Gangguan sistem urologi
fokus gagal ginjal
Dr. Eddy Susatyo, SpPD FinaSIM
RSU dr. Sutrasno
Rembang
STRUCTURE OF THE KIDNEYS
Chronic Kidney Disease ?
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.
Prevalence of CKD
How About the Function of Renal ?
 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
Brain
ADH
Renin
Angiotensin II
Lung
Kidney
Ang II
Angiotensin I
Adrenal
Angiotensinogen
Hepar
Na+ excretion
H2O excretion
Aldosteron
RAAS
The Most
Common Causes of CKD
 Glomerulonefritis
 Penyakit ginjal herediter
 Hipertensi
 Uropathy obstruktif
 Infeksi
 Nefropati diabetik
The Most
Common Causes of CKD
Other
Other
10%
Glomerulonephritis
Glomerulonephritis
13%
Diabetes
Hypertension
50.1%
27%
Primary Diagnosis for Patients Who Start on Dialysis
Pe Reabs Na
Hipertrofi sel renal
Pe eksr sisa metab
Ggn konstentrasi urin
Penurunan GFR
Pe ekskr kalium
Ggn fs ekskresi
Pe ekskr PO4
Pe ekskr ion H
CKD
Ggn Reproduksi
Ggn Imun
Ggn fs non ekskresi
 prod eritropoetin
Pe abs Ca
JENIS PEMERIKSAAN
PENUNJANG
• Urinalisis
• Evaluasi Fungsi Ginjal
• Evaluasi Serologis
• Pemeriksaan Radiologis
• Biopsi Ginjal
Equations for Estimating GFR
Abbreviated MDRD Study Equation
GFR (mL/min/1.73 m2) = 186.3 X SCr -1.154 X Age-0.203
X 0.742 (if female) X 1.210 (if African American)
Cockcroft-Gault Equation
(140 – Age) X Weight in kg
Ccr =
(mL/min)
72 X SCr
MDRD = Modification of Diet in Renal Disease; Ccr = creatinine clearance.
Levey et al. Ann Intern Med. 2003;139:137-147.
= 0.85 if female
CKD Progresses in Stages Defined by
Kidney Function: GFR
CKD
Stage
Prevalence
Patients/
Nephrologist
90
5,900,000
1180
Mild decr. in GFR
60-89
5,300,000
1060
3
Mod dec. in GFR
30-59
7,600,000
1520
4
Severe decr in GFR
15-29
400,000
80
5
Kidney failure
<15
300,000
70 (145-160
by 2010)*
Description
GFR
1
Kidney damage
normal incr. GFR
2
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.
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
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
STAGES OF CKD
NORMAL
INCREASED RISK
COMPLICATIONS
CKD
DEATH
DAMAGE
LOW GFR
RENAL FAILURE
Considerations for Patients with CKD?
Susceptibility Risk
Factors
• 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
• Higher level of
proteinuria
• Higher BP
• Poor glycemic control
• Smoking
• Hyperlipidemia
• Drug use
Levey et al. Ann Intern Med. 2003;139:137-147.
USRDS. 1999 Annual Data Report. Available at: www.usrds.org.
Complications
• CVD
• Anemia
• Altered bone &
mineral metabolism
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;139:137-147.
2-year Follow-Up of Medicare Patients: Focus
on Diabetes, CKD or Both
100
No Events
ESRD
Death
80
60
61.6
67.6
84.0
40
6.1
2.9
20
0.3
29.5
32.3
- DM,
+CKD
+ DM,
+ CKD
15.7
0
+ 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.
LVH Increases With CKD Progression
80
LVH at Baseline (%)
60
40
20
0
50-75
25-50
<25
eGFR (mL/min/1.73 m2)1
eGFR = estimated glomerular filtration rate.
1. Levin et al. Am J Kidney Dis. 1999;34:125-134.
2. Foley et al. J Nephrol. 1998;11:239-245.
Dialysis
Start
Anemia Rates Increase as Levels of CKD
Severity Progress
100
Anemia Prevalence (%)
80
60
10
Hgb Values
15
11-12 g/dL
10-11 g/dL
<10 g/dL
15
8
40
20
17
9
5
14
0
<2
8
62
43
20
2-2.9
3-3.9
Creatinine (mg/dL)
Chronic Kidney Disease (CKD) Progression
Hgb = hemoglobin.
Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.
≥4
Specific Interventions for Complications
of CKD
Complication
Intervention
Target Goals
Diabetes
Glycemic control
preprandial glucose 90-125 mg/dL
A1C <7%
Hypertension
Secondary HPT
BP control
PTH control
Dyslipidemia
Maintain lipids to target
Anemia
Malnutrition
Reach Hgb goal
Dietary modification
< 130/80 mm Hg
CKD stage 3 = 35-70 pg/mL
4 = 70-110 pg/mL
LDL-C <100 mg/dL (70?) TG
<150 mg/dL
HDL-C >40 mg/dL
11-12 g/dL
Adequate energy intake
A1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone; LDL-C = low-density
lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density lipoprotein cholesterol; Hgb = hemoglobin.
Summary: Clinical Actions for Progressive
Stages of CKD
CKD
Stage
Risk
Description
At increased risk
GFR
Action*
(mL/min/1.73 m2)
90 with
CKD risk factors
Evaluate for CKD
Reduce/control CKD risk factors
1
Kidney damage with
normal
or  GFR
90
2
Kidney damage with
mild  GFR
60-89
Estimate progression
*All actions for prior stages
3
Moderate  GFR
30-59
Evaluate and treat complications
*All actions for prior stages
4
Severe  GFR
15-29
Prepare for kidney replacement
Evaluate and treat complications
5
Kidney failure
<15 or dialysis
Diagnose and treat comorbid conditions
Address progression factors
Reduce/control CVD risk factors
Kidney replacement if uremia present
*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.
Cause of death in dialysis
patients
unknown
cardiac disease
others
infection
CVA
malignancy
withrawal of
RRT
Decisions in renal
replacement
• Pre-dialysis care
• Active treatment
- Peritoneal dialysis (PD)
- Haemodialysis (HD)
- Transplantation
• Conservative (non-dialytic) care. Symptom
management.
Penatalaksanaan CKD
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
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
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
Example URR
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.
How About
Acute kidney injury in Sepsis ?
Critical ill patient potentially AKI
AKI in ICU  5 –25%
Mortality AKI 40-80%
RIFLE criteria for Acute Renal Dysfunction
Oliguria
Abrupt (1-7 days)
Decreased UO relative to
decrease (> 25%) in GFR or
the fluid input
Scr x 1.5
UO < 0.5/ml/kg/h x 6hr
Sustained (> 24 hrs)
Risk
Injury
Adjusted creat or GFR
decrease> 50% or
Scr x 2
Failure
Loss
ESRD
UO < 0.5/ml/kg/h
x 12 hr ??
Adjusted creat or GFR
UO < .5/ml/kg/h
decrease > 75%
Scr x 3 or Scr > 4mg% x 24 hr
When acute > 0.5mg% Anuria x 12 hrs
Irreversible ARF or persistent
ARF > 4 wks
ESRD > 3 months
Specificity
Non-Oliguria
ARF ~ earliest
time point for
provision of RRT
Klasifikasi/staging AKI modifikasi RIFLE
Stadium
kriteria kreatinin
kriteria urin output
1.
Risk
serum kreatinin meningkat > 0,3 mg/dl
atau meningkat lebih dari 150-200 %
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
Sepsis
Ischemic insult
Nephrotoxic insult
Ischemia-reperfusion
Endotoxin release
Pro-inflamatory
mediators
+
-
Anti-inflamatory
mediators
Oxygen free radicals
Nitric oxide
Heat shock proteins
Arachidonic acid
metabolities
Cellular activation
(PMN, endothelial cells…)
Endothelins
 Urinary KIM-1, NAG
Complement activation
Proteases
Chemokines
Platelet activating factor
Acute kidney injury
 Urine output
 GFR
Pathogenic mechanism of sepsis related acute kidney injury
 Serum creatinine
Possible pathogenetic mechanisms in ATN.
Tubular damage
(proximal tubules and
ascending thick limb)
Ischemia
Nephrotoxins
(1)
Vasoconstriction
Renin-angiotensin
endothelin
PGI2
NO
(5)
? Direct glomerular
effect
(2)
Obstruction
by casts
Intratubular
pressure
GFR
(3)
Tubular
backleak
(4)
Interstitial
inflammation
Tubular
fluid flow
Oliguria
Effects of ischemia on renal tubules in the
pathogenesis of ischemic AKI
Schrier et al, J Clin Invest 2004, 114:5-14
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 ?
Tight control of blood glucose
Intensive insulin therapy  sepsis by 45%
Blood glucose 80-110 mg/dl  morbidity and mortality
Mechanism :  bacterial phagocytosis and antiapoptotic effect of
insulin