Chronic Kidney Disease

one of frequent changes occur along with the aging process is decreased function
kidney. This thing caused by changes in anatomical factors, physiological and clinical.
Kidney function decrease and by the age of 70, about 30-50% of the cortical glomerular tissue
has been lost. For every decade over Age of 40 years, Glomerular Filtration Rate (GFR)
decreases about 10 ml/ min so that on age 70 years GFR has decrease about 30 ml/ min .
Decrease function kidney on aging this irreversible.
The aging process is also aggravated by clinical factors that are risk factors for kidney
disease. The clinical factor is disease suffering from chronic as hypertension, diabetes,
hyperlipidemia , disease cardio vasculature , etc.
Disease Kidney Chronic ( Chronic Kidney Disease) is a disease kidney where there is drop
function long kidney period monthly until year marked with drop glomerular filtration rate
(GFR ) slowly in long period. there is no symptom in beginning on disease kidney chronic,
however along time moment disease kidney chronic heavy, will arise symptoms such as :
swelling on the legs, fatigue , nausea and vomiting , loss lust eat , and confusion.
Hypertension often occur on CKD patients with variation of prevalence depends from
causes of CKD and function kidney. Generally the cause of kidney chronic disease is drop
blood flow to kidney caused by hypertension , damage cell mesangial by Diabetes Mellitus .
Count estimation Creatinine clearance patient with the Cockroft formula Gault ( Cockcroft
and Gault , 1976):
female :
0,85 x ( 140−usia ) x BB
LFG =
72 x serum kreatinin ( )
mg
dl
On scenario :
Age = 78 year
weight = 79 kg
Creatinine = 1.71 mg/dl
female :
 0,85 x ( 140−78 ) x 79
LFG =
72 x 1,71( )
mg
dl
= 30.8 ml/ min
According to Chronic Kidney Disease Improving Global Outcomes (CKD KDIGO) proposed
classification , it can be shared be :
So , on scenario patient enter into stage G3b (moderate -severe )

Management
Management disease kidney chronic include :
1) Therapy Specific to disease basic before happening decrease in GFR, so that deterioration
function kidney not happening.
2) Prevention and therapy on comorbid condition. factors comorbid among other things,
disturbance balance fluids, uncontrolled hypertension, controlled infection, tract urinary
obstruction, tract urine , drugs nephrotic , material radiocontrast , or enhancement activity
disease basically.
3) Delayed function progression kidney. Main factor reason of bad function kidney is
hyperfiltration glomerulus. Two method important for reduce hyperfiltration glomerulus
are : Restrictions protein intake , which is done at GFR 60 ml/ min , whereas on mark the
restrictions intake protein is not recommended . Protein given is 0.6-0.8/kg. weigh/ day ,
of which 0.35-0.50 gr of which is a protein biology high value. Amount of calories 30-
35kcal/ kgBW / day . When occur malnutrition , amount protein intake and calories can
improved.
4) Prevention and therapy to disease cardiovascular , use drug antihypertensive. A number
of drug antihypertensives, especially blocker angiotensin converting enzymes (ACE
inhibitors), such as captopril via a number of studies proven could slow down the
deteriorating process function kidney .
5) Prevention and therapy happened to complications . A number of possible complications
occur namely anemia ( evaluation done if HB level 10g% or hematocrit 30%).
Complications next that is renal osteodystrophy .
 6) Therapy replacement kidney in the form of dialysis or transplant kidney , done on disease
kidney chronic stage 5, ie low GFR from 15ml/ min . Therapy the in the form of
hemodialysis, peritoneal dialysis or transplant kidney .

Prevention
Prevention to kidney chronic disease should already start done at an early stage disease
kidney chronic . Various effort prevention that has been proven beneficial in prevent disease
kidney and cardiovascular , that is treatment hypertension ( more low pressure blood more
small risk drop function kidney ), sugar blood control, fat blood , anemia , discontinuation
smoking , increase physical activity and body weight control.

Type II DM

Diabetes Mellitus is one of metabolic disorders with hyperglycemia characteristics because

abnormality insulin deficiency caused work interruption and or insulin secretion. Elderly with a
long enough DM on generally own less good quality life because have a negative influence to
physique and psychological of sufferer . physiological changes on human experience drop drastic
on age over 40 years. Diabetes mellitus often appear after somebody enter range age vulnerable
that is after 45 years old

Factors that become the originator occurrence of DM at age carry on that is

- Change composition body
- Decreasing activity physique
 - Lifestyle changes
- neuro –hormonal changes ( decreased plasma DHES and IGF-1 concentrations )
- Increased oxidative stress
- There is age related metabolic adaptation

Governance
Non -pharmacological therapy
1. Diet control
2. Sport
3. Stop smoke

Therapy Pharmacology
Therapy Pharmacology Polypharmacy in DM treatment in elderly patient often happen.
Simplification regimen treatment recommended for reduce risk of hypoglycemia. In
determination regimen treatment, recommended medicine that have risk low hypoglycemia

1. metformin
Metformin is first agent line for type 2 DM . Metformin is safe and effective for elderly
patient because not causing hypoglycemia. Latesr studies show that metformin can used
safely on patient with glomerular rate filtration 30 mL/min/1.73 m 2 . However, This drug
is contraindicated in patients with advanced renal insufficiency and is used with caution
in patients with impaired liver function or heart failure because of the increased risk of
lactic acidosis. Metformin may be temporarily discontinued prior to invasive procedures,
during hospitalization, and in the presence of acute illness that may impair kidney or liver
function.
2. Thiazolidinediones
3. Drugs of this class should be used with extreme caution in elderly patients with
congestive heart failure and elderly patients who have a high risk of falls or fractures.
4. Sulfonylureas
Sulfonylureas are associated with a risk of hypoglycemia and should be used with
caution. If used, a shorter acting sulfonylurea such as glipizide is recommended.
 Glibenclamide/glyburide is a long-acting sulfonylurea and is contraindicated in elderly
patients.
5. DPP-IV inhibitors
Drugs belonging to the DPP-IV inhibitor class have minimal risk of hypoglycemia, but
the high cost of the drug may be a barrier for some elderly patients.
6. SGLT-2 inhibitors
Data on the long-term use of this class of drugs are still limited, although preliminary
safety and safety data have been reported
7. insulin therapy
Insulin therapy requires the patient or the patient's caregiver to have good functional and
cognitive abilities. Insulin therapy relies on the patient's ability to inject insulin alone or
with the help of a caregiver. The insulin dose should be titrated to meet individual
glycemic targets and to avoid hypoglycemia. Basal insulin injection therapy given once
per day is associated with minimal side effects and may be a good option. Administration
of insulin in doses more than once per day may be too complicated for elderly patients
with advanced diabetes complications, activity-restricting comorbid diseases, or limited
functional status.

Prevention
- - Primary prevention, all activities aimed at preventing the onset of hyperglycemia in
individuals at risk for diabetes or the general population
- - Secondary prevention, finding people with DM as early as possible, for example by
screening tests, especially in high-risk populations. With the diagnosis of previously
undiagnosed diabetes patients can be caught, so that efforts can be made to prevent
complications or even if there are complications they are still reversible.
- - Tertiary prevention, all efforts to prevent complications or disability due to
complications, including:
 Prevent complications
 Prevent the progression of these complications so as not to become organ failure
 Prevent body defects

To prevent chronic complications in the elderly:

  Control blood sugar
 Control blood pressure
 Control blood fat

Ref:

1. Prasetyo , Agung . 2019. Management of Diabetes Mellitus on Patient Geriatrics .

Education Doctor , Faculty Medicine , University Tanjungpura , Pontianak, Indonesia.
CDK-277/ vol. 46 no. 6 yrs . 2019
2. Rochmah , Wasila . 2014. Diabetes Mellitus on Age Continue . Knowledge Disease In
Volume II Edition VI. page 2424
3. Aulia , 2017. Diagnosis, Classification , Prevention , Therapy Disease Kidney Chronic .
Directorate Prevention and Control Disease No Infectious Directorate General Prevention
and Control disease . Ministry Health Republic of Indonesia. in access on May 10, 2022.
http://p2ptm.kemkes.go.id/activity-p2ptm/subdit-disease-diabetes-melitus-dan-angguan-
metab olik/diagnosis-classification-pentahanan-therapy-disease-ginjal-kronis
4. Suwitra , Ketut . 2014. Disease Kidney Chronicle . Knowledge Disease In Volume II
Edition VI. Pg 2159.
5. Fadhilah , Agnez Zahrah . 2014. Chronic Kidney Disease Stage V. J Agromed Unila
Volume 1 Number 2. Faculty of Medicine, Lampung University