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 Renin Angiotensin II

ADH

Kidney Ang II Adrenal Aldosteron

Lung

Na+ excretion H2O excretion

Angiotensin I
Angiotensinogen Hepar

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
50.1%

Hypertension 27%

Primary Diagnosis for Patients Who Start on Dialysis

Pe Reabs Na Hipertrofi sel renal Ggn konstentrasi urin Penurunan GFR Ggn fs ekskresi Pe eksr sisa metab Pe ekskr kalium Pe ekskr PO4 Pe ekskr ion H Ggn Reproduksi Ggn Imun Ggn fs non ekskresi prod eritropoetin

CKD

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

= 0.85 if female

MDRD = Modification of Diet in Renal Disease; Ccr = creatinine clearance.

Levey et al. Ann Intern Med. 2003;139:137-147.

CKD Progresses in Stages Defined by Kidney Function: GFR

CKD Stage
1 2 3 4 5

Description
Kidney damage normal incr. GFR Mild decr. in GFR Mod dec. in GFR Severe decr in GFR Kidney failure

GFR
90 60-89 30-59 15-29 <15

Prevalence
5,900,000 5,300,000 7,600,000 400,000 300,000

Patients/ Nephrologist
1180 1060 1520 80 70 (145-160 by 2010)*

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

DAMAGE

LOW GFR

COMPLICATIONS

CKD DEATH

RENAL FAILURE

Considerations for Patients with CKD?

Susceptibility Risk Factors
Diabetes Hypertension Older age Family history of CKD Racial or ethnic minority

Progression Factors
Higher level of proteinuria Higher BP Poor glycemic control Smoking

Complications
CVD Anemia Altered bone & mineral metabolism

Other: low income, Hyperlipidemia minimal education, kidneymass reduction, known Drug use kidney disease
Levey et al. Ann Intern Med. 2003;139:137-147. USRDS. 1999 Annual Data Report. Available at: www.usrds.org.

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 80 60 40 2.9 20 15.7 0
+ DM, - CKD - DM, +CKD + DM, + CKD

No Events ESRD Death 67.6 84.0 6.1 32.3 61.6

0.3

29.5

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 60 40 20 0

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.

LVH at Baseline (%)

50-75

25-50

<25

eGFR (mL/min/1.73 m2)1

Dialysis Start

Anemia Rates Increase as Levels of CKD Severity Progress

100 Anemia Prevalence (%) 80 60 40 20 0
9 5 14 15 8 17 62 8 20 43 10 15

Hgb Values 11-12 g/dL 10-11 g/dL <10 g/dL

<2

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.

Specific Interventions for Complications of CKD

Complication
Diabetes

Intervention
Glycemic control

Target Goals
preprandial glucose 90-125 mg/dL A1C <7% < 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

Hypertension Secondary HPT

Dyslipidemia

BP control PTH control

Maintain lipids to target Reach Hgb goal Dietary modification

Anemia Malnutrition

A1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone; LDL-C = lowdensity lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density lipoprotein cholesterol; Hgb = hemoglobin.

Summary: Clinical Actions for Progressive Stages of CKD

CKD Stage
Risk

GFR Description
At increased risk Kidney damage with normal or GFR Kidney damage with mild GFR Moderate GFR Severe GFR Kidney failure

(mL/min/1.73 m2)
90 with CKD risk factors 90

Action*
Evaluate for CKD Reduce/control CKD risk factors Diagnose and treat comorbid conditions Address progression factors Reduce/control CVD risk factors Estimate progression *All actions for prior stages Evaluate and treat complications *All actions for prior stages Prepare for kidney replacement Evaluate and treat complications

2
3 4 5

60-89
30-59 15-29 <15 or dialysis

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/dL15 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

Non-Oliguria Risk Oliguria

Injury

Adjusted creat or GFR decrease> 50% or Scr x 2

UO < 0.5/ml/kg/h x 12 hr ??

Failure Loss ESRD

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

ARF ~ earliest time point for provision of RRT

Irreversible ARF or persistent ARF > 4 wks ESRD > 3 months

Specificity

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)

Klasifikasi/staging AKI modifikasi RIFLE

Stadium 1. Risk 2. Injury 3. Failure

kriteria kreatinin serum kreatinin meningkat > 0,3 mg/dl atau meningkat lebih dari 150-200 % dari awal serum kreatinin meningkat sampai > 200% sampai 300% dari data awal serum kreatinin meningkat > 300%, (serum kreatinin > 4mg/dl dengan peningkatan akut 0,5mg/dl, indikasi untuk renal replacement therapy

kriteria urin output < 0,5ml/kg per jam untuk >6jam < 0,5 ml/kg per jam untuk 12 jam <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 ESRD

Persistent renal failure for >4 weeks 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

Complement activation

Pro-inflamatory mediators Oxygen free radicals

+ -

Anti-inflamatory mediators Arachidonic acid metabolities

Nitric oxide
Heat shock proteins Endothelins

Cellular activation (PMN,endothelialcells)

Proteases
Chemokines Platelet activating factor

Urinary KIM-1, NAG

Acute kidney injury

Serum creatinine

Urine output

GFR

Pathogenic mechanism of sepsis related acute kidney injury

Possible pathogenetic mechanisms in ATN.

Ischemia Nephrotoxins
Tubular damage (proximal tubules and ascending thick limb)

(1) Vasoconstriction Renin-angiotensin endothelin PGI2 NO

(2) Obstruction by casts

(3) Tubular backleak

(4) Interstitial inflammation

Intratubular pressure

Tubular fluid flow

(5) ? Direct glomerular effect

GFR

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