Masalah Penatalaksanaan Penyakit Ginjal...

MasalahPenatalaksanaanPenyakit Ginjal Kronis

Pranawa

Division of Nephrology and Hypertension Department of Internal Medicine

Faculty of Medicine, Airlangga University Dr. Sutomo Hospital

Surabaya

Tahapan Penyakit Ginjal Kronik

Tahap DeskripsiGFR

(ml/men/1.73 m2)

1 Kerusakan ginjal dengan LFG normal

atau turun

>/= 90

2 Kerusakan ginjal dengan penurunan

ringan LFG

60-89

3 Penurunan LFG sedang 30-59

4 Penurunan LFG berat 15-29

5 Gagal Ginjal < 15 atau dialisis

PenatalaksanaanPenyakit Ginjal Kronis

Konservatif (pra dialisis)

Aktif(ESRD)

Dialisis

Transplantasi

Hemodialisis

PD

Masalah

Sosio Epidemiologik

Medik

Masalah Sosial EpidemiologiK

Meningkatnya jumlah pasien

Ketersediaan sarana prasarana dan ketenagaan

Sistem pembeayaan

Pengertian pasien dan masyarakat

Results

9.412 Subject (64,1% Female)

Mean age 43,3+12,9 years.

Hypertension 19,4%

Proteinuria 2,8 %

Current Smooking 19,8% and Obesity 32,5%.

In subjects with either hypertension, proteinuria and/or diabetes, CKD was found in 12,5% (CG), 8,6% (MDRD) or 7,5% (Chinese MDRD).

Incidence of CKD in Indonesia

o based on the 2007 National Health Survey by the Ministry of Health Indonesia

okidney dysfunction : 3.8% (CKD-EPI eGFR

Prevalence of CKD in Selected Asian Countries

9Tsukamoto et al. Clin Exp Nephrol. 2009. Published online. doi 10.1007/s10157-009-0156-8; Ong-ajyooth L et al. BMC Nephrol.

2009;10:35; Wen et al. Lancet. 2008;371:2173-2182; Chen W et al. Nephrol Dial Transplant. 2009;24:1205-1212.

Area CKD Prevalence (stages) N

China

Beijing 9.3% (I-V), 1.7% (III-V) 13,925

Guangzhou/Zhuhai 12.1% (I-V), 3.2% (III-IV) 6311

Korea 1.39% (I), 3.64% (II), 2.67% (III-V) 329,581

Japan 9.2% (III-V) 574,023

Singapore 4.45% (III-V) 2112

Vietnam 3.9% (III-V) 8509

Indonesia 5.8% (I), 7.0% (II), 5.2% (III-V) 6040

Taiwan 11.9% (I-V) 462,293

Thailand 8.1% (III), 0.2% (IV), 0.15% (V) 3117

CKD, chronic kidney disease.

Indonesia almost 2 million square

kilometers 18,307 islands population : 255,339,621



255.000 pasien ESRD

CAUSES OF ESRD in HD pts in SURABAYA

CAUSES 1994dr. Soetomo Hosp

1996-1998private Hosp

2000dr. Soetomo Hosp

Renal Stones 32% 16.8% 8.8%

Glomerulonephritis 27% 36.4% 34.3%

Hypertension 22% 15.9% 22.8%

Diabetic Nephropathy 14% 23.4% 32.0%

Others 2% 7.5% 2.1%

Causes of CKD at the start of HD

Hypertension 31%

Diabetes 26%Glomerulopathy 14%

Pyelonephritis 10%

Obstruction 7%

Obstruction 7% Uric Acid 2%Lupus 1% Polycystic 1%Unknown 2%

Others 6%

Indonesian Renal Registry 2013

INDONESIANRENAL REGISTRY

Jumlah Unit HD Per propinsi Yang Mengirimkan Data tahun 2016

Propinsi Sign UP Kirim Data

Aceh 10 4

Sumut 35 20

Sumbar 6 4

Riau 3 2

Kepri 6 2

Jambi 4 2

Bangka 4 3

Sumsel 7 3

Lampung 15 3

Bengkulu 2 1

Jabar 109 100

Banten 11 7

DKI 59 37

Jateng 57 18

DIY 15 6

Jatim 65 32

Bali 24 14

NTT 1 1

Kaltim 10 6

Kalsel 6 3

Sulut 3 3

Sulteng 1 1

Sulsel 7 6

Jumlah 460 278




Aceh 10 4

Sumut 35 20

Sumbar 6 4

Riau 3 2

Kepri 6 2

Jambi 4 2

Bangka 4 3

Sumsel 7 3

Lampung 15 3

Bengkulu 2 1

Jabar 109 100

Banten 11 7

DKI 59 37

Jateng 57 18

DIY 15 6

Jatim 65 32

Bali 24 14

NTT 1 1

Kaltim 10 6

Kalsel 6 3

Sulut 3 3

Sulteng 1 1

Sulsel 7 6

Jumlah 460 278

Diperkirakan baru 50%

INDONESIANRENAL REGISTRY Jumlah pasien Baru dan Pasien Aktif

2007- 2016

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Pasien Baru 4977 5392 8193 9649 15353 19621 15128 17193 21050 25446

Pasien Aktif 1885 6543 8603 11484 17259 22140 21759 21165 30554 52835

0

10000

20000

30000

40000

50000

60000Pasien aktif 52.835

INDONESIANRENAL REGISTRY Jumlah pasien Baru dan Pasien Aktif

2007- 2016

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Pasien Baru 4977 5392 8193 9649 15353 19621 15128 17193 21050 25446

Pasien Aktif 1885 6543 8603 11484 17259 22140 21759 21165 30554 52835

0

10000

20000

30000

40000

50000

60000Pasien aktif 52.835

Diperkirakan 105.000 pasien

INDONESIANRENAL REGISTRY INSIDENSI DAN PREVALENSI PASIEN

HEMODIALISIS

9th Report Of Indonesian Renal Registry

2016

7

Data dari propinsi Jawa Barat dapat dilihat pada diagram di bawah ini

Data ini didapatkan dari 90 % unit HD yang ada maka data ini dirasa cukup lengkap dan dapat menilai insidensi dan prevalensi di wilayah tersebut. 90 % dibiayai oleh JKN baik PBI maupun non PBI. Penduduk Jawa Barat peserta JKN sebanyak 29 juta

Untuk data tahun 2016 dapat dihitung sbb :

Jumlah Total

Penduduk Jawa Barat 46,5 juta

Jumlah Pasien JKN (90%)

Peserta JKN Jawa Barat 29 Juta

Pasien Baru 6288 135 per juta penduduk

5659 195 per juta penduduk

Pasien Aktif 14869 319 per juta penduduk


Distribusi Usia pasien HD Dalam Persen Tahun 2016:

Proporsi pasien terbanyak masih pada kategori 45 sd 64 tahun. Bila dilihat pada tabel di atas pasien yang berusia kurang dari 25 tahun memberi kontribusi sebesar 2,79 % hal ini menunjukkan sudah saatnya memberi perhatian pada kelompok usia muda untuk mulai memperhatikan kesehatan ginjal.

5029

74656288

7381

9382

14869

0

2000

4000

6000

8000

10000

12000

14000

16000

2014 2015 2016

Pasien Baru Pasien Aktif

BILA PESERTA JKN SELURUH INDONESIA SEBANYAK 130 JUTA ORANG MAKA JUMLAH PASIEN BARU PER TAHUN : 130 X 195 = 25.350

DAN PASIEN AKTIF PER TAHUN : 130 X 512 = 66.600Dan bila seluruh Indonesia menjadi peserta JKN maka pasien aktif HD

sebanyak :250 x 512 =

128.000 orang

INDONESIAN

RENAL REGISTRY

2016

Grafik Jumlah Pasien Penyakit Ginjal Kronik Tahap 5 (N18) berdasarkan Diagnosa Etiologi Di Indonesia

E1 (Glumerulopati Primer) (GNC)

6%

E2 (Nefropati Diabetika)52%

E3 (Nefropati Lupus) (SLE)1%

E4 (Penyakit ginjal Hipertensi)

24%

E5 (Ginjal Polikistik)1%

E6 (Nefropati Asam

Urat)1%

E7 (Nefropati Obstruksi)

4%

E8 (Pielonefritis Chronic0 (PNC)

3%

E9 (Lain-Lain)6%

E10 (Tidak Diketahui)2%

Global: 2,522,000 dialysis patients

Fresenius Medical Care : ESRD Patients in 2013 A Global Perspective

Comparison of HD and PD patient numbers in the 15 largest countries ranked by total dialysis patient population


Kebutuhan mesin HD dan perawat255.000 pasien ESRD

90 % hemodialisis : 225. 000 pasien

10% CAPD : 25. 000 pasien

Dengan 3 shift 2 kali/mnggu

Diperlukan 2 x 225.000 = 450.000 tindakan/mnggu

Diperlukan 450.000 : 6 = 75.000 : 3 = 25.000 mesin

Diperlukan 25.000 perawat

Kebutuhan mesin HD dan perawat

Keadaan sekarang

105.000 - 128.000 pasien

Untuk 3 shift 2x/minggu

Diperlukan 12.500 mesin HD dan 12.500 perawat

INDONESIANRENAL REGISTRY Jumlah Perawat HD & Jumlah Mesin

Tahun 2016

Jumlah

Jumlah Perawat 4728

Jumlah Perawat Bersertifikat 3350

Jumlah Mesin 6604

0

1000

2000

3000

4000

5000

6000

7000

INDONESIANRENAL REGISTRY Jumlah Perawat Tahun 2016

Bersertifikat, 3350

Belum bersertifikat,

1378,

Perawat

Bersertifikat

Belum bersertifikat

Beaya BPJS untuk hemodialysis di Jawa Timur tahun 2016Rp 456.757.511.500

Beaya BPJS untuk hemodialysis di Jawa Timur tahun 2016Rp 456.757.511.500

Indonesia 3 T

CKD oleh Karena DM meningkat

Prevalensi DM meningkat

Harapan hidup pasien DM lebih baik

Tersedianya sarana terapi pengganti ginjal

Nephrology 19 (2014) 450458

Number of Dialysis Patient Will Increase Significantly, Particularly Due to National Insurance (JKN)

Masalah Medik Perjalanan PGK dan Prognosis

Kesempurnaan instalasi dan kelengkapan saranaprasarana

Ketramplilan Tenaga Pelaksana

Kedisiplinan Pasien

Stages in Progression of

Chronic Kidney Disease and Therapeutic Strategies

Complications

Normal Increased

RiskDamage GFR

Kidney

failure

CKD

death

Screening

for CKD risk

factors

CKD risk

reduction,

Screening

for CKD

Diagnosis &

treatment,

Treat

comorbid

conditions,

Slow

progression

Estimate

progression,

Treat

complications,

Prepare for

replacement

Replacement

by dialysis &

transplant

Deteksi dini

Prevensi primer dan sekunder

Diabetic kidney disease markers.

Current markers

1. Creatinine, Cystatin C (estimated GFR).

2. Microalbuminuria

3. Macroalbuminuria or Proteinuria

Candidate markers in future

1. Urinary podocytes

2. NGAL

3. KIM-1

4. Smad 1

5. CTGF

6. TGF-

7. TNF-NGAL = Neutrophil Gelatinase-Associated Lipocalin; KIM-1 = Kidney Injury Molecule 1; CTGF = Connective tissue growth factor; TGF- = Transforming growth factor beta; TNF- = Tumor necrosis factor alpha.

Open J Nephrol. 2012; 2(2): 518.

Masalah Medik Perjalanan PGK dan Prognosis

Kesempurnaan instalasi dan kelengkapan saranaprasarana

Ketramplilan Tenaga Pelaksana

Kedisiplinan Pasien

KenyataanUkuran ruangan

Ratio mesin dan perawat

Kualitas air

Masih tinggi prevalensi hepatitis C

Kualitas hidup pasien ( termasuk nutrisi )


LAMA HIDUP DENGAN HD DI INDONESIA TAHUN 20169th Report Of Indonesian Renal Registry

2016

17

Proporsi berdasarkan lama hidup dengan Hemodialisis

Lama Hidup dari mulai HD, n=1683 n (%)

36 Bulan 165 (9,8)

Tiga puluh sembilan persen pasien meninggal pada 3 bulan pertama menjalani hemodialisis dan hanya 9,8% saja yang menjalaninya lebih dari 36 bulan

n

Lama HD

Mean SD Median (IQR) Min Maks

Jenis Kelamin

Laki-laki 696 20 24 8 (3 30) 1 140

Perempuan 539 18 24 7 (2 28) 1 116

Usia

65 Tahun 222 21 26 8 (3 32) 1 139

Etiologi

Glomerulopati 7

10 13

3 (1 18)

1 30

Nefropati Diabetik 61 14 20 5 (2 24) 1 92

Penyakit Ginjal Hipertensi 59

9 16 3 (1 8) 1 96

Lain-lain 29 11 16 3 (2 11) 1 72

P.Penyerta 1, n (%)

Hipertensi

45

14 19

4 (2 29)

1 92

Diabetes melitus 50 6 8 3 (1 8) 1 36

Kelainan Kardiovaskular 6 8 10 4 (1 8) 1 28

INDONESIANRENAL REGISTRY Jumlah tindakan HD berdasarkan

Durasi HD (Td) 2016

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

< 3 Jam 2294 6368 3295 4207 3714 4817 5393 12608 5802 7613

3 - 4 Jam 76736 111647 120028 164541 226993 360753 359495 375557 374751 483129

> 4 Jam 36011 62973 91719 105546 239981 236193 314138 315102 339107 457402

0

100000

200000

300000

400000

500000

600000


Grafik Jumlah tindakan HD berdasarkan Durasi Se Indonesia tahun 2016

Durasi HD > 31%

DurasiHD 3 - 4 Jam51%

DurasiHD > 4 Jam48%

Upaya perbaikan

Terus menyempurnakan SKN dan JKN dan pelaksanannya

Menyempurnakan regulasi

Mengikuti regulasi yang berlaku

Mengikuti pedoman pelaksanaan HD

Meningkatkan upaya prevensi PGK (penyempurnaan terapihipertensi dan DM)

Ringkasan

Outlines

Terminology

Epidemiology

Pathology and Pathophysiology

Management

Summary

http://www.unckidneycenter.org/kidneyhealthlibrary/diabetes.html

Typical pattern of kidney damage in T2D patients Expansion of mesangial matrix with diffuse and nodular glomerulosclerosis (Kimmelstiel-Wilson nodules)

Thickening of glomerular and tubular basement membrane

Arteriosclerosis and hyalinosis of afferent and efferent arterioles

Tubulointerstitial fibrosis

Glomerular classification of DNRenal Pathology Society

Class Description

I Mild or nonspecific LM changes andEM-proven GBM thickening

II a Mild mesangial expansion

II b Severe mesangial expansion

III Nodular sclerosis (KimmelstielWilson lesion)

IV Advanced diabetic glomerulosclerosis

J Am Soc Nephrol , 2010. doi: 10.1681/ASN.2010010010

54

1. Photomicrograph adapted from Netter FH. The Ciba Collection of Medical Illustrations. Vol 6. Kidneys, Ureters, and Bladder. West Caldwell, NJ: CIBA Medical Education Division 1973:7. 2. Mauer MS, et al. Diabetic nephropathy. In: SchrierRW, Gottschalk CW, eds. Diseases of the Kidney. 5th ed. Vol 3. Boston: Little, Brown and Company; 1993:363. 3. Photomicrographs adapted from Fogo A, Weedman B. Diabetic nephropathy. In: AJKD Atlas of Renal Pathology. Available at: http://www2.us.elsevierhealth.com/ajkd/atlas/34/5/atlas34_5.htm (accessed May 2012).

Structural changes in the progression of diabetic nephropathy to end-stage renal disease (ESRD)

ESRD2,3

Kidney failure or ESRDGFR

PATHOPHYSIOLOGY

Hyperglycemia

AGE

Cytokine

Autoimmune

Adaptive ImmunityOdegaard, 2012

56

Traditional Epidemiology

DiseaseExposure

Molecular Epidemiology

Markers of Exposure Markers of Disease

Exposure Internal

Dose

Biologically

Effective

Dose

Early

Biological

Effect

Clinical

Disease

Prognostic

Significance

Altered

Structure/

Function

Markers of Susceptibility

Figure 13-1 Aspects of continuum between an exposure and a disease that can be studied by

molecular epidemiology. (Figure 1.2, p.6, from Schulte and Perera, 1993. Reproduced with permission

from the author and Elsevier Science)

57

CV, cardiovascular; LIFE, Losartan Intervention for Endpoint Reduction in Hypertension.

Ibsen H, et al. Diabetes Care. 2006;29:595600.

LIFE: Albuminuria predicts risk of CV events in people with Diabetes and Hypertension

Incidence of primary composite endpoint* stratifiedby time-varying albumin to creatinine ratio

0 20 30 40 50 70

End

po

int

rate

0.00

0.36

0.24

0.12

0.06

10

13 mg/mmol

(n=255, 238, 250)

1 mg/mmol

(n=274, 406, 311)

0.30

0.18

Month*Primary composite endpoint included cardiovascular death, myocardial infarction and stroke

Numbers in parentheses refer to the numbers of at-risk patients in each range at baseline and at years 2 and 4

60

312 mg/mmol

(n=267, 239, 213)

12 mg/mmol

(n=267, 174, 175)

ADA Executive Summary: Standards of Medical Care in Diabetes 2014

...............microalbuminuria (30299 mg/24 h) and macroalbuminuria(>300 mg/24 h) will no longer be used,

Persistent albuminuria at levels 30299 mg/24 h

and levels >300 mg/24 h.

Normal albumin excretion is currently defined as

Patients with diabetes are at high risk of kidney disease

59

Up to 40% of those with T2D will eventually

suffer from kidney failure2,3,6

1040%

Mortality is more frequent in T2D patients with kidney disease than in those without

60

Percentages indicate absolute excess mortality above the reference group (individuals with no diabetes or kidney disease)*No diabetes and no kidney disease; GFR, glomerular filtration rate; T2D, type 2 diabetesAfkarian M et al. J Am Soc Nephrol 2013;24:302

Stan

dar

dis

ed 1

0-y

ear

cu

mu

lati

ve

inci

de

nce

of

mo

rtal

ity

(95

% C

I)

4.1%

17.8%

23.9%

47.0%

7.7%

0

10

20

30

40

50

60

70

No kidney disease Albuminuria Impaired GFR Albuminuria &impaired GFR

No diabetes, nokidney disease

Excess mortality

Increased mortality

DM

Diabetic Kidney Disease

(Microalbuminuria / Proteinuria)

ESRD

Cardiovascular Disease

CVD as cause of death in CKD

CKD is a health burden, estimates of nearly 20 million affected in US

Causes of death in CKD

Infection15%

Other heart disease2%

Cerebrovascular

6%Unknown

7%

Other26%

Cancer4%

CHD41%

(NKF-K/DOQI 2003)

Uri

nar

ypro

tein

excr

etio

n(m

g/d

)

Glo

mer

ula

rfi

ltra

tion

rate

(GFR

)(m

L/m

in)

Functional

Structural

GFR -

(90-95%)

Renal

hypertrophy

Microalbuminuria,hypertension

Mesangial expansion,

glomerular basement

membrane thickening,arteriolar hyalinosis

Proteinuria, nephroticsyndrome, GFR

Mesangial nodules

(Kimmelstiel-Wilsonlesions)

Tubular-interstitial fibrosis

Natural history of diabetic nephropathyUrinary protein excretionGFR

Years

0

150

100

50

5 10 15 20 25

1000

200

20

5000

Incipient diabeticnephropathy

Pre Overt diabeticnephropathy

End-stage

renal disease

1 2 3 4 5

Natural History

Future DKD prevalence will be determined primarily by:

(i) ongoing trends with respect to diabetes prevalence;

(ii) the impact of improved diabetes management and primary prevention of DKD; and

(iii) the impact of early detection and secondary prevention of the progression of DKD.

Nephrology 19 (2014) 450458

Outlines

Terminology

Epidemiology


Management

Summary

ADA Executive Summary: Standards of Medical Care in Diabetesd 2014NEPHROPATHY

General Recommendations

Optimize glucose control to reduce the risk or slow the progression of nephropathy.

Optimize blood pressure control to reduce the risk or slow the progression of nephropathy.

Diabetes Care Volume 37, Supplement 1, January 2014 S1

Comparison of tight BP vs tight glucose

control in UKPDS

-50

-40

-30

-20

-10

0

Tight glucose control

Tight BP control

Microvascular

endpoints

*

Stroke

Any diabetes-

related endpoint

Diabetes-related

deaths

*

*

*

* p

Kim, 2017

DRUG ADJUSTMENT

IN DKD

Tuttle, 2014

DPP-4 INHIBITOR KIDNEY PROFILE

Kim, 2017

74

Weight Gain and Hypoglycemia in Patients With Type 2 Diabetes and Moderate-to-Severe

Chronic Renal Insufficiency1

LS

Mea

n B

od

y W

eig

ht

Ch

ang

e F

rom

B

asel

ine

at W

eek

54, k

g

Sitagliptin(n=143)

Glipizide(n=148)

6,2

17.0

0

2

4

6

8

10

12

14

16

18

Symptomatic Hypoglycemia

Sitagliptin(n=210)

Glipizide(n=212)

a25 mg once daily or 50 mg once daily.bMean dose of glipizide was 7.7 mg per day. Glipizide was initiated at 2.5 mg/day and titrated to a maximum of 20 mg/day.

APaT = All Patients as Treated; LS = least squares.

1. Arjona Ferreira JC et al. Diabetes Care. 2013;36:10671073.

Pat

ien

ts W

ith

1

Hyp

og

lyce

mic

Eve

nt

Ove

r 54

Wee

ks, %

P=0.001

Baseline weight; sitagliptin = 68.0 kg; glipizide = 70.2 kg

a

0.6

1.2

b

1.5

1.0

1.5

0

0.5

0.5

1.0

LS mean difference at week 54 1.8; P

75

APaT, Excluding Data After Initiation of Glycemic Rescue Therapy

Weight Gain and Hypoglycemia in Patients With Type 2 Diabetes and End-

Stage Renal Disease on Dialysis1

6,3

10,8

0

2

4

6

8

10

12

Symptomatic HypoglycemiaP

atie

nts

Wit

h

1 E

pis

od

e o

f H

ypo

gly

cem

ia ,

%

Sitagliptin(n=64)

Glipizide(n=65)

0.2 (1.4, 1.1)

0.8 (0.5, 2.1)

-1,5

-1

-0,5

0

0,5

1

1,5L

S M

ean

Bo

dy

Wei

gh

t C

han

ge

Fro

m

Bas

elin

e at

Wee

k 54

, kg

Sitagliptin(n=45)

Glipizide(n=41)

APaT = All Patients as Treated; LS = least squares; CI = confidence interval.a25 mg once daily.bMean dose of glipizide was 5.3 mg per day. Glipizide was initiated at 2.5 mg/day and titrated to a maximum of 20 mg/day.

1. Arjona Ferreira JC et al. Am J Kidney Dis. 2013;61:579587.

Baseline, kg 68.2

a

b

LS Mean Between-Group Difference (95% CI)

1.0 (2.8, 0.9)

a

b

LS Mean Between-Group Difference (95% CI):

4.5% (15.3, 5.6); P=0.3

69.8


HYPERTENSION/BLOOD PRESSURE CONTROL

Pharmacological therapy for patients with diabetes and hypertension should comprise a regimen that

includes either an ACE inhibitor or an angiotensin receptor blocker (ARB).


Blood pressure management inCKD ND patients with diabetes mellitus

We suggest that an ARB or ACE-I be used in adults with diabetes and CKD ND with urine albumin excretion of 30 to 300 mg per 24 hours (or equivalent*).

We recommend that an ARB or ACE-I be used in adults with diabetes and CKD ND with urine albumin excretion >300 mg per 24 hours (or equivalent*).

KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney DiseaseKidney International Supplements (2012) 2, 347356

XII. Treatment of Hypertension in association with Diabetic

Nephropathy

If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5

ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control

of volume is desired

THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg

DIABETES

with

Nephropathy

ACE Inhibitor

or ARB

IF ACEI and ARB are contraindicated or not tolerated,

SUBSTITUTE

Long-acting CCB or

Thiazide diuretic

Addition of one or more ofLong-acting CCB or Thiazide diuretic

3 - 4 drugs combination may

be needed

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Pharmacological therapy for patients with diabetes and hypertension

Guidelines Anti hypertesion

KDOQI ACE-I or ARB

KDIGO ARB or ACE-I

ESH ACE-I or ARB

ADA ACE-I or ARB

JNC 8 All

CHEP ACE-I or ARB

BP Targets in Diabetes Mellitus

GUIDELINES TARGET

KDOQI(2007) 130/80

KDIGO (2012) 140/90 (130/80)

ESH(2013) 140/85

JNC 8 (2014) 140/90

ADA (2014) 140/80

CHEP (2015) 130/80

Kim, 2017

EMERGING TREATMENT

A multifactorial intervention strategy is recommended in DKD

ACEi, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; DKD, diabetic kidney disease; HbA1c, glycated haemoglobin1. National Kidney Foundation. Am J Kidney Dis 2012;60:850; 2. NICE. Clinical guideline: Type 2 diabetes (CG87), May 2009 85

Glucose

BP

Lipids

ACEi/ARB

HbA1c target individualised, but generally ~7%1

Target of

We recommend that metformin be continued in people with GFR 45 ml/min/1.73 m2 (GFR categories G1-G3a); its use should be reviewed in those with GFR 3044 ml/min/1.73 m2 (GFR category G3b); and it should bediscontinued in people with GFR


Medical Nutrition Therapy

Supplements for Diabetes Management (1)

There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies.

Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety.

. Diabetes Care Volume 37, Supplement 1, January 2014 S1



Supplements for Diabetes Management

Evidence does not support recommending n-3 (EPA and DHA) supplements for people with diabetes for theprevention or treatment of cardiovascular events.

There is insufficient evidence to support the routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes.




Supplements for Diabetes Management

There is insufficient evidence to support the use of cinnamon or other herbs/supplements for the treatment of diabetes.

It is reasonable for individualized meal planning to include optimization of food choices to meetrecommended daily allowance/dietary reference intake for allmicronutrients.


We recommend that adults with CKD seek medical orpharmacist advice before using over-the-counter medicines or nutritional protein supplements.

We recommend not using herbal remedies in people with CKD.

Kidney International Supplements (2013) 3, 1962

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD

Outlines

Terminology

Epidemiology


Management

Summary

SUMMARY

There is a linear growth in the incidence of Diabetic Kidney Disease(DKD)

DKD is a health problem with difficult management.

Problems in the handling of DKD, among others, in terms ofdiagnostics, monitoring and therapy that can be caused by variousfactors.

Some things to consider in the management of DKD is the controlof blood sugar and blood pressure .

There are some emerging and future treatments for DKD



255.000 pasien ESRD

MasalahEpidemioogi

Ketersediaan sarana prasarana

Tenaga

Tehnik pelaksanaan tindakan hemodialysis

Upaya pencegahan

Perjalanan klinis PGK

Sistem pembeayaan

Causes of CKD at the start of HD

Hypertension 31%

Diabetes 26%Glomerulopathy 14%

Pyelonephritis 10%

Obstruction 7%

Obstruction 7% Uric Acid 2%Lupus 1% Polycystic 1%Unknown 2%

Others 6%

Indonesian Renal Registry 2013




Aceh 10 4

Sumut 35 20

Sumbar 6 4

Riau 3 2

Kepri 6 2

Jambi 4 2

Bangka 4 3

Sumsel 7 3

Lampung 15 3

Bengkulu 2 1

Jabar 109 100

Banten 11 7

DKI 59 37

Jateng 57 18

DIY 15 6

Jatim 65 32

Bali 24 14

NTT 1 1

Kaltim 10 6

Kalsel 6 3

Sulut 3 3

Sulteng 1 1

Sulsel 7 6

Jumlah 460 278

INDONESIAN

RENAL REGISTRY

2016

Grafik Jumlah Pasien Penyakit Ginjal Kronik Tahap 5 (N18) berdasarkan Diagnosa Etiologi Di Indonesia

E1 (Glumerulopati Primer) (GNC)

6%

E2 (Nefropati Diabetika)52%

E3 (Nefropati Lupus) (SLE)1%

E4 (Penyakit ginjal Hipertensi)

24%

E5 (Ginjal Polikistik)

1%

E6 (Nefropati Asam Urat)

1%

E7 (Nefropati Obstruksi)

4%

E8 (Pielonefritis Chronic0 (PNC)

3%

E9 (Lain-Lain)6%

E10 (Tidak Diketahui)2%

INDONESIANRENAL REGISTRY INSIDENSI DAN PREVALENSI PASIEN

HEMODIALISIS

9th Report Of Indonesian Renal Registry

2016

7

Data dari propinsi Jawa Barat dapat dilihat pada diagram di bawah ini

Data ini didapatkan dari 90 % unit HD yang ada maka data ini dirasa cukup lengkap dan dapat menilai insidensi dan prevalensi di wilayah tersebut. 90 % dibiayai oleh JKN baik PBI maupun non PBI. Penduduk Jawa Barat peserta JKN sebanyak 29 juta

Untuk data tahun 2016 dapat dihitung sbb :

Jumlah Total

Penduduk Jawa Barat 46,5 juta

Jumlah Pasien JKN (90%)

Peserta JKN Jawa Barat 29 Juta

Pasien Baru 6288 135 per juta penduduk


Pasien Aktif 14869 319 per juta penduduk


Distribusi Usia pasien HD Dalam Persen Tahun 2016:

Proporsi pasien terbanyak masih pada kategori 45 sd 64 tahun. Bila dilihat pada tabel di atas pasien yang berusia kurang dari 25 tahun memberi kontribusi sebesar 2,79 % hal ini menunjukkan sudah saatnya memberi perhatian pada kelompok usia muda untuk mulai memperhatikan kesehatan ginjal.

5029

74656288

7381

9382

14869

0

2000

4000

6000

8000

10000

12000

14000

16000

2014 2015 2016

Pasien Baru Pasien Aktif

BILA PESERTA JKN SELURUH INDONESIA SEBANYAK 130 JUTA ORANG MAKA JUMLAH PASIEN BARU PER TAHUN : 130 X 195 = 25.350

DAN PASIEN AKTIF PER TAHUN : 130 X 512 = 66.600Dan bila seluruh Indonesia menjadi peserta JKN maka pasien aktif HD

sebanyak :250 x 512 =

128.000 orang

Global: 2,522,000 dialysis patients


Comparison of HD and PD patient numbers in the 15 largest countries ranked by total dialysis patient population


Hong Kong Renal Registry Report 2012Trends in point prevalent distribution of renal replacement therapy patients as of December 31 of each year from 1996 to 2011.

Hong Kong Journal of Nephrology (2013) 15, 28e43

Kebutuhan mesin HD dan perawat255.000 pasien ESRD

90 % hemodialisis : 225. 000 pasien

10% CAPD : 25. 000 pasien

Dengan 3 shift 2 kali/mnggu

Diperlukan 2 x 225.000 = 450.000 tindakan/mnggu

Diperlukan 450.000 : 6 = 75.000 : 3 = 25.000 mesin

Diperlukan 25.000 perawat

Kebutuhan mesin HD dan perawatKeadaan sekarang

128.000 132.000 pasien

Untuk 3 shift 2x/minggu

Diperlukan 12.500 mesin HD dan 12.500 perawat

INDONESIANRENAL REGISTRY Jumlah Perawat Tahun 2016

Bersertifikat; 3350; 71%

Belum bersertifikat;

1378; 29%

Perawat

Bersertifikat

Belum bersertifikat

INDONESIANRENAL REGISTRY Jumlah Perawat HD & Jumlah Mesin

Tahun 2016

Jumlah

Jumlah Perawat 4728

Jumlah Perawat Bersertifikat 3350

Jumlah Mesin 6604

0

1000

2000

3000

4000

5000

6000

7000

Bermain angka untuk pasien CKD di Indonesia

Jumlah pasien ESRD 0,1% dari 250.000.000 diperkirakan 250.000

Jumlah yang dilayani hemodialisis 5700 X 3 x3 = 51.300 (diperkirakan kemkes50.000)

Biaya tahun 2014 Rp 2.165.507.578.258,-

Jika terlayani semua pasien ESRD terlayani HD akan perlu beaya 5 X Rp2.165.507.578.258,- = Rp 10.827.537.891.290,-

Masalah Penatalaksanaan Penyakit Ginjal...

Documents

diabetik nefropati cetak

Nefropati Yani Presus 3

Nefropati Dm

GUIDELINE 12_ USE OF DIURETICS IN CKD.pdf

Nefropati Diabetik Referat

Hypertension and CKD.pdf

Dm Nefropati

paper nefropati diabetik.docx

Ig a nefropati

Nefropati Diabetikum

DM Dan Nefropati Diabetik

IgA Nefropati

Dm Nefropati Ppt

Nefropati Diabetika

Ret He n CKD.pdf

Referat Nefropati Diabetikum

Referat Contras Induce Nefropati

Nefropati Diabetik Ita

diabetik nefropati

Ppt Referat Nefropati Diabetik