8/7/2018 1 CKD in Indonesia and Its Management Mohammad Yogiantoro Data presented only for those countries from which relevant information was available; “.” signifies data not reported. All rates are unadjusted. Israel, Japan, and Taiwan are dialysis only. Percent change from 2004-2005 is not reported for countries whose reporting methods changed during this period. USRDS Annual Report 2008 and 2009 CKD is Growing Globally at 8% Annually and Dialysis Patient Population Doubled Since 2000 CKD Growth Drivers • Aging population • No. 1 cause of CKD is diabetes (40%–50%) • No. 2 cause of CKD is hypertension (20%–30%) Stage 5 Country Data Asia Pacific - Global prevalence of CKD : 11-13% (majority stage III) - RRT : HD, CAPD, renal transplantation - Incidence rate ESRD per million in Indonesia (2002- 2006), increasing from 10.2 to 23.4 - 117,162 new case ESRD in USA (2013), incidence rate : 363 per million/year • Most Px CKD asymptomatic, until developed ESRD • Early detection reduce incidence (morbidity, mortality, cost) • Etiology CKD in Indonesia : – Glomerulonephritis (39.87%) – Diabetic nephropathy (17.54%) – Hypertension (15.72%) – Obstructive & infective (13.44%) – Unknown (10.93%) – Polycystic kidney disease (2.51%)
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8/7/2018
1
CKD in Indonesia and Its Management
Mohammad Yogiantoro
Data presented only for those countries from which relevant information was available; “.” signifies data not reported. All rates are unadjusted. Israel, Japan, and Taiwan are dialysis only. Percent change from 2004-2005 is not reported for countries whose reporting methods changed during this period.
USRDS Annual Report 2008 and 2009
CKD is Growing Globally at 8% Annually and Dialysis Patient Population Doubled Since 2000
CKD Growth Drivers
• Aging population
• No. 1 cause of CKD is diabetes (40%–50%)
• No. 2 cause of CKD is hypertension (20%–30%)
Stage 5 Country Data
Asia Pacific
- Global prevalence of CKD : 11-13% (majority stage III)- RRT : HD, CAPD, renal transplantation- Incidence rate ESRD per million in Indonesia (2002-
2006), increasing from 10.2 to 23.4- 117,162 new case ESRD in USA (2013), incidence rate :
363 per million/year
• Most Px CKD asymptomatic, until developed ESRD
• Early detection reduce incidence (morbidity, mortality, cost)
• Etiology CKD in Indonesia :– Glomerulonephritis (39.87%)
– Diabetic nephropathy (17.54%)
– Hypertension (15.72%)
– Obstructive & infective (13.44%)
– Unknown (10.93%)
– Polycystic kidney disease (2.51%)
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Distribution of dialysis centers and seven geographic areas studied
• CKD growing rapidly, progression to ESRD
• 13 nephrology centers (questionnaire)
• Previous data prevalence ESRD increased
• CAPD as alternative RRT
• High cost
• Covered by government health insurance
• Management approach should shifted from treatment to prevention
Results: Of 9412 subjects recruited, 64.1% were female. Persistent
proteinuria was found in almost 3%. Systolic and diastolic hypertension was
found in 10%, isolated systolic hypertension in 4.8% and isolated diastolic
hypertension in 4.6%. CKD was found in 12.5% (CG), 8.6% (MDRD) or
7.5% (Chinese MDRD) of subjects with either hypertension, proteinuria
and/or diabetes.
Proteinuria, systolic blood pressure and a history of diabetes mellitus
were independent predictors of impaired eGFR.
Obesity and smoking history were found in 32.5% and 19.8%,
respectively.
Conclusion: The present study showed a high prevalence of CKD in
representative urban and semi-urban areas and argues for screening
and treatment of all Indonesians, particularly those at an increased risk of
CKD
PAGE 12 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 12 |
Dialysis in Indonesia
Belum ada data menyeluruh
Indonesian Renal Registry (2015) PERNEFRI & DEPKES
Reporting rate : ~ 40%
Hemodialysis, Peritoneal, CRRD, Hybrid
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PAGE 13 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 13 |
Dialysis in Indonesia (IRR 2015)
89%
7%
4%Cause
Chronic Kidney Disease
Acute Kidney Failure
Acute on ChronicPAGE 14 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 14 |
Dialysis in Indonesia (IRR 2015)
Hypertension, 44%
Diabetes, 22%
Unknown, 3%
Other, 9%
Chronic Pyelonephritis,
7%
Secondary Nephropathy, 7%
Primary GN, 8% Etiology
PAGE 15 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 15 |
Dialysis in Indonesia (IRR 2015)
76%
13%
3% 3% 4% 1%0%
10%
20%
30%
40%
50%
60%
70%
80%
Vascular Access Type
Vascular Access Type
Av Shunt Femoral Other
D/T Jugular D/T Subclavia2 D/T Femoral2
PAGE 16 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 16 |
Dialysis in Indonesia (IRR 2015)
< 3 mo27%
3 - 6 mo18%
6 - 12 mo33%
12 - 36 mo14%
> 36 mo8%
TIME FROM DIALYSIS TO DEATH (MONTHS) IN 2015
Cause of Death
Cardiovascular 44%
Cerebrovascular 8%
GI Bleeding 3%
Septicemia 16%
other 29%
Majority Death : < 12 months; COD : Cardiovascular, Sepsis
PAGE 17 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 17 |
Jaminan Kesehatan Nasional (JKN)
1 Januari 2014 - now
Kepesertaan
1 Dec 2017: ~ 186 Juta (± 74%)
Pengeluaran Penyakit Kronis -> Tinggi 2016 : 21% Budget (~ USD 1.05 Billion)
PAGE 18 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 18 |
Jaminan Kesehatan Nasional (JKN)
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PAGE 19 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 19 |
Jaminan Kesehatan Nasional (JKN)
PAGE 20 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 20 |
Pembiayaan Pasien HD (IRR 2015)
National Health Insurance
86%
Private/Company3%
Out of Pocket10%
Other1%
Dialysis Cost Source
National Health Insurance Private/Company Out of Pocket Other
PAGE 21 | Present situation of Dialysis in Indonesia
PAGE 22 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
CKD : ~ 0,3%
Dialysis : ~78.000 (28 HD Unit)
Total 58 HD Unit
PAGE 22 |
Dialysis (Jawa Timur)
Populasi (2015) : 42 Juta Jiwa
PAGE 23 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 23 |
Dialysis (Jawa Timur)
Peningkatan pasien Meningkat 25 – 30% Sejak JKN Akses Fakses Naik -> Deteksi lebih awal
Keterbatasan Unit Mesin HD : ~ 540 Units ( ~ 11% Nasional) SDM Khusus Mayoritas pada rumah sakit
Demand vs. Supply Discrepancy
• CKD growing rapidly, progression to ESRD
• 13 nephrology centers (questionnaire)
• Previous data prevalence ESRD increased
• CAPD as alternative RRT
• High cost
• Covered by government health insurance
• Management approach should shifted from treatment to prevention
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difference
100
10
0
No Treatment
Current Treatment
Early Treatment
4 7 9 11
Time (years)
Kidney Failure
GFR
(m
L/m
in/1
.732
)
130/80 mmHg
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Treat the BP to Target Division of Nephrology and Hypertension - Departement of Internal MedicineSchool of Medicine Airlangga University - Dr. Soetomo Teaching Hospital
NEPHROLOGY AT A GLANCE
Filtration, Reabsorption and Secretion
Normal GFR 120 ml/min/1.73m2
Only 20% nephrons work at a time
In a day 210 L of water is filtered
2 L /day of urine is excreted
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How the Proteinuria Induces Renal
Damage ?
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Urinary ExcretionProteinLipidsComplements
Glomerular Disease
DILTIAZEM
Microalb/Proteinuriais early marker of kidney damage
Systemicbloodpressure Urinary space
of Bowman’scapsule
Tubulus
Albumin excretion increased by :* Systemic or glomerular hypertension* Reduced negative charge repulsion
on basement membrane* Enlarge filtration pores
Fenestrated capillaryendotheliumBasement membraneEphitelial cellfoot process
Filtration of Albumin into urinary spaceDILTIAZEM
DILTIAZEM
Microalbuminuria: A Manifestation of Diffuse Endothelial Cell Injury
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Microalbuminuria
Injured Endothelium
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Data presented only for those countries from which relevant information was available; “.” signifies data not reported. All rates are unadjusted. Israel, Japan, and Taiwan are dialysis only. Percent change from 2004-2005 is not reported for countries whose reporting methods changed during this period.
USRDS Annual Report 2008 and 2009
CKD is Growing Globally at 8% Annually and Dialysis Patient Population Doubled Since 2000
CKD Growth Drivers
• Aging population
• No. 1 cause of CKD is diabetes (40%–50%)
• No. 2 cause of CKD is hypertension (20%–30%)
Stage 5 Country Data
Asia Pacific
Cardiovascular Risk Factors are the Top 6 Leading Causes of Death
Hypertension
• How can I tell if I have High Blood Pressure?– Usually NO SYMPTOMS!
– “The Silent Killer”
– May have: • Headache
• Blurry vision
• Chest Pain
• Frequent urination at night
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Lifestyles, Fitnessand Rehabilitation
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Hipertenzija - samo dio višestrukogrizičnog sindroma sa teškim
posljedicama
Treat the BP to Target
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Intrauterineprogramming
Mosaic 2007
Environmental
Renal
Anatomical
Adaptive
NeuralEndocrine
Humoral
Haemodynamics
Genetic
BP
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WHAT IS THE BLOOD PRESSURE TARGET
FROM TIME TO TIME?
48
IN CKD
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Parving et al., Br Med J, 1989Viberti et al., JAMA, 1993Hebert et al., Kidney Int, 1994Lebovitz et al., Kidney Int, 1994Bakris et al., Kidney Int, 1996Bakris et al., Hypertension, 1997
Klahr et al., N Engl J Med, 1993Maschio et al., N Engl J Med, 1996GISEN Group, Lancet, 1997
Bakris et al., Am J Kidney Dis, 2000
Diabetes Non-diabetes
0
-2
-4
-6
-8
-10
-12
-14
GF
R (
ml/m
in/y
ea
r)
95 98 113110107104101 119116
130/80 140/90 Untreated HTN
r = 0.69; p < 0.05
MAP (mmHg)
What is the Optimal Blood Pressure in CKD?
MAP = [(2 x diastolic)+systolic] / 3
Mrs. Smith 160/95
Adequate BP management delays the progression of CKD
Bakris et al., Am J Kid Disease, 2000
If Rita’s blood pressure was consistently below target, the GFR loss per year would be
reduced by 80%
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Treat the BP to Target
5.3
Blood Pressure and ESRD in Men16 Years Follow-Up Study of Subjects (MRFIT)
Peripheral artery disease- intermittent claudication- ankle brachial index < 0.9
III. Assessment of the overall cardiovascular risk
BP 130/80 mmHg
Treat the BP to Target
HULU
HILIR
1. Tekanan Darah >60 thn 150/90 mmHg2. Tekanan Darah <60 thn
• Tidak ada komplikasi 140/90 mmHg• DM positif 130/80 mmHg• CKD positif 130/80 mmHg• Mikroalbuminuria positif 130/80 mmHg
3. DM A1C 6,5 – 7,04. LDL Kolesterol <705. Asam Urat <7,06. Mikroalbuminuria Negatif7. EGFR (kreatinin 0,9‐1,2) >60%8. Lingkar Perut wanita < 80 cm, Laki‐laki <90 cm9. Hb antara 10‐11 gr%
TARGET HIDUP SEHAT
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Treat the BP to Target
CONCLUSION
Protection, Prevention, and Regression the Progressivity of
Atherosclerotic Syndrome Dominited by :
130/80
140/90HILIR
AKIBAThulu
Treat the Risk FactorsTreat the BP to Target
CONCLUSION
Protection, Prevention, and Regression the Progressivity of
Atherosclerotic Syndrome Dominited by :
HULU Treat the Organ DamageTreat the BP to Target
CONCLUSION
Protection, Prevention, and Regression the Progressivity of
Atherosclerotic Syndrome Dominited by :
HILIR
What’s new in CKD?
What Old New
Blood Pressure Targets
People with >1g proteinuria/ day –BP target 125/75 mmHg
People with CKD (or other conditions) – BP target 130/80 mmHg
All other conditions – BP target 140/90 mmHg
People with CKD - should maintain a BP consistently below 140/90 mmHg
People with diabetes or microalbuminuria should maintain a BP consistently below 130/80 mmHg
Blood Pressure Targets
Stages of Chronic Kidney Disease(K/DOQI Guidelines 2002)
Stages of Chronic Kidney Disease(K/DOQI Guidelines 2002)
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
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
< 15 or dialysis< 15 or dialysisKidney failureKidney failure55
15 – 2915 – 29Severe GFRSevere GFR44
30 – 5930 – 59Moderate GFRModerate GFR33
60 – 8960 – 89Kidney damage with mild GFRKidney damage with mild GFR22
> 90> 90Kidney damage with normal or GFRKidney damage with normal or GFR
* Includes presentations from preceding stage. Chronic kidney disease is dfined 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 adnormalities in blood or urine or tests or imaging studies
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Risk factors for the development, progression, and complications of CKD
Risk factor Definition Examples
Development Increases susceptibility to kidney damage
Older age, family history of CKD, US racial or ethnic minority status, low income, reduced kidney mass, hyperfiltration states
Directly initiates kidney damage
Diabetes, high blood pressure, obesity, dyslipidaemia, autoimmune diseases, infections, stones, obstruction, neoplasia, recovery from acute injury
Risk factors for the development, progression, and complications of CKD
Risk factor Definition Examples
Progression Worsens kidney damage or accelerates GFR decline
Higher level of proteinuria
Increases the risk of complications of decreased GFR
Factors related to hypertension, anaemia, malnutrition, bone and mineral disorders, neuropathy, drugs and procedure with kidney or systemic toxicity
Risk factors for the development, progression, and complications of CKD
Risk factor Definition Examples
Complications Accelerate the onset or recurrence of CVD
Traditional CVD risk factors, non-traditional ‘CKD-related’ risk factors
Increase morbidity and mortality in kidney failure
Late referral, dialysis factors, comorbid conditions