Professional Documents
Culture Documents
Candra Wibowo
Nephrology Division, Medical School of Trisakti University Jakarta
OBJECTIVE
Outcomes of CKD
Early detection
Early treatment
Slow progression
Optimizing the therapeutic
Pathological abnormalities or
Markers of kidney damage, including abnormalities in the
composition of blood or urine, or abnormalities in imaging tests
Classification
GFR
(mL/min/1.73 m2)
Without HBP
With HBP
Without HBP
90
HBP
NORMAL
60 89
HBP with
GFR
GFR@
30 59
15 29
< 15
(or dialysis)
ICEBERG PHENOMENONE
Description
GFR
Prevalence Prevalence
(mL/min/1.73m2)
Mild GFR
3
4
5
5.9 million
3.3%
60-89
5.3 million
3.0%
Moderate GFR
30-59
7.6 million
4.3%
Severe GFR
Kidney Failure
15-29
400,000
0.2%
< 15 or dialysis
300,000
0.2%
GFR 15-29
N=27998
Died
RRT
Event Free
Disenrolled
GFR 30-59
GFR 60-89; + Proteinuria
GFR 60-89, No
Proteinuria
0% 20
%
40
%
60
%
80 100
% %
COSTS OF ESRD
QUALITY OF LIFE
Anemia
Ca-Ph disorders
Hypertension
Volume overload
Infection on immunocompromised state
CVD/CHF
CVA
Others
EARLY DETECTION :
SCREENING & LOOKING FOR CAUSE OF CKD
Older age
Ethnic : Afro-america, Indian, Hispanic,
Asian/Pacific Islander
Exposure to certain chemical/ environmental
conditions
Low income / education
CAUSES OF CKD
DM
GNC
Hypertension
Glomerulonephritis primer
Chronic UTI
Obstruction (stones, malignancy, vesicouretero valve impaired
metastasis, cicatrix, iatrogenic, etc)
Tubulointerstitial disease
Polycystic disease
Autoimmune disease (APS, lupus, etc)
Chronic poisoning (lead Pb/Cd/Hg, drugs, antibiotic, traditional
medicine, chemotherapeutic, contrast, cell lysis syndrome, etc)
Gout / hyperuricaemia
NSAID
Pre/eclamptia
OTHERS
Patients with CKD are More Likely to Die than Go onto Dialysis
Nephroprotective Treatment :
more effective when started earlier
Blood pressure
Urinalysis
Dipstick for proteinuria, or microalbuminuria
Kidney function test (creatinin, ureum, cystatin C, CCT)
Kidney imaging (USG, IVP, CT, MRI, Renal study)
Kidney biopsy
BLOOD PRESSURE
Pts should be seated with their backs supported, arms bared & at heart
level
Refrain from smoking or ingesting caffeine 30 preceding the
measurement
Start after at least 5 of rest
Appropriate cuff size: the bladder within the cuff should encircle at least
80% of the arm
Taken preferably with a mercury sphygmomanometer or calibrated
aneroid manometer or validated electronic device
The 1st appearance of sound (phase 1) is used to define for SBP & the
disappearance of sound (phase 5) is used to define DBP
2 or more readings separated by 2 min should be averaged. If the 1 st
readings differ by more than 5 mm Hg; additional readings should be
obtained and averaged
OR : 1st is discarded to ensure that pts is relaxed, & the mean of 2 nd 3rd
readings is calculated
AMBULATORY BP MONITORING
Useful in pts with apparent drug resistance, hypotensive
symptoms with antihypertensive drugs, episodic hypertension.
Seldom required & should not be used to delay appropriate
therapy
BP tends to be higher in clinic than outside of the office
(white-coat hypertension)
Ambulatory results are an average of 10/5 mm Hg lower than
office BP
No agreement on upper limit of normal home BP; but reading
of 135/85 or greater should be considered elevated. Definition
HTN 140/90 or greater.
Awake < 135/85 mm Hg and asleep 125/75 mm Hg. majority;
BP falls 10-20% during the night
BLOOD PRESSURE
In mild hypertension : reassessment 3 months later
In moderate hypertension : reassessment 3-4 weeks
later
In severe hypertension (>180/110 mm Hg) :
reassessment 2 weeks later and treatment started if this
level is sustained
Immediate treatment is required in accelerated
hypertension (papilloedema, retinal haemorrhages and
exudates, acute cardiac complication (aortic dissection)
URINALYSIS
Recommended collection of urine sampling :
Mid stream urine
Fresh urine (within 3 h)
At the morning 30-60 min after the 1st mixture
Examination
Macroscopic :
- Chemist reaction :
Colour
pH
Smell protein/albumin
Bubble
glucose
SG
nitrite
Microscopic :
Urine collection
methods
Total
Protein
Albumin
Normal
Micro
albuminuria
Albuminuria or
clinical proteinuria
24 h excretion
NA
< 30 mg/dl
NA
> 30 mg/dl
NA
24 h excretion
< 30 mg/d
30 300 mg/d
< 3 mg/dl
> 3 mg/dl
NA
17 250 mg/g
25 355 mg/g
Gender specific cut-off values are from a single study. Use of the same cut-off value
leads to higher values of prevalence for women than men. Current recommendation from
ADA do the cut-off values for spo t urine alb-to- creat ratio for microalbuminuria and
albuminuriaas 30 and 300 mg/g respectively w/o regard to gender
Category
Abnormal values
Normal
24-h excretion albumin
< 30 mg/d
Microalbuminuria
24-h excretion albumin/creatinine ratio
30-300 mg/d
> 2.5 mg/mmol cr
Clinical proteinuria
24-h excretion protein/creatinine ratio
(140 age) x BW
72 x P.cr
Decrease
Reduced muscle mass
Malnutrition
Elderly age
COCKCROFT-GAULT EQUATION
TO PREDICT GFR
Developed to predict creatinine clearance, thus an
overestimate of GFR
Prediction based on age, gender, creatinine and ideal
body weight
ClCr (cc/min) = [140-age] x BW/72 x SCr x [0.85 if female]
http://www.kidney.org/professionals/KDOQI/gfr.cfm
COCKCROFT-GAULT
VS
MDRD
PREVENTION
YES
NORMAL
RISK
Screening
for CKD
risk factor
GFR
PRIMARY PREVENTION
K/DOQI NKF, 2002
DAMAGE
ESRD
DEATH
RRT by dialysis
or transplant
Estimate
progression,
treat complic,
prepare for RRT
SECONDARY PREVENTION
TERTIARY PREVENTION
SLOWING PROGRESSION
DO EARLIER GET BETTER
DIABETES MELLITUS
IF,
everybody exercised
few hours a week,
type 2 diabetes would be
virtually nonexistent
DIABETIC EVOLUTION
Moderate Worse
80 109
110 125
126
110 144
145 179
180
A1C (%)
< 6.5
6.5 8
>8
< 200
200 239
240
LDL-C (mg/dL)
< 100
100 129
130
HDL-C (mg/dL)
> 45
Triglyceride (mg/dL)
< 150
150 199
200
IMT (kg/m2)
18.5-22.9
23 25
> 25
< 130/80
130-140/80-90
> 140/90
ADA, 2002
H
Y
P
E
R
T
E
N
S
I
O
N
JNC 7 2002
Systolic
Diastolic
Systolic
Diastolic
Category
Optimal
< 120
< 80
< 120
< 80
Normal
< 130
< 85
High-normal
130 -139
85 89
Prehypertension
Borderline hypertens
140 - 149 90 94
140 - 159 90 - 99
Stage I
Grade I (mild)
140 - 159 90 99
Grade 2 (moderate)
160
100
Stage II
Grade 3 (severe)
180
110
Isolated systolic
hypertension
>140
< 90
>140
< 90
Isolated systolic
hypertension
Subgroup borderline
> 140
< 90
Normal
Systolic
Diastolic
Optimal
<120
and
<80
Normal
120129
and/or
8084
High normal
130139
and/or
8589
Grade 1 hypertension
140159
and/or
9099
Grade 2 hypertension
160179
and/or
100109
Grade 3 hypertension
>180
and/or
>110
>140
and
<90
Isolated systolic hypertension should be graded (1 ,2,3) according to systolic blood pressurevalues in the ranges indicated,
provided that diastolic values are <90 mmHg. Grades 1 , 2and 3 correspond to classication in mild, moderate and
severe hypertension, respectively. These terms have been now omitted to avoid confusion with quantication
of total cardiovascular risk.
Blood Pressure
Target
(mm Hg)
Preferred Agents
for CKD, with or
without
Hypertension
Other Agents
to Reduce CVD Risk
and Reach Blood
Pressure Target
ACE inhibitor
or ARB
None preferred
<130/80
TREATMENT OF HYPERTENSION
Life style modification
Not at Goal BP
(<140/90 mmHg for those with DM or CKD)
Initial drug choices
Hypertension without
compelling indications
Stage 1
Thiazide type diuretics
Consider ACE-I, ARB,
BB, CCB or combination
Hypertension with
compelling indications
Stage 2
2 drugs combination
for most
Not at Goal BP
Optimize dosages or
add additional drugs
SUMMARY
As most cases with CKD even though
ESRD are not known by physicians, so
we need active detect subjects at risk in
an early phase.
Such screening is needed as it enables
early prevention not only of progressive
CKD; but also of progressive CVD.
Screening for albuminuria and eGFR is
simple, cheap and important things.
SUMMARY
Screening for albuminuria helps to detect
subjects at risk of progression CKD & CVD; but
also subjects at risk for new DM and new HTN
Albuminuria :
stage 1 & 2 CKD is presented in 5-6% of the general
population
stage 3 is presented in another 4-5% of the general
population
SUMMARY
Screening for albuminuria and early
treatment of those found positive is cost
effective to prevent CKD and also CVD.
Lowering albuminuria helps to prevent
progressive CKD & CVD in general
population.