2 Penyakit Ginjal Kronik - Diagnosis Dan Indikasi Terapi Pengganti Ginjal

MODUL 1.
TERAPI PENGGANTI GINJAL PADA GANGGUAN GINJAL
PENYAKIT GINJAL KRONIK: DIAGNOSIS

DAN INDIKASI TERAPI PENGGANTI GINJAL
Program Pendalaman Materi & Keterampilan Dialisis Dasar
Perhimpunan Nefrologi Indonesia
Februari 2020
CHRONIC KIDNEY DISEASE (CKD)
• Is a silent condition
• Is becoming increasingly common due to ageing and a rising
incidence of DM and hypertension
• Is a potent independent risk factor for CVD
CKD IS A POTENT RISK FOR CV DISEASE
• Individual with CKD have a 10-20-fold greater risk of cardiac death
• Even early CKD constitutes a significant risk factor for CV events and
death
Floege J, Johnson RJ, Feehally J. Comprehensive Clinical Nephrology, 4th Ed. Saunders Elseviers. 2010
DEFINISI PENYAKIT GINJAL KRONIK
KDIGO 2012
Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
Kidney International Supplements (2013)

5
INVESTIGATION FOR CKD
• The diagnosis and staging are based on estimation of glomerular filtration rate
(eGFR) and assessment of albuminuria (or proteinuria).
• Screening process for CKD:
• Calculated GFR
• Urinalysis
• ACR and/or PCR
Biljak VR. The role of laboratory testing in detection and classi cation of chronic kidney disease: national recommendations. Biochemia Medica
2017;27(1):153–76
Woodhouse S. The Glomerular Filtration Rate: An Important Test for Diagnosis, Staging, and Treatment of Chronic Kidney Disease. Labmedicine. 2006:37(4);244-
6.
EQUATIONS FOR ESTIMATING GLOMERULAR FILTRATION RATE
Developed from a large database of participants in research studies and patients from clinical populations with diverse
characteristics, including those with and without kidney disease, diabetes, and a history of organ transplantation.
Inker LA, Fan L, Levey AS. Assessment of renal function. In: Johnson RJ, Feehally J, Floege J. Comprehensive Clinical Nephrology. 5th Ed. Elsevier
Saunders. Phiadelphia. 2015.
COMPARISON OF THE ESTIMATION OF THE FORMULAS TO THE
GOLD STANDARD GFR
Michels WM et al. Performance of the Cockcroft-Gault, MDRD, and New CKD-EPI Formulas in Relation to GFR, Age,
and Body Size. Clin J Am Soc Nephrol. 2010 Jun; 5(6): 1003–1009.
EVALUATION OF CKD - EVALUATION OF GFR
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
EVALUATION OF CKD - EVALUATION OF GFR
FACTORS AFFECTING SERUM CREATININE CONCENTRATION
Levey AS. Assessing the effectiveness of therapy to prevent the progression of renal disease. Am J Kidney Dis. 1993;22(1):207-214.
THE SAME SERUM CREATININE:
VERY DIFFERENT eGFR
Is Cystatin C a More Accurate Filtration Marker than Creatinine?
• Some studies show that serum levels of cystatin C estimate GFR

better than serum creatinine alone.
• Recent studies have clearly demonstrated that cystatin C is a better

predictor of adverse events in the elderly, including mortality, heart
failure, bone loss, peripheral arterial disease, and cognitive
impairment, than either serum creatinine or estimated GFR.
Madero M, Sarnak MJ, Stevens LA. Serum cystatin C as a marker of glomerular ltration rate. Curr Opin Neph Hypertens. 2006;15(6):610-616.
Sarnak MJ, Katz R, Stehman-Breen CO, et al. Cystatin C concentration as a risk factor for heart failure in older adults. Ann Intern Med. 2005;142(7):497-505.
Shlipak MG, Sarnak MJ, Katz R, et al. Cystatin C and the risk of death and cardiovascular events among elderly persons. N Engl J Med. 2005;352(20):2049-2060.
How often should GFR be monitored in CKD?
Arici M. Clinical assessment of a patient with chronic kidney disease. In: M. Arici (ed.), Management of Chronic Kidney Disease,
Springer-Verlag Berlin Heidelberg 2014.
URINALYSIS AND ALBUMINURIA IN CKD
• Urinalysis and assessment of albuminuria are very informative.
• Tests for both screening and diagnosing CKD.
• Role of albuminuria tests:

• defining severity of kidney dysfunction
• estimating prognosis of CKD-related outcomes
• associated cardiovascular risk
• guides treatment
Arici M. Clinical assessment of a patient with chronic kidney disease. In: M. Arici (ed.), Management of Chronic Kidney Disease,
Springer-Verlag Berlin Heidelberg 2014.
URINALYSIS
• A complete urinalysis should be carried out in the first examination

of all CKD patients.
• Urinalysis provides important information on clues for underlying

etiologies of chronic kidney disease
• Needs a proper collection of a urine sample.
• First-void (early) morning urine is usually preferred.

URINALYSIS
Parameter Fisik Parameter Kimia Mikroskopik
• Warna • pH • Sel
• Kekeruhan • Darah/Hb • Casts
• Bau • Glukosa • Kristal
• Osmolalitas • Protein • Bakteria
• Berat Jenis • Keton • Jamur
• Leukosit esterase • Parasit
• Nitrit
• Urobilinogen
Fogazzi GB. Am J Kidney Dis 2008;51:1052-67

CLINICAL APPROACH TO HEMATURIA
EVALUATION OF ALBUMINURIA
Relationship of eGFR and Albuminuria with
mortality
RRs of decreased eGFR and increasing ACR with future
complications
STADIUM PGK - LFG
KDIGO 2012

22
STADIUM PGK - ALBUMINURIA
KDIGO 2012

23
PROGNOSIS OF CKD BY GFR AND ALBUMINURIA CATEGORY
THE TREATMENT IN CKD PATIENTS CAN:
• Prevent or delay the progression of CKD
• Reduce or prevent the development of complications
• Reduce the risk of CV disease
Risk factors
MANAGEMENT
• Stage 1 and 2 (eGFR ≥ 60 ml/min)
• Goals :
• Reduce progression of kidney disease
• Reduce CV risk
Management MANAGEMENT
• Stage 1-2 CKD management (eGFR ≥ 60 ml/min)
Monitoring:
• 3-6 monthly clinical review
• Clinical assessment : BP, weight, urine dipstick
• Laboratory assessment: ureum, creatinine, electrolytes, eGFR,
fasting glucose, fasting lipids
Levin A, Hemmelgarn B, Culleton, et al. Guidelines for the management of chronic kidney disease, CMAJ 2008,179(1):1154-1162
65-100 mmol/day ~ 3-4 mg/day
KDIGO-CKD Guidelines, 2012
LDL Cholesterol level < 2.0 mmol/L ~ < 77mg/dL
Fasting plasma glucose 4-7 mmol/L ~ 72-126 mg/dL
Stage 3 CKD management
(eGFR 30-59 ml/min)
• Goals
• Reduce CV risk
• Early detection and management of complications
• Avoidance of nephrotoxic medications and agents
• Adjustment of medication doses to levels appropriate for kidney function
(eGFR 30-59 ml/min)
• One to three monthly clinical review
• Clinical assessment: BP, weight, urine dipstick
• Laboratory assessment: urea, creatinine, electrolytes, eGFR, fasting
glucose, fasting lipids, iron stones, Ca-P, PTH (quarterly), full blood
count
(eGFR 15-29 ml/min)
• Goals:
• Reduce CV risk
• Avoidance of renally-excreted and nephotoxic medications.
• Adjustment of medication doses
• Preparation for renal replacement therapy
Stage
Stage44CKD
CKDmanagement
management
(eGFR
(eGFR15-29
15-29ml/min)
ml/min)
• Monitoring
• Monthly clinical review
• Clinical assessment: BP, weight, edema, urine dipstick
• Laboratory assessment: urine dipstick ,urea, creatinine, electrolytes, eGFR,
fasting glucose, fasting lipids, full blood count, iron stores, Ca-P, PTH
(quarterly)
(eGFR <15 ml/min)
• Goals:
• Reduction in CV and renal risk
• Avoidance of renally-excreted and nephrotoxic medications
• Adjustment of medication doses to levels appropriate for kidney function
Stage
Stage55CKD
CKDmanagement
management
(eGFR
(eGFR<15
<15ml/min)
ml/min)
• Monitoring
• Monthly clinical review
• Clinical assessment: BP, weight, edema
• Laboratory assessment: urea, creatinine, electrolytes, eGFR, fasting glucose,
fasting lipids, full blood count, iron stores, Ca-P, PTH (quarterly)
Recommended dietary intake for chronic kidney and end-stage renal disease patients*
≥35 kcal/kg/day; if the body weight is greater than 120 percent of

normal or the patient is greater than 60 years of age a lower amount
may be prescribed
Overview of the management of chronic kidney disease in adult. Uptodate, 2013

Protein Intake
KDIGO-CKD Guidelines, 2012

INDIKASI TERAPI PENGGANTI GINJAL
• Umumnya jika eLFG <8 ml/menit/1,73 • Indikasi dialisis segera:
m2 • Gangguan neurologis: neuropati,
• Inisiasi dialisis dipercepat jika ada ensefalopati
gejala/tanda berikut: • Pleuritis atau perikarditis tanpa
• Overload cairan dan/atau hipertensi yang penyebab lain
refrakter
• Gangguan perdarahan/koagulasi
• Hiperkalemia refrakter
• Asidosis metabolik refrakter
• Hiperfosfatemia refrakter
• Anemia refrakter
• Penurunan kondisi fisik/fungsional umum
• Perburukan status nutrisi
Daugirdas. Handbook of dialysis. 5th ed. 2015

PILIHAN TERAPI PENGGANTI GINJAL
• Transplantasi ginjal, termasuk preemptive transplantation
• Dialisis: hemodialisis, peritoneal dialisis
• Menunda dialisis: very low protein diet plus ketoanalogues,
tatalaksana cairan ketat; terutama untuk usia lanjut dengan kondisi
yang masih baik (komorbid relatif sedikit)
• Terapi paliatif: terapi konservatif, terutama untuk pasien yang dengan
komorbid yang banyak dan berat
Daugirdas. Handbook of dialysis. 5th ed. 2015

Perbandingan: HD vs PD
Kelebihan HD Kekurangan HD
Sudah lebih tersosialisasi luas Kualitas hidup kurang, tidak bebas
Dilakukan di RS, lebih terkontrol Adaptasi perlu waktu lama
Tidak harus setiap hari Risiko infeksi dan trombosis
Akses pemberian Fe IV mudah Penurunan RRF lebih cepat
Pasien tidak perlu repot sendiri Hemodinamik kurang stabil, perlu
heparinisasi
Kelelahan di hari dialisis
Kelebihan PD
Penurunan RRF lebih lambat Kekurangan PD
Dapat hidup lebih normal Risiko malnutrisi
Survival di tahun awal lebih baik Tidak cocok untuk orang tertentu
Kebutuhan Epo/Fe IV berkurang Risiko peritonitis / infeksi exit-site
Pemberian antibiotik dan insulin Peluang masalah teknik masih tinggi
Cocok untuk anak dan lansia Pemberian Fe IV tidak bisa
Tidak perlu heparinisasi Butuh ketelatenan tinggi
Hemodinamik lebih stabil Risiko hiperglikemia dan obesitas
47

2 Penyakit Ginjal Kronik - Diagnosis Dan Indikasi Terapi Pengganti Ginjal

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2 Penyakit Ginjal Kronik - Diagnosis Dan Indikasi Terapi Pengganti Ginjal

Uploaded by

Copyright:

Available Formats

MODUL 1.

TERAPI PENGGANTI GINJAL PADA GANGGUAN GINJAL

PENYAKIT GINJAL KRONIK: DIAGNOSIS

Kidney International Supplements (2013)

• Some studies show that serum levels of cystatin C estimate GFR

• Recent studies have clearly demonstrated that cystatin C is a better

• Role of albuminuria tests:

• A complete urinalysis should be carried out in the first examination

• Urinalysis provides important information on clues for underlying

• Needs a proper collection of a urine sample.

• First-void (early) morning urine is usually preferred.

Parameter Fisik Parameter Kimia Mikroskopik

Fogazzi GB. Am J Kidney Dis 2008;51:1052-67

Kidney International Supplements (2013)

Kidney International Supplements (2013)

≥35 kcal/kg/day; if the body weight is greater than 120 percent of

Overview of the management of chronic kidney disease in adult. Uptodate, 2013

KDIGO-CKD Guidelines, 2012

Daugirdas. Handbook of dialysis. 5th ed. 2015

Daugirdas. Handbook of dialysis. 5th ed. 2015

You might also like