Kajian Ilmiah

CKD KDIGO 2012

DIVISI GINJAL HIPERTENSI

BAGIAN ILMU PENYAKIT DALAM
RUMAH SAKIT UMUM PUSAT MOH. HOESIN PALEMBANG
 Definition

CKD  Kidney damage for ≥3 months, as defined by

structural or functional abnormalities of the kidney, with
or without decreased GFR or GFR <60 mL/min/1.73m2
for ≥3 months, with or without kidney damage.

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Criteria

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 Classification

CKD is classified based on cause, GFR category and

albuminuria category (CGA).
Assign cause of CKD based on presence or absence of
systemic disease and the location within the kidney of
observed or presumed pathologic anatomic findings.

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Criteria

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 Predicting Prognosis

Identify cause of CKD;

GFR category;
Albuminuria category;
Other risk factors and comorbid conditions.

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 Evaluation of Chronicity

In people with GFR <60 mL/min/1.73m2 or markers of

kidney damage, review past history and previous
measurements to determine duration.
• If duration is >3 months, CKD is confirmed. Follow
recommendations for CKD.
• If duration is not >3 months or unclear, CKD is not
confirmed. Patients may have CKD or acute kidney
diseases (including AKI) or both and tests should be
repeated accordingly

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 Evaluation of Causes

Evaluate the clinical context, including personal and

family history, social and environmental factors,
medications, physical examination, laboratory measures,
imaging, and pathologic diagnosis to determine the causes
of kidney disease.

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 Evaluation of Causes

Using serum creatinine and a GFR (1A)

Additional tests (such as cystatin C or a clearance
measurement) for confirmatory testing in specific
circumstances when eGFR based on serum creatinine is
less accurate. (2B)
Measuring cystatin C in adults with eGFR creat 45-59
who do not have other markers of kidney damage if
confirmation of CKD is required. (2C)

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 Evaluation Albuminuria

Initial testing of proteinuria (early morning urine sample is

preferred) (2B)
urine albumin-to-creatinine ratio (ACR) and urine protein-
to-creatinine ratio (PCR) in untimed urine samples in
addition to albumin concentration or proteinuria
concentrations rather than the concentrations alone. (1B)

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 Progression

GFR Category G1 to G5
Rapid progression is defined as a sustained decline in
eGFR of more than 5 mL/1.73m2/year
Assessing progression is increasing number of serum
creatinine measurements and duration of follow-up

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 Management of Progression and
Complications of CKD

BP targets and agents according to age, coexistent

cardiovascular disease and other comorbidities, risk of
progression of CKD, presence or absence of retinopathy (in
CKD patients with diabetes), and tolerance of treatment

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 Management of Progression and Complications
of CKD

Both diabetic and nondiabetic adults with CKD with BP

systoltic >140 mmHg and diastolic >90 mmHg and urine
albumin excretion <30 mg/24 hours (or equivalent*) treated
with BP-lowering drugs to maintain a BP that is consistently
≤140 mm Hg systolic and ≤90mm Hg diastolic. (1B)

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 Management of Progression and
Complications of CKD

Both diabetic and non-diabetic adults with CKD with BP

>130 mm Hg systolic or >80 mm Hg diastolic and with urine
albumin excretion of ≥30 mg/24 hours (or equivalent*)
treated with BP-lowering drugs to maintain a BP that is
consistently ≤130 mm Hg systolic and ≤80 mm Hg diastolic.
(2D)

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 Management of Progression and
Complications of CKD

ARB or ACE-I can be used in diabetic adults with CKD

and urine albumin excretion 30-300 mg/24 hours (or
equivalent*).
ARB or ACE-I can be used in both diabetic and non-
diabetic adults with CKD and urine albumin excretion >300
mg/24 hours (or equivalent*).

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 Management of Progression and
Complications of CKD

Lowering protein intake to 0.8 g/kg/day in adults with

diabetes or without diabetes and GFR <30 ml/min/1.73m2
Avoiding high protein intake (>1.3 g/kg/day) in adults with
CKD at risk of progression.
Lowering salt intake to <90 mmol (<2 g) per day of
sodium (corresponding to 5 g of sodium chloride) in adults,
unless contraindicated

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 Management of Progression and
Complications of CKD

People with CKD be encouraged to take exercise (aiming

for at least 30 minutes 5 times per week), achieve a healthy
weight (BMI 20-25, according to country specific
demographics), and stop smoking.

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 Management of Progression and
Complications of CKD

People with CKD measure Hb concentration

▪ When clinically indicated in people with GFR ≥60
ml/min/1.73 m2
▪ At least annually in people with GFR 30-59 ml/min/1.73
m2
▪ At least twice per year in people with GFR <30
ml/min/1.73 m2

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 Management of Progression and
Complications of CKD

Measuring serum levels of calcium, phosphate, PTH, and

alkaline phosphatase activity at least once in adults with
GFR <45 ml/min/1.73 m2 in order to determine baseline
values and inform prediction equations if used.
If bicarbonate concentrations <22 mmol/l treatment with
oral bicarbonate supplementation be given to maintain
serum bicarbonate within the normal range, unless
contraindicated

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 Other Complication

Cardiac and vascular disease (CVD)

Medication dosage
Patient safety
Infections
Hospitalizations
Caveats for investigating complications

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 Timing of The Initiation of Renal
Replacement Therapy
One or more of the following are present:
symptoms or signs attributable to kidney failure (serositis,
acidbase or electrolyte abnormalities, pruritus)
Inability to control volume status or blood pressure
A progressive deterioration in nutritional status refractory
to dietary intervention, or
Cognitive impairment
This often but not invariably occurs in the GFR range
between 5 and 10ml/min/1.73 m2.

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Timing of The Initiation of Renal
Replacement Therapy

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 Dialysis Modalities and Availablility

In-center, satellite and self-care, where dialysis is

undertaken with access to support staff to aid in the dialytic
procedure
Home dialysis (continuous ambulatory and automated
peritoneal dialysis)
Urgent and non-urgent dialysis

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Dialysis Modalities and Availablility

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Dialysis Modalities and Availablility

How CAPD works

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Dialysis Modalities and Availablility

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