PENYAKIT GINJAL KRONIK

Arwedi Arwanto
RSUP DR KARIADI
 FUNGSI GINJAL
Struktur tulang

Metabolisme limbah Pembentukan darah

Keseimbangan Vitamin D
Calcium Aktifasi

Pembentukan
pembuangan Erythropoietin
Urea, Creatinine

Keseimbangan Cairan
Keseimbangan
Kalium

pembentukan Pembuangan
Bicarbonate garam
Tekanan Darah
Aktifitas jantung
Keasaman darah
 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

• 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
 FAKTOR RISIKO
 Susceptibility (peningkatan
risiko)
 Bertambahnya umur
 Penurunan massa ginjal &
BB lahir rendah
 Riwayat keluarga
 Edukasi & pendapatan yg
rendah
 Inflamasi sistemik
 dyslipidemia
 Initiation
(faktor atau keadaan yg
secara langsung dpt
menyebabkan kerusakan
ginjal)
 Diabetes melitus
 Hipertensi
 Penyakit autoimun
 Penyakit ginjal polikistik
 Toksisitas obat
 Progresifitas

faktor faktor yg menyebabkan kerusakan ginjal

semakin memburuk
 Glikemia
 Peningkatan tekanan darah
 Proteinuria
 merokok
 Patogenik awal
PATOFISIOLOGI
Glomeruler injury

Diabetes melitus Penurunan area filtrasi Arteriosclerosis

Perubahan hemodinamik adaptif

Glikasi produk akhir
hiperlipidemia

Peningkatan aliran Peningkatan tek kapiler Hipertensi sistemik

darah glomeruler glomeruler

Hipertrophy Epithelial injury Endothelial injury Mesangial injury

glomeruler
Epithelial foot processes proteinuria meluas
Kerusakan fokal

Deposisi hyaline Microthrombi pada

glomeruler Kapiler glomeruler

Glomerulosclerosis

Progresi penyakit ginjal

 Chronic Kidney Disease
 Diabetic Nephropathy
 Glomerulonephritis
 Hypertension
 Obstructive Nephropathy
 Polycystic Kidney Disease
Glomerulonephritis
Hypertension
Polycystic Kidney Disease
Obstructive Nephropaty
 Definition of CKD
KDIGO 2012
CKD is defined as abnormalities of kidney structure or function, present for > 3
months, with implications for health.

22
Kidney International Supplements (2013)
 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
• Role of albumin tests :
defining severity of kidney dysfunction
estimating prognosis of CKD-related outcomes
associated cardiovascular risk
guides treatment
Woodhouse S. The Glomerular Filtration Rate: An Important Test for Diagnosis, Staging, and Treatment of Chronic Kidney
Disease. Labmedicine. 2006:37(4);244-6.
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
EVALUATION OF CKD - EVALUATION OF GFR

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
THE SAME SERUM CREATININE:
VERY DIFFERENT eGFR
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.
Proteinuria and Urine Sediment Abnormalities in
Differential Diagnosis of Common causes of CKD

Angela C Webster Lancet 2017;389: 1238-52

Symptoms and signs of
CKD
Appearance
Hypertension
Shortness of breath
Kidneys
Itch and cramps
Cognitive changes
Gastrointestinal symptoms
Change in urine output
Haematuria
Proteinuria
Peripheral oedema

Angela C Webster Lancet 2017;389: 1238-52

Risk factors

Floege J, Johnson RJ, Feehally J. Comprehensive Clinical Nephrology, 4th Ed. Saunders Elseviers. 2010
Changes in Mineral Metabolism as a consequence of
CKD

Stage Changes in
serum levels
GFR 1,25D PO4 CaPTH
60-90 2 ↓ ↔ ↔↑
30-59 3 ↓↓ ↑ ↔ ↑2-fold
15-30 4 ↓↓↓ ↑↑ ↓ ↑4-fold
<15 5 ↓↓↓↓ ↑↑↑ ↓↓ ↑8-fold

CKD-MBD
-Laboratory abnormalities
-Calcification
-Renal Osteodystrophy
Floege J, Johnson RJ, Feehally J. Comprehensive Clinical Nephrology, 4 th Ed. Saunders Elseviers. 2010
A Clinical Action Plan
 Stage 1 and 2 CKD management
(eGFR ≥ 60 ml/min)

Goals :
• Reduce progression of kidney disease
• Reduce CV risk
Monitoring:
• 3-6 monthly clinical review
• Clinical assessment : BP, weight, urine dipstick
• Laboratory assessment: ureum, creatinine,
electrolytes, eGFR, fasting glucose, fasting
lipids
 EVALUASI

 Diagnosis (tipe gangguan ginjal);

 Keadaan yg menyertai;
 Keparahan, dinilai berdasarkan derajat fungsi ginjal
 Komplikasi, terkait dengan derajat fungsi ginjal
 Risiko penurunan fungsi ginjal;
 Risiko penyakit kardiovaskuler
 TATALAKSANA TERAPI – DIABETIK PASIEN
NON-FARMAKOLOGI
 evaluasi pembatasan diet
protein :
 Rekomendasi The National
Kidney Foundation : asupan
protein pd px dg GFR < 25
ml/menit = 0,6 g/kg/hari
 pembatasan diet garam
 diet garam dpt
meningkatkan BP, GFR, dan
menurunkan aliran plasma
ginjal
FARMAKOLOGI
 Terapi Insulin intensif
 Pemberian insulin 3 kali
atau lebih sehari
 Target glukosa darah
prepandrial 70-120 mg/dL,
postpandrial < 180 mg/dL
 Kontrol hipertensi yg
optimal
 JNC-7 merekomendasikan
target tekanan darah
<130/85 mmHg
 XII. Treatment of Hypertension in association with
Diabetic Nephropathy
THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg

DIABETES Addition of one or more of

ACE Inhibitor
with
or ARB Long-acting CCB or Thiazide
Nephropathy diuretic
IF ACEI and ARB are
contraindicated or not
tolerated, 3 - 4 drugs combination may
SUBSTITUTE be needed
• Long-acting CCB or
• Thiazide diuretic

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5

ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control
of volume is desired

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
KDIGO-CKD Guidelines, 2012
Strategi terapi utk mencegah progresivitas GGK
Strategi Terapi utk mencegah progresivitas GGK pd
Pasien Nondiabetik
 TATALAKSANA TERAPI – NONDIABETIK
PASIEN

NONFARMAKOLOGI FARMAKOLOGI
 Meta analysis & RCTs  Antihipertensi
 penurunan asupan protein px  Intervensi lain utk
gg ginjal ringan-berat dpt
menunda onset GGT & membatasi progesifitas
menurunkan kematian ± 40% penyakit :
 The Modification of Diet in
 Tx hiperlipidemia
Renal Disease  Tx anemia
 px dgn GFR < 25
ml/min/1,73m2, dg asupan
0,6 g/kg/hari signifikan
menurunkan progresifitas
ginjal (±41% / 0,2g/kg/hari)
 Pemeriksaan Laboratorium

 GFR normal atau abnormal dg atau tanpa abnormalitas

struktur ginjal
 Adanya albumin urin atau protein
 Patologi pd jaringan ginjal
 Endokrin
 Peningkatan sensititifitas thdp insulin
 Hyperparatiroid sekunder
 Penurunan aktivasi vit D
 Deposisi β2-microglobulin, gout
 Hematologi
 Anemia, defisiensi besi, pendarahan
 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

 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.
Relationship of eGFR and Albuminuria with
mortality

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
Kidney International Supplements (2013)
 Life Style Management for Patients with CKD

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

Levin A, Hemmelgarn B, Culleton, et al. Guidelines for the management of chronic kidney disease, CMAJ 2008,179(1):1154-1162
Levin A, Hemmelgarn B, Culleton, et al. Guidelines for the management of chronic kidney disease, CMAJ 2008,179(1):1154-1162
 LDL Cholesterol level < 2.0 mmol/L ~ < 77mg/dL

Levin A, Hemmelgarn B, Culleton, et al. Guidelines for the management of chronic kidney disease, CMAJ 2008,179(1):1154-1162
Levin A, Hemmelgarn B, Culleton, et al. Guidelines for the management of chronic kidney disease, CMAJ 2008,179(1):1154-1162
Levin A, Hemmelgarn B, Culleton, et al. Guidelines for the management of chronic kidney disease, CMAJ 2008,179(1):1154-1162
 Stage 3-5 CKD management
(eGFR <15-59 ml/min)

• Goals
• Reduce progression of kidney disease
• 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
• Preparation for renal replacement therapy (4-5)
 (TIDAK DIANJURKAN)

Floege J, Johnson RJ, Feehally J. Comprehensive Clinical Nephrology, 4 th Ed. Saunders Elseviers. 2010
INDIKASI TERAPI PENGGANTI
GINJAL
• Umumnya jika eLFG <8 • Indikasi dialisis
ml/menit/1,73 m2
segera:
• Inisiasi dialisis dipercepat • Gangguan neurologis:
jika ada gejala/tanda
berikut: neuropati,
• Overload cairan dan/atau ensefalopati
hipertensi yang refrakter • Pleuritis atau
• Hiperkalemia refrakter perikarditis tanpa
• Asidosis metabolik refrakter penyebab lain
• Hiperfosfatemia refrakter
• Gangguan
• Anemia refrakter
• Penurunan kondisi
perdarahan/koagulasi
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
INTEGRASI TERAPI PENGGANTI GINJAL

TRANPLANTASI

TERAPI PENGGANTI
GINJAL

HEMODIALISIS PERITONEAL DIALISIS

Terima kasih