04. chronic kidney diseases slide - residen & coass1

8/3/2019 04. Chronic Kidney Diseases Slide - Residen & Coass1

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Klasifikasi hipertensi pada kehamilan :

Gestational hypertension

Hypertension chronic in pregnancy

Preeclampsia

Superimposed preeclampsia


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Gestational hypertension

Normotensi hamil hipertensi partus - normotensi

Hypertension chronic in pregnancy

Hipertensi hamil hipertensi partus hipertensi

Preeclampsia

Normotensi n- hamil hipertensi proteniuri partus -normotensi

Superimposed preeclampsia

Hipertensi hamil hipertensi- proteinuri partus hipertensi


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C H R O N IC H R O N I

CC

K I D N E YK I D N E Y

D I S E A S ED I S E A S E


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The Relationship of Blood Urea Nitrogen (BUN) o

Serum Creatinine Concentration to

Glomerular Filtration Rate.

ken lines indicate that there is a family of curves rather than a single one for


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Methods of Glomerular Filtration

Rate (GFR) Measurement

Inulin Clearance

Alternative Filtration Markers

125I-Iothalamate, 51Cr-EDTA, 99mTc-DTPA and

non-radioactive iohexol

Plasma Creatinine

Creatinine ClearancePredictive Creatinine Clearance (the Cockroft-Gault Formula


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Creatinine ClearanceCreatinine Clearance

Ccr =Ucr x V

Pcr

Pcr = Plasma concentration of creatinineUcr = Urine concentration of creatinineV = Urine flow rate

V : 24 hr collectionOver night collectionTime collection


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EXAMPLESEXAMPLES

Patient 1 :

In a 68 years old dibetic female weighing 50 kg with aplasma creatinine level of 5.0 mg/dl the creatinineclearance would be:

(140-68) x 50 x 0.85

-------------------------- = 8.5 ml/minute

72 x 5.0This woman is ready to start maintenance dialysis

Patient 2 :A 30 year old 70 kg male with with a plasma creatinine

value of 5.0 mg/dl has, by the formula, a creatinineclearance of 21 ml/minute and does not yet requiredialysis therapy


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Patients with chronic kidney disease should be evaluateto determine :

Diagnosis (type of kidney disease)

Comorbid conditions

Severity, assessed by level of kidney function

Complications, related to level of kidney functions

Risk for loss of kidney function

Risk for cardiovascular disease

Evaluation and Treatment

Am J Kidney Dis 2002 ; 39 (suppl 1


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Treatment of chronic kidney disease should include :

Spesific therapy, based on diagnosis

Evaluation and management of co-morbid conditions

Slowing the loss of kidney function Prevention and treatment of cardiovascular disease

Prevention and treatment of complications of decreased kidney function

Preparation for kidney failure and kidney replacement therapy

Replacement of kidney function by dialysis and transplantation, if sign an

symptoms of uremia are present

Am J Kidney Dis 2002 ; 39 (suppl 1

Evaluation and Treatment


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Individuals at increased risk for CKD should be

tested at the time of a health evaluations to

determine if they have CKD.

Diabetes

Hypertension

Autoimmune diseases

Systemic infections

Exposure to drugs or procedures associated with acute

decline in kidney function

Recovery from acute kidney failure

Age > 60 years

Family history of kidney disease Reduced kidney mass (includes kidney donors and

transplant recipients)


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Measurements should included :

Serum creatinine for estimation of GFR

Assessment of proteinuria

Urinary sediment of urine dipstick for red blood

cells and white blood cells


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Progression of renal disease :Progression of renal disease :

A irreversible decline in GFR because

of structural damage to the renal

vasculature, tubules or interstitium.


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Definitions of Progression, Remission, andDefinitions of Progression, Remission, and

Regression of Proteinuric Chronic NephropathyRegression of Proteinuric Chronic Nephropathy

VariableVariable ProgressionProgression RemissionRemission RegressionRegression

Proteinuria

Glomerular filtration rate

Renal structural changes

1g/24 h

Declining

Worsering

< 1g/ 24 h

Stable

Stable

< 0.3g / 24 h

Increasing

Improving

Ruggenenti P, et al. Lancet2001 ; 357

Pi t l l f l l h t i i th


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Systemic HypertensionPrimary Renal Disease

Renal Ablation

Aging

Diabetes Mellitus

Dietary Factor

ENDOTHELIAL INJURYRelease of vasoactive factors

Vascular lipid deposition

Intracapillary throbosis

MESANGIAL INJURYAccumulation of macromolecules

Matrix production

Cell proliteration

EPITHELIAL INJURY

ProteinuriaPermeability to water

GLOMERULAR SCLEROSIS

GLOMERULAR HYPERTENSION

Pivotal role of glomerular hypertension in the

initiation and progression of structural injury

Brenne


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THE MECHANISM OF PROGRESSION OFTHE MECHANISM OF PROGRESSION OF

CHRONIC KIDNEY DISEASECHRONIC KIDNEY DISEASE

1.1. HYPERTENSIONHYPERTENSION

2.2. PROTEINURIAPROTEINURIA

3.3. ANGIOTENSIN-IIANGIOTENSIN-II

4.4. HYPERGLYCEMIA.HYPERGLYCEMIA.

5.5. PROTEIN INTAKEPROTEIN INTAKE

6.6. SODIUM INTAKESODIUM INTAKE

7.7. WATER INTAKEWATER INTAKE

8.8. HYPERLIPIDEMIAHYPERLIPIDEMIA

9.9. SMOKINGSMOKING

10.10. NSAIDNSAID

11.11. ANEMIAANEMIA

12. HYPERINSULINEMIA12. HYPERINSULINEMIA

13. HOMOCYSTEINEMIA13. HOMOCYSTEINEMIA

14. HYPERPHOSPHATEMIA14. HYPERPHOSPHATEMIA

15. POTASSIUM DEPLETION15. POTASSIUM DEPLETION

16. HYPERCOAGULATION16. HYPERCOAGULATION

17. GENDER17. GENDER

= LEVEL 1

= LEVEL 2

= LEVEL 3

Hebert LA, et al : Kidney Int2001;


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Aims of Dietary protein restriction :

To slow the progression of kidney disease

Minimize accumulation of uremic toxins Preserve protein nutritional status

(GFR mL/min) :

>50 : No restriction recommended

25 50 : 0.6 to 0.75 g/kgBW


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ADEQUACY OF HD (2)ADEQUACY OF HD (2)

DOQI recommends that Kt/V > 1.3

These recommendations are based on thrice weeklydialysis; twice weekly dialysis cannot be adequateunless there is substantial residual renal function

(glomerular filtration rate 5 10 ml/min).

A URR > 65% is equivalent to Kt/V > 1.2DOQI recommends a target of 70% (equivalent to

Kt/V of 1.3)

Goals for renoprotection approach in CKD patient (1)


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BP control


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Antihypertensive therapy

First step, ACE inhibitor or ARB

Second step, diureticIn stage 3, loop diuretic

Third step, CCB or BB

Fourth step, BB or CCB if not used before.Consider other alternatives such as alpha blocker or

centrally acting drugs.



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T H A N KT H A N K

Y O UY O U

04. chronic kidney diseases slide - residen & coass1

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