CHRONIC KIDNEY DISEASEDisampaikan oleh : Wilda Maula Miftah NurAknowledgement : dr. Mia Melinda, Sp.PD,

Chronic Kidney Disease (CKD)Penyakit kronis progresif yang ditandai dengan penurunan fungsi dan kinerja nefron secara terus-menerus (terjadi selama beberapa tahun).

Awalnya, nefron yg masih bisa berfungsi dg baik, berusaha mengambil alih tugas dg cara meningkatkan filtrasi & reabsorpsi solut. Namun hal ini akan merusakkan nefron itu sendiri, shg akan berkembang menjadi ESRD dan perlu dialisis / transplantasi.

Chronic Kidney Disease (CKD)Komplikasi dari CKD timbul akibat :Bahan berbahaya yg seharusnya diekskresiKekurangan vit D aktif & erythropoietin

Sindroma uremik :Komplikasi CKD yg ditandai dg anemia, asterixis, seizure, coma, confusion, pericardial effusion, gatal, renal osteodystrophy

Azotemia: blood urea nitrogen meningkat(BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL)

CHRONIC KIDNEY DISEASE (CKD)Structural or functional abnormalities of the kidneys for >3 months, as manifested by either:

1. Kidney damage, with or without decreased GFR, as defined bypathologic abnormalitiesmarkers of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests2. GFR

Tahap CKD

Faktor RisikoChronic Kidney Disease (CKD)Diabetic NephropathyDiabetes most common contributor to ESRDHypertensionCRF with HypertensionGlomerulonephritisPolycystic Kidney DiseaseRapidly progressive glomerulonephrities (vasculitis)

Renal Vascular Disease (i.e., renal artery stenosis)MedicationsAnalgesic Nephropathy (progression after many years)Pregnancy: high incidence of increased creatitine and HTN during pregnancy associated with CRF

Risk Factors for Renal Disease ProgressionHuether SE, Pathophysiology,4th Edition, 2002, Chapter 35, 1191-1216

Proteinuria > 1.5 g/24 hrDiabetes mellitus (DM) or family history of diabetesProtein to Creatinine ratio > 1 g/gHyperlipidemiaHypertensionSmokingType of underlying renal diseaseHigh protein dietAfrican American racePhosphate retentionMale sexMetabolic acidosisObesity

CKD vs Acute Kidney InjuryCalsium , PO4 PTHUSG : ukuran ginjal 90 tahunFungsi ginjal berubah cepat (KS atau < 40 mikromol / L selama > 24 jam)Kreatinin serum > 350 mikromol / LKehamilan (meningkatkan KS sampai 20%)Katabolisme bermaknaAmputasi pada tungkai dan lengan massa otot berkurang

Rumus MDRD untuk Hitung GFRGFR = 186 x (SCr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if African American)

Rumus Modified Diet in Renal Disease yg melibatkan 4 variabel (kreatinin serum, usia, sex, ras) ini dikembangkan pd tahun1999 menggunakan data dr 1,628 px CKD dg GFR 5 - 90 ml /minute / 1.73 m2. Rumus ini memperkirakan GFR yg telah disesuaikan dg luas permukaan tubuh (rumus C&G tidak) & lebih akurat dari pada pengukuran klirens kreatinin dari 24-hour urine collections atau perhitungan dg rumus Cockcroft and Gault.

Rumus MDRD TerstandarisasiRumus ini di sesuaikan lagi pd thn 2005 agar dapat digunakan dg standardized serum creatinine assay, shg diperoleh nilai kadar kreatinin serum 5 % lebih rendah 5, 6:

GFR = 175 x (Standardized SCr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if African American)

dimana GFR = mL/min/1.73 m2, SCr = serum creatinine (mg/dL), & usia = tahun.

Keterbatasan MDRDRumus MDRD kurang akurat jika GFR > 60 mL/min/1.73 m2.

Jika GFR < 60 mL/min/1.73 m2, rumus ini akurat utk hampir semua orang tanpa tgt ukuran tubuh. Lebih akurat dr rumus C&G, terutama utk lansia & obesitas

Keterbatasan : (1) hanya memakai kreatinin serum sbg filtration marker; (2) kurang akurat pd GFR yg lebih tinggi; & (3) non-steady state conditions for the filtration marker when GFR is changing.

MDRD Tidak Dapat Digunakan Tanpa penyakit ginjal, misal pd pasien muda dg DM tipe 1 tanpa microalbuminuria / calon pendonor ginjal

Belum divalidasi pd usia 85 thn, atau pd ras / sub etnis ttt (mis : Hispanics).

Rumus ini tidak memperhitungkan pengaruh nutrisi / obat ttt terhadap kadar kreatinin serumTidak boleh digunakan untuk menghitung penyesuaian dosis; tetapi dapat digunakan scr langsung utk menilai stage CKD

Perhitungan C&G vs MDRDFor a white female, serum creatinine 1.2 g/dl, weight 125 lbs

Metode Perkiraan GFR (lanjutan)Klirens UreaJika digunakan iothalamate untuk membandingkan klirens kreatinin (Ccr) dg klirens urea (Curea), maka hasilnya Ccr > GFR krn adanya sekresi kreatinin via tubuler, dan Curea< GFR krn adanya absorpsi urea di tubulerCystatin CProtein BM rendah yg dihasilkan oleh semua sel berinti pd manusiaSerum marker of kidney insufficiency & dpt deteksi kondisi CKD tahap dini Lbh sensitif dr Scr utk deteksi kondisi CKD tahap dini; unggul utk hitung GFR pd anak, px transplan & sirosis

Proteinurea vs Albuminuria

Metode Pengumpulan UrinNormalMikroalbuminuriaAlbuminuria / Proteinuria KlinisProtein TotalEkskresi 24 jam 300 mg / hari Dipstick Urin sewaktu (spot)< 30 mg/dL-> 30 mg / dLUrin sewaktu (protein : kreatinin) < 200 mg/g-> 200 mg / gAlbuminEkskresi 24 jam< 30 mg/ hr30-300 mg / hari> 300 mg / hariDipstick Urin sewaktu (spot)< 3 mg/dL> 3 mg / dL-Urin sewaktu (protein : kreatinin) < 17 mg/g (pria)< 25 mg / g (wanita)17 250 mg / g (pria)25 355 mg / g (wanita)> 250 mg/g (pria)> 355 mg / g (wanita)

Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD

Stage

Description

GFR

Evaluation

Management

At increased risk

Test for CKD

Risk factor management

1

Kidney damage with normal or ( GFR

>90

Diagnosis

Comorbid conditions

CVD and CVD risk factors

Specific therapy, based on diagnosis

Management of comorbid conditions

Treatment of CVD and CVD risk factors

2

Kidney damage with mild ( GFR

60-89

Rate of progression

Slowing rate of loss of kidney function 1

3

Moderate ( GFR

30-59

Complications

Prevention and treatment of complications

4

Severe ( GFR

15-29

Preparation for kidney replacement therapy

Referral to Nephrologist

5

Kidney Failure

Specific Interventions for Complications of CKD A1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone; LDL-C = low-density lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density lipoprotein cholesterol; Hgb = hemoglobin.

K/DOQI guidelines (11 set)Hemodialysis AdequacyPeritoneal DialysisVascular AccessAnemia ManagementNutritionChronic Kidney Disease: Evaluation, Classification, and StratificationDyslipidemiaBone Metabolism and Disease in Chronic Kidney DiseaseBone Metabolism and Disease in Chronic Kidney Disease in ChildrenHypertension and Antihypertensive Agents in Chronic Kidney DiseaseCardiovascular Disease in Dialysis Patients

Tata Laksana Dasar CKDObati penyakit dasarKendalikan keseimbangan air & garamDiet rendah protein, tinggi kaloriKendalikan gula darahKendalikan keseimbangan elektrolitCegah & obati renal osteodystrophyObati uremiaDeteksi dini infeksi & obatiPengaturan dosis obatDeteksi dini komplikasi & obatiDialisis & transplantasi

Tata Laksana Dasar CKD (lanjutan)Kendalikan tekanan darahKendalikan gula darahHilangkan sumbatan (obstruksi)Obati infeksi saluran kemihLain-lainAnemiaFeAsam folatEritropoetinGatalDiet rendah proteindifenhidraminMualDiet rendah proteinObati penyakit DasarTx khusus untuk gejala & keluhan uremia

Daftar PustakaK/DOQI Guidelines, 2002OGallaghan C, Brenner BM. The Kidney at A Glance. 2000. Oxford : Blackwell ScienceAshley C, Morlidge C. Introduction to Renal Therapeutics. 2008. London : Pharmaceutical PressSuzuki H, Saruta T. Kidney and Blood Pressure Regulation. 2004. Basel : KargerSobh MA. Essential of Clinical Nephrology. 2000. Cairo : Dar El ShoroukYogiantoro M. Materi Kuliah S2 Farmasi Klinis Ubaya. 2009RCS 6080. Medical and Psychosocial Aspects of Rehabilitation Counseling

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