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Renal replacement therapy

dr. Drajat

Years Until Kidney Failure (GFR < 15 mL/min/1.73 m2) Based on Level of GFR and Rate of GFR Decline
Rate of GFR Decline (mL/min/1.73 m2 per year) 10 7.5 6.5 5.5 4.5 3.5 2.5 1.5 0.5 8 9.4 8.1 6.8 5.6 4.4 3.1 1.9 0.6 6 13 11 9.2 7.5 5.8 4.2 2.5 0.8 4 19 16 14 11 8.8 6.3 3.8 1.3 2 38 33 28 23 16 13 7.5 2.5 1* 75 65 55 45 35 25 15 5

Level of GFR (mL/min/1.73 m2)

90 80

70
60 50 40 30 20

Average age-related GFR decline after age 20-30 year MDRD Study: average rate of decline in GFR is 4 ml/min/year. 85% declined,15% stabile or improvement

Attemps to prevent and correct acute decline on chronic renal failure


Volume depletion IV radiographic contrast Antimicrobial agent (aminoglycoside,amphotericine B) NSAID (including Cox2) ACE/ARB Cyclosporine and tacrolimus Obstruction of the urinary tract

Interventions that have been proven to be effective


Diabetic Kidney Disease Strict giycemic control ACE inhibitors or angletensin-receptor blockers Yes * I:80-120
II:100-140 HbA1C(%):<7

Non diabetic Kidney disease NA

Kidney disease In the transplant Not tested

Yes

Yes (greater affect in patients with proteinuria)

Not tested

Strict blood pressure control

Yes < 125/75 mm Hg

Yes <130/80 mm Hg (greater affect in patients with proteinuria) <125/75 mm Hg (greater affect in patients with proteinuria)

Not tested

* Prevents or delays the onset of diabetic kidney discase.

Should be referred to nephrologist


Most cases of nonprogressive chronic kidney disease can be managed without referral to a nephrologist. Referral to a nephrologist is recommended : - patients with acute kidney failure - GFR less than 30 mL/min/1.73 m2 - progressive decline of kidney function - inability to achieve treatment targets - urine albumin to creatinine ratio greater than 500 mg/24 h)

Guidelines for the management of chronic kidney disease (Canadian Medical Association)

Late vs early referral

Timing of initiation renal replacement therapy


Pernefri,2005 : KK < 15 ml/min for DM, <10 ml/min for non DM. Earlier if uremic symptoms persist.

National Kidney Foundation (2006) estimated GFR 15.0 ml per minute and 15.0 ml per minute when patients have coexisting conditions or symptoms of uremia Canadian Society of Nephrology, 2008 Patients with an estimated GFR < 20 mL/min/m2 may require initiation of renal replacement therapy if any of clinical indicator are present: - symptoms of uremia (after excluding other causes) - refractory metabolic complications (hyperkalemia, acidosis) - volume overload (manifesting as resistant edema or hypertension) - decline in nutritional status (as measured by serum albumin, lean body mass or Subjective Global Assessment) that is refractory to dietary intervention .

Level of GFR at initiation of replacement therapy in US

Data 2009 : - eGFr of 15 ml/min/1.73 m2 increased from 4% to 17% - eGFr of 15 ml/min/1.73 m2 increased from 4% to 17%

USRDS,1999

Modality renal replacement therapy (for chronic kidney disease)


Kidney transplant Hemodialysis (HD) Continuos Ambulatory Peritoneal Dialysis (CAPD)

kidney transplant
Data
ABO/Rh HLA Crossmatch HBsAg/Anti HSV1 HSV2 Anti CMV HCV HIV VDRL/TPHA Hb Lekosit Trombosit

resipien
o/+ A24(A9),A66/A10(?) 20%, pasca imuran 2 mg : 20% -/+ IgG+/IgM+ IgG+/IgM+ IgG+/IgM-tive -tive -tive/-tive 9,1 5.7 186

donor
o/+ A(11)? -/IgG+/IgMIgG-/IgGIgG+/IgM-tive -tive -teve/-tive 12,3 5.4 300

Hemodialysis

Preparation of access for HD

CAPD

Preparation for CAPD

Apa peranan perawat pada penanganan pasien CKD ?


Asuhan keperawatan pasien CKD Asuhan keperawatan pasien renal replacement therapy (kidney transplant,HD,CAPD) Perawat OK (operasi kidney transplant,CAPD,akses HD) Perawat dialisis : melaksanakan HD, merawat kateter HD dan CAPD Edukasi pasien