CLINICAL CARE PATHWAY FOR CKD

GROUP 2

ANDARIAS PILANG (P1337420818023)

NOVITA WULANDARI (P1337420818036)
ALIQUL SAFIQ (P1337420818038)
GENTUR WICAKSONO (P1337420818018)
NIYA FITTARSIH (P1337420818025)
ICHE NILA KUSNA (P1337420818024)
PUTRI WULANDARI (P1337420818017)
INNEKE NOVIANA (P1337420818015)
ANGGORO SUGITO (P1337420818016)
DINAR JANTIK WULANDARI (P1337420818014)
NADHIFAH RAHMAWATI (P1337420818002)
YUDI HERDIYANA (P1337420818022)

POST GRADUATE APPLIED NURSING PROGRAM

HEALTH POLYTECHNIC MINISTRY OF HEALTH REPUBLIC OF
INDONESIA
2019/2020
 CARE PATHWAY FOR CKD

A. BACKGROUND

Chronic renal failure is a pathophysiologic process with varying

etiology, causing a decline in kidney function that is irreversible dam goes

progressively to kidney failure. Kidney failure in performing its functions

cause Patients requiring renal replacement therapy in the form of dialysis or

kidney transplantation. Besides chronic disease of kidney failure can also be

defined by the occurrence of damage to the kidneys (renal damage) that

Occurs for more than 3 months

Non-communicable disease(NCD) or so-called non-communicable

diseases has Become a world where the issue of development increasing,

especially in cases of non-communicable diseases. One of the chronic

diseases that need attention are chronic kidney disease, the which is a

complication of Several NCDs such as hypertension, diabetes mellitus, and

other renal diseases. Chronic renal failure is a progressive decline in renal

function ireveriabel roomates when the kidneys are Unable to maintain

metabolic balance,

Based on the World Health Organization (WHO) Showed that both

acute kidney failure or chronic reach 50%, while the unknown and treatment

is only 25% and 12.5% were treated well.

Chronic renal failure is a health problem with a prevalence of the

number of Patients is increasing, estimated in 2025 in Southeast Asia, the

Middle East and the Mediterranean and Africa can reach more than 380

million people, it is affected by population growth, urbanization, an Increase

in the aging process, unhealthy lifestyles and obesity2, Reported by

RISKESDAS 2018 Showed the prevalence of Patients with chronic renal

failure in Indonesia was 3.8% previously to 2.0% in 2013. The prevalence of

chronic kidney failure Patients who were / are undergoing dalisis in 2018 in

Indonesia by 19, 3%,

Based on Data Obtained from the Reporting and Recording System

Hospital (SP2RS), Obtained a description that chronic kidney disease was

ranked four out of ten non-communicable diseases that cause most deaths in

hospital in Indonesia amounted to 3:16%, or about 3047 numbers of death ,

whereas Indonesia According to the data from the 2010 Health profile, ranks

sixth of kidney failure as the cause of death in Patients hospitalized in

Indonesia the which amounted to 2.99%,

One of the therapies performed by Chronic Renal Failure Patients to

replace the damaged kidney function is hemodialysis therapy. This therapy is

a procedure that is expensive and familiar Because most Often served

Patients with Chronic Renal Failure, and a high technology to excrete waste

from the body and substances harmful toxins in the body through a semi-

permeable the which serves as a barrier between blood and dialysate fluid on

the tool dialiser through the process of diffusion, osmosis or ultrafiltrate.

Approximately More than 70% of the countries reported there were at least

80% of the Patients using hemodialysis therapy.

 Hemodialysis is the most commonly used therapy in the United

States and Europe about 46% -98% of Patients running hemodialysis

therapy, Although hemodialysis is Effectively Able to Contribute

Effectively to extend the patient's life, but the morbidity and mortality is

quite high, only 32 % - 33% of Patients who undergo hemodialysis

therapy can survive in the fifth year,

B. RISK FACTOR

1. Direct Risk Factors

a. Diabetes

b. Hypertension

c. autoimmune Diseases

d. drug toxicity

e. Acute renal failure

f. natural medicine

g. metabolic syndrome

h. systemic infection

i. Urinary tract infection

j. urinary stones

k. Lower urinary tract obstruction

l. cardiovascular disease

2. Insecurity

a. Age> 60 years

b. A family history of CKD

 3. Progressive Risk Factors

a. high proteinuria

b. hypertension

c. Uncontrolled blood sugar

d. Smoke

e. hyperlipidemia

f. use of drugs

C. CKD Management in Hospitals at Indonesia Country

Perform routine checks for patients at risk of CKD

1. Serum creatinine to determine an estimate of GFR

2. microalbuminuria test

3. Urinalysis for the presence of white blood cells and red

4. screening of eGFR and albumin to creatinine ratio in urine (ACR).

5. If eGFR <60 and / or ACR> 60, repeat within 2 -4 weeks

If not Does the patient have a high albumin to creatinine ratio?

1. Diabetes:> 30mg albumin / creatinine lg

- Non-diabetics:> 300 mg

- Follow-up monitoring of CKD

2. Tests for CKD risk per year

3. Provide health education to reduce risk factors whenever possible

If Yes Does the patient have a normal GFR> 3 Months

1. Determine Stage of CKD

a. Phase 1 GFR> 90 /min/1.73 m2

 b. Phase 2 GFR 60-89 m2 /min/1.73

c. Phase 3 GFR30-59 /min/1.73

d. Stage 4 GFR 15-29 m2 /min/1.73

e. Stage 5 GFR <15 /min/1.73

2. Next intervention conducted after the above steps, namely:

a. Starting CKD Treatment: Clinical develop an action plan (Box.5)

b. Collaborate with nephrologist plans make:

- Evaluate the types of kidney disease

- Evaluating and managing comorbid conditions (primary

care, all phases)

- Slow the loss of kidney function (co-management, all

phases)

- To prevent and treat cardiovascular disease (primary care,

all phases)

- Preventing and treating complications of decreased kidney

function (co-management, all phases)

- Consult nephrology if the action plan can not be done or

done when GFR <60.

c. Identify the risks associated with CKD

- Consider these types of kidney disease

- Evaluation of complications of kidney disease: anemia,

hypertension, diseases of malnutrition, bone, metabolic

 acidosis, congestive heart failure, hyperkalemia, edema was

determined to be fluid overload, neuropathy

- Evaluation of the risk of loss of kidney function

- Evaluating comorbid conditions

- Evaluation of the risk of cardiovascular disease

d. Review the use of the drug in a follow-up visit

- Evaluation for dose adjustment is required based on the

level of kidney function

- Evaluation of side effects of drugs on kidney function

(NSAIDs, IV)

If not

- Evaluation for drug interactions

- Counsel patients to avoid nephrotoxic drugs and contrast IV

- Evaluating the suitability for ARB / ACE inhibitor with a

diagnosis of hypertension

- Evaluation of the need for therapeutic drug monitoring

e. Assess barriers to treatment adherence

- Family and social support

- Depression

- Income and unemployment worries

- Stress and coping mechanisms

- Perception of disease and treatment access

- Limited to medications and / or treatments

The patient's condition should be normal with a GFR of> 3 months

a. If yes

- Monitor the progression of CKD and GFR with annual

mikroalbumin

- Consult / refer nephrologist

b. If not

- Consult a nephrologist if hematuria or proteinuria, decreased

GFR> 4ml / min / year

- Refer the patient for nephrologist for evaluation when GFR

<30 mL / min / 1.732