Chronic Kidney Disease

Chronic Kidney DiseaseGatot Sugiharto, MD, InternistInternal Medicine DepartmentFaculty of Medicine, Wijaya Kusuma University Surabaya

Excretion organ systemField, Pollock, Harris, The Renal System, 2001Fungsi GinjalMengeluarkan sisa metabolisme : ureum,kreatinin,uric acid,aliphatic amine,2 microglobulin,PTH,myoglobulin,dllMengeluarkan kelebihan air dan elektrolit (K,Na,Al,H,P)Produksi erythropoietin, renin-angiotensin,vitamin D3 aktifMenjaga keseimbangan asam basaMembuang toksin dan obatReplaced partially by HD

AJKD 2002: 39(2)4Why Classify Severity as the Level of GFR?

AJKD 2002: 39(2)

5Stages of chronic kidney disease StageDescriptionGFR (mL/min/1.73 m2)1Kidney damage with normal or GFR 902Kidney damage with mild GFR60-893Moderate GFR30-594Severe GFR15-295Kidney failure200 mcg/min (albumin is more specific for glomerular disease than protein)Consider : Ingestion of high-protein meal and vigorous exercise -> increase protein in urineEtiologyChronic Kidney Disease (CKD) loss of functioning nephrons d/tprimary kidney disease systemic disease secondary to acute event causing damage to kidneyLeading cause of end stage renal disease (ESRD)diabetes (43%)hypertension (26%)chronic glomerulonephritis (8%)

Possible causes of chronic kidney diseaeInclude:glomerulonephritis - accounts for 25% of cases multisystem disease: eg Diabetesacute pyelonephritis / tubulointerstitial disease hypertension and vascular causes polycystic kidney disease - the most common cause of familial chronic renal failure idiopathic in 15% of cases Rarely: drugs - toxic nephropathy e.g. analgesic nephropathy connective tissue disease e.g. polyarteritis nodosa

Distribution of the etiology of chronic kidney disease (CKD) in children based upon age

Drug Induced Kidney DiseaseAnalgesic nephropathy - habitual ingestion/misuse of analgesics (and usually caffeine/codeine)renal papillary necrosis (primary lesion)Interstitial nephritis (secondary lesion) Analgesic Syndrome - includes above +anemia, peptic ulcer disease, urinary tract infection, atherosclerosis NSAIDs- may induce ischemic state within renal medulla by decreasing prostaglandin mediated vasodilatation

AJKD 2002: 39(2)22Risk factors for CKDNon-modifiable risk factorModifiable risk factorOlder ageHypertensionMale genderProteinuriaBlack RaceDyslipidemiaGenotypeHyperuricemiaSmoking23The non-modifiable risk factors are important for risk stratification by screening and for understanding the pathophysiology of CKD progression. These risk factors include ethnicity, which is a risk factor for many kidney diseases. For example, African-American patients with diabetes have a two-three fold higher risk of developing kidney failure compared to white patients. Modifiable risk factors are important for both understanding disease progreassion and as a possible option for prevention or therapy. For example, the heavy consumption of analgesics has been associated with the development of kidney failure. The number of patients that develop kidney disease and at risk for developing kidney disease will increase with the increasing prevalence of diabetes and aging of the population. USRDS ADR, 2007Diabetes and hypertension are leading causes of kidney failure

Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race. 24CLINICAL PRESENTATIONEarly stages of CKD asymptomatic.Direct kidney injury or disease.Incidental findings of an elevation in the serum creatinine concentration and/or abnormalities on urinalysis.Detection of congenital or structural anomalies by imaging studies.Poor growth. Symptoms and/or signs of severe renal impairment.Systemic symptoms and findings due to a concurrent systemic disease Clinical featuresSymptoms FatigueDyspnoeaPleuritic pain Ankle SwellingRestless legsNausea, anorexia-vomiting DiarrhoeaPruritusReduced concentration Bone painImpotence/ infertility Menorrhagia

SignsPallor^ BPCardiomegalyPleural effussionPericarditisPulm / peripheral oedemaRetinopathyProx myopathyPeriph neuropathyLate: Aryythmias, encephalopathy, seizures, coma

Uremic stateanorexianausea,vomitinggrowth retardationplatelate dysfunction pericardial diseaseperipheral neuropathy central nervous system abnormalities ranging from loss of concentration and lethargy to seizures, coma and death.

Age (gender)cSchwartz equation Mean GFR SD mL/min/1.73m21 week (males and females)GFR=0.33*(Length/SCr) in Preterm40.6 14.8GFR=0.45*(Length/SCr) in Term2-8 weeks (males and females)GFR=0.45*(Length/SCr)65.8 24.8>8 weeks (males and females)GFR=0.45*(Length/SCr)95.7 21.72-12 years (males and females)GFR=0.55*(Length/SCr)133.0 27.013-21 years (males)GFR=0.70*(Length/SCr)140.0 30.013-21 years(females)GFR=0.55*(Length/SCr)126.0 22.0SCr: serum creatinine in mg/dLNormal GFR in children and young adults COMPLICATIONS OF CKDDisorders of fluid, electrolytes & acid basedRenal OsteodystrophyAnemiaHypertensionDyslipidemiaEndocrine abnormalitiesGrowth impairmentDecreased clearance of renally excreted substances from the body (uremia).Fluid and electrolyte abnormalities Sodium and water balanceUsually is maintained untill GFR 10 years old to prevent pancreatitisHDL