kelainan ukuran atau jumlah ginjalKelainan ukuran atau jumlah ginjal

• HidronefrosisHidronefrosis

• Batu traktus urinariusBatu traktus urinarius

Kidney disease Kidney disease 3 month : 3 month :

GFR (Cockroft Gault)GFR (Cockroft Gault)

60 ml/mnt/1.73 m260 ml/mnt/1.73 m2

Kidney damage (+)Kidney damage (+)- CKD- CKD

Kidney damage (-)Kidney damage (-) - normal- normal

< 60 ml/mnt/1.73 m2< 60 ml/mnt/1.73 m2- CKD- CKD

ETIOLOGY OF CKDETIOLOGY OF CKDEtiology of CKD are :Etiology of CKD are :

1.1. Diabetes MellitusDiabetes Mellitus

2.2. Chronic GlomerulonephritisChronic Glomerulonephritis

3.3. Chronic PyelonephritisChronic Pyelonephritis

4.4. HypertensionHypertension

5.5. Urinary tract stoneUrinary tract stone

6.6. Obstruction (tumor, prostate)Obstruction (tumor, prostate)

7.7. Immunological disease (SLE)Immunological disease (SLE)

8.8. Congenital (polycystic kidney)Congenital (polycystic kidney)

9.9. MalignancyMalignancy

10.10. Others :Others :

• pregnancypregnancy

• chronic liver diseasechronic liver disease

Etiology of CKD:Etiology of CKD:(another version)(another version)

Diabetes MellitusDiabetes Mellitus Non-Diabetes Mellitus:Non-Diabetes Mellitus:

Glomerular (e.g. Autoimmune dis, neoplasia)Glomerular (e.g. Autoimmune dis, neoplasia) Vascular (e.g.Hypertension)Vascular (e.g.Hypertension) Tubulo-intersititial ( UTI, Renal stone, drugs)Tubulo-intersititial ( UTI, Renal stone, drugs) CysticCystic Transplantation (e.g.chronic host-rejection) Transplantation (e.g.chronic host-rejection)

AnamnesisAnamnesis Urine volumeUrine volume Frequency of micturition Frequency of micturition Urine appearance and colour Urine appearance and colour

Pain: Pain: in loins, back, abdomen, suprapubic area? in loins, back, abdomen, suprapubic area? Constant or intermittent? Constant or intermittent? Related to micturition? Related to micturition?

Nonspecific symptoms, including:Nonspecific symptoms, including: FatigueFatigue Nausea-vomitingNausea-vomiting Weight lossWeight loss PallorPallor OedemaOedema Dyspneu on effort (associated with heart failure)Dyspneu on effort (associated with heart failure)

Physical ExaminationPhysical Examination

HypertensionHypertension Anemia Anemia EdemaEdema Sign of complications e.g. heart hypertrophy,Sign of complications e.g. heart hypertrophy,

AscitesAscites

1. 1. Gejala NeurologikGejala Neurologik

- lelah- lelah

- sakit kepala- sakit kepala

- kejang – kejang- kejang – kejang

- neuropati perifer- neuropati perifer

2. 2. Gastro intestinalGastro intestinal

- mual, muntah, diare- mual, muntah, diare

- singultus, stomatitis- singultus, stomatitis

3. 3. Kulit keringKulit kering

- Pruritus- Pruritus

Akibat menumpuknya Akibat menumpuknya

toksin uremik, berupa toksin uremik, berupa

: fosfat, ion hidrogen, : fosfat, ion hidrogen,

urea dan kreatinin, urea dan kreatinin,

phenol, indol, phenol, indol,

guanidin, hormon guanidin, hormon

paratiroid, oksalat, paratiroid, oksalat,

homosistein. homosistein.

Patophysiology of hypertension in CKDPatophysiology of hypertension in CKD

1.1. -Sodium retention-Sodium retention

- fail of the kidney for excreted water and sodium- fail of the kidney for excreted water and sodium

2. Acceleration of Renin Angiotensin System2. Acceleration of Renin Angiotensin System

- increased secretion of renin- increased secretion of renin

Angiotensinogen Angiotensinogen ((produced by liver)produced by liver)

Renin(produced by kidney

Angiotensin I

Angiotensin Converting Enzyme

(ACE)

Renin Angiotensin Aldosterone System

Suprarenal cortexSuprarenal cortex

Aldosteron

Angiotensin II

Ischemic Kidney

PATHOPHYSIOLOGY OF ANEMIA IN CKD

1. Erythropoitin insufficiency

- decreased of erythropoitin secreted by the kidney

2. Iron deficiency

- chronic bleeding

- low intake

3. Others

- haemolysis / decreased of erythrocyte live spend

- depressed of bone marrow by uraemic substances

Patients with chronic kidney disease should be

evaluated to determine:

1. Diagnosis (type of kidney disease)

2. Comorbid conditions;

3. Severity; assessed by level of kidney function;

4. Complications, related to level of kidney function;

5. Risk for loss of kidney function;

6. Risk for cardiovascular disease

COMPLICATION OF CKDCOMPLICATION OF CKD

1. Cardiac diseases1. Cardiac diseases

- coronary artery disease- coronary artery disease

- congestive hearth disease- congestive hearth disease

- acute left hearth failure- acute left hearth failure

2. Metabolic acidosis2. Metabolic acidosis

3.3. Electrolyte imbalanceElectrolyte imbalance

- hyper / hypokalemia- hyper / hypokalemia

- hyper / hyponatremia- hyper / hyponatremia

4. Renal osteodystrophy (renal bone disease)4. Renal osteodystrophy (renal bone disease)

IMPORTANT !!IMPORTANT !!

Treatment for chronic kidney disease should include:

1. Specific therapy, based on diagnosis

2. Evaluation and management of comorbid conditions;

3. Slowing the loss of kidney function

4. Prevention and treatment of cardiovascular disease;

5. Prevention and treatment of complications of decreased kidney function

6. Preparation for kidney failure and kidney replacement therapy;

7. Replacement of kidney function by dialysis and transplantation, if signs and symptoms of uremia are present

StageStage DescriptionDescription GFR GFR

(mL/min/1.73 m2)(mL/min/1.73 m2)

Actions*Actions*

II Kidney damage with Kidney damage with

normal or normal or GFR GFR

9090 Diagnosis and treatment. Treatment of Diagnosis and treatment. Treatment of

comorbid conditions, Slowing comorbid conditions, Slowing

progression, CVD risk reductionprogression, CVD risk reduction

IIII Kidney damage with mild Kidney damage with mild

GFRGFR

60-8960-89 Estimating progressionEstimating progression

IIIIII Moderate Moderate GFR GFR 30-5930-59 Evaluating and treating complicationsEvaluating and treating complications

IVIV Severe Severe GFR GFR 15-2915-29 Preparation for kidney replacement Preparation for kidney replacement

therapytherapy

VV Kidney failure Kidney failure < 15 or dialysis< 15 or dialysis Replacement (if uremia present)Replacement (if uremia present)

STAGES OF CKD: A CLINICAL ACTION PLAN

Chronic Kidney Disease is defined as either kidney damage or GFR < 60 mL/min/1.73 m 2 for 3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies

* Includes actions from proceeding stages

Konservatif

Dialisis

Aktif

Transplantasi

Konservatif

Dialisis

Aktif

Transplantasi

11. Menghilangkan faktor-faktor yang reversibel . Menghilangkan faktor-faktor yang reversibel

2. Mengendalikan faktor-faktor yang ireversibel2. Mengendalikan faktor-faktor yang ireversibel

3. Nutrisi dan keseimbangan cairan3. Nutrisi dan keseimbangan cairan

4. Mengatasi komplikasi4. Mengatasi komplikasi

5. Mencegah pemberian obat nefrotoksik5. Mencegah pemberian obat nefrotoksik

6. Mengatasi keluhan6. Mengatasi keluhan

diet : kalori 35-40 kkal/kg bb/hari

protein 0,8 – 1 gr/kg bb/hari

air : masuk = 500 cc + produksi urin/24 jam

Elektrolit : - rendah garam

- rendah kalium (buah-buahan)

RESUME TERAPI NUTRISI PADA PENDERITA GGK PREDIALISIS

Kalori • Jumlah : 30-35 kcal/kg bb/hari• Jenis : 20-25% dalam bentuk lipid

Protein • Jumlah : 0.8-1.0 g/kg bb/hari• Jenis : Kombinasi asam amino esensial (AAE) dan

asam amino non esensial (AANE)

Karbohidrat:• Jumlah : melengkapi kebutuhan kalori

- rata-rata 6-8 g / kg bb / hari

Elektrolit : Natrium 70 meq/L

Kalium : dibatasi

Fosfat 500 - 600 mg/hari

Resume of Nutritional Requirement of Dialytic PatientsResume of Nutritional Requirement of Dialytic Patients

Protein 1-1.4 g/kg/day

Energy 35 kcal/kg/day

Water 600-700 cc + urine output during previous 25 hours

Sodium 65-100 mEq/day

Potassium 40-70 mEq/day

Calcium 1000 mg/day

Phosphorus 800-1000 mg/day

Iron 600 mg/day as ferrous sulphate

Vitamins Water-soluble vitamins which are lost during dialysis