Chronic kidney disease dan

acute renal failure

2016
 Fungsi Ginjal
Mengeluarkan sisa metabolisme :
ureum,kreatinin,uric acid,aliphatic amine,2
microglobulin,PTH,myoglobulin,dll
Mengeluarkan kelebihan air dan elektrolit
(K,Na,Al,H,P)
Produksi erythropoietin, renin-
angiotensin,vitamin D3 aktif
Menjaga keseimbangan asam basa
Membuang toksin dan obat

Replaced partially by HD
Apa yang terjadi bila fungsi ginjal
rusak berat ?
Uremia (gejala akibat tertahannya zat-zat
toksik dalam tubuh): mual muntah, nafsu
makan turun, gatal, kesadaran turun
Tertahannya garam(Na) dan air
:bengkak,sesak,hipertensi
Keseimbangan asam basa terganggu:
asidosis
Fungsi hormonal terganggu :anemia, kalsium
menurun
 Uraemic toxins :

Low MW : urea,creatinine
Middle MW : B2 microglobulin, PTH
High MW : myoglobulin

Middle MW sulit dihilangkan dgn HD, tapi

efektip dgn Peritoneal Dialisis dan Highflux
dialisis
 Penyebab Gagal Ginjal

Glomerulonephritis
Diabetic Nephropathy
Urinary Stones Disease
Hypertension
Analgesic nephropathy
Polycystic Kidney
Definition of Chronic Kidney Disease

Criteria
1. Kidney damage for 3 months, as defined by structural or
functional abnormalities of the kidney, with or without
decreased GFR, manifest by either :
Pathological abnormalities; or
Markers of kidney damage, including
Abnormalities in the composition of the blood or
urine, or abnormalities in imaging tests

2. GFR < 60 mL/min/1.73 m2 for 3 mounths, with or without

kidney damage
 Assesed level of kidney function
Equation
Author, Year (No of Equation
Subjects)
Cockcroft-Gault Equation
Cockcroft 1976 (N = 236)
Ccr ml/min
140 - Age x Weight x 0.85 if famele
72 x Scr
Abbreviated MDRD Study
Equation GFR (ml/min/1.73 m2 ) = 186 x (So)-1.154 x (Age)-0.203
Levey, 1999 (N = 1070 X (0.742 if femele) x (1.210 if African American)
558 in Validation set)
Schwartz Formula Schwartz 0.55 x Length
1976 (N = 186) Ccr (ml/min)
S cr
0.43 x Length
Counahan-Barratt Equation GFR (ml/min/1. 73m 2 )
Counahan, 1976 (N = 108) S cr
 Clinical Situations in Which Clearance Measures
May be Necessary to Estimate GFR
GFR= urine Cr(mg/kg) x urine vol (ml)
plasma Cr (mg/kg)

Extremes of age and body size

Severe mainutrition or obesity
Disease of skeletal muscle
Paraplegia or quadriplegia
Vegetararian diet
Rapidly changing kidney function
Prior to dosing drugs with significant toxicity that
are excreted by the kidneys
 Clinical Presentations of Kidney Disease
GFR (mL/mLn/1.73
Clinical Presentation m2) Proteinuria Urine Sediment Imaging Studies Other Features
Complications due
Decreased GFR: 15-89 NA NA NA
to GFR
< 15 or treated by
Kidney Failure: NA NA NA Uremia
dialysis
Usually >1500
Nephritic syndrome
NA mg/d or 1000 RBCs and RBC casts NA Edema, HBP
(nephritis) :
mg/g creatinine
Fatty casts, oval fat
>3500 mg/d or Edema, low serum
Nephrotic syndrome bodies, with or
NA >3000 mg/g NA albumin, elevated
(nephrosis) : without RBCs and
creatinine serum lipids
RBC casts
fluid and
Usually <1500 electrolyte
Tubular syndromes : Usually normal mg/d or 1000 Usually normal Usually normal abnormalities,
mg/d creatinine inability to
concentrate urine
Usually due to
Usually <1500
Kidney disease with urinary tract
NA mg/d or <1000 NA Usually normal
urinary tract symptoms : infection, stones or
mg/g creatinine
obstruction
RBCs with or without
Asymptomatic urinalysis <3.500 mg/d or < RBC casts, WBCs
abnormalities
90 3.000 mg/g with or without WBC NA No Symptoms
(proteinuria, hematuria,
pyuria or others
creatinine casts, tubular cell or
casts
Hydronephrosis
dilated calycas, dilated
Asymptomatic radiologic collecting ducts (on
90 Usually normal Usually normal No Symptoms
abnormalities IVP), cysts, asymmetry
of kidney size of
function
Hypertension due to
NA HBP
kidney disease
 Years Until Kidney Failure (GFR < 15 mL/min/1.73 m2)
Based on Level of GFR and Rate of GFR Decline

Level of GFR
Rate of GFR Decline (mL/min/1.73 m2 per year)
(mL/min/1.73 m2) 10 8 6 4 2 1*
90 7.5 9.4 13 19 38 75
80 6.5 8.1 11 16 33 65
70 5.5 6.8 9.2 14 28 55
60 4.5 5.6 7.5 11 23 45
50 3.5 4.4 5.8 8.8 16 35
40 2.5 3.1 4.2 6.3 13 25
30 1.5 1.9 2.5 3.8 7.5 15
20 0.5 0.6 0.8 1.3 2.5 5
Average age-related GFR decline after age 20-30 year
MDRD Study: average rate of decline in GFR is 4 ml/min/year. 85% declined,15% stabile or improvement
 The risk for loss of kidney function
Type Definition Examples
Susceptibility Increased susceptibility to Older age, family history
factors kidney damage
Initiation factors Directy initiate kidney damage Diabetes, high blood
pressure, autoimmune
diseases, systemic
infections, urinary tract
infections, urinary stones,
lower urinary tract
obstruction, drug toxicity
Progression Cause worsening kidney Higher lavel of proteinuria,
factors damage and faster decline in higher blood pressure
kidney function after initiation level, poor glycemic
of kidney damage control in diabetes,
smoking
Endstage Increase morbidity and Lower dialysis dase (KW),
factors mortality in kidney failure temporary vascular
access, anemia, low serum
albumin, late referral
 Attemps to prevent and correct
acute decline on chronic renal
failure
Volume depletion
IV radiographic contrast
Antimicrobial agent (aminoglycoside,amphotericine B)
NSAID (including Cox2)
ACE/ARB
Cyclosporine and tacrolimus
Obstruction of the urinary tract
Infection of urinary tract
 Interventions that have been proven to be
effective

Diabetic Non diabetic Kidney disease

Kidney Kidney disease In the
Disease transplant
Strict giycemic Yes * I:80-120 NA Not tested
control II:100-140
HbA1C(%):<7

ACE inhibitors Yes Yes Not tested

or angletensin- (greater affect in patients with
receptor blockers proteinuria)
Strict blood Yes Yes Not tested
pressure control < 125/75 mm <130/80 mm Hg
Hg (greater affect in patients with
proteinuria)
<125/75 mm Hg
(greater affect in patients with
proteinuria)

* Prevents or delays the onset of diabetic kidney discase.

 Interventions that have been studied,
but the result of which are
inconclusive

Dietary protein restriction (0.6 0,8

gr/kgBB/day)
Lipid lowering therapy (LDL<100 mg/dl)
Partial correction anemia
 Apakah RRT ?

1. Transplantasi ginjal
2. Hemodialisis
3. Continuos Ambulatory Perito-
neal dialysis
 INDIKASI RENAL
REPLACEMENT THERAPY
CHRONIC KIDNEY DISEASE

Kliren kreatinin <10 ml/menit pada non

DM, atau <15 ml/menit apabila sudah
terdapat uremia

Kliren kreatinin <15 ml/menit apabila

nefropati diabetik
Acute renal failure
(ARF)
 Definisi
Penurunan fungsi ginjal (GFR) secara
mendadak (dalam 1-7 hari) dan bertahan
> 24 jam.Biasanya disertai penurunan
produksi urine.
RIFLE CRITERIA FOR ACUTE RENAL DYSFUNCTION
GFR CRITERIA URINE OUTPUT CRITERIA

Increased creatinine
UO < 0.5 ml/kg/h
Risk x1.5 or GFR
x 6 hr
decrease > 25% High
Increased creatinine Sensitivity
UO < 0.5 ml/kg/h
Injury x2 or GFR decrease
x 12 hr
> 50%

Increased creatinine UO < 0.3 ml/kg/h

Failure x3 or GFR decrease x 24 hr or Anuria
> 75% x 12 hrs

Persistent ARF**= complete loss

Loss of kidney function > 4 weeks High
End Stage Kidney Disease Specificity
ESKD (> 3 months)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&
db=PubMed&list_uids=8605788&dopt=Abstract
 20-30% 15%
50-60%
 Penyebab ARF
Pre renal : volume depletion,inadequate
cardiac function, obstruksi arteri renalis
Renal : glomerular, tubulointerstitial
disesase, obat, toksin
Post renal :stones, tumor, strictur,
kompresi
 Treatment of ARF
Pharmacologic :
- Fluid
- Vasopressor
- Loop diuretic
- Avoid nephrotoxic drug
- treat infection
- Treat complication : overload,acidosis, electrolyte disturbance
- Atrial natriuretic
- Fenoldopam,Insulin-like GF1,Thyroxine
Renal support :
- Continuous Renal Replacement Therapy
- Intermittent hemodialysis : SLED, SCUF, Daily
HD, Alternate-Day HD
- Acute Peritoneal Dialysis
 ARF Management: Conceptual
Framework
(1) Insult avoidance
INSULT (s)
(2) ARF Prophylaxis eg NAC
pre-contrast exposure

ACUTE RENAL INJURY

(INFLAMMATORY Specific ARF
DAMAGE) Pharmacotherapy:
(1) Minimise injury
ACUTE RENAL FAILURE (ARF) (2) Facilitate recovery

Accumulation of toxic uraemic

DERANGED HOMEOSTASIS -- solutes and metabolites
eg fluid overload, acid-base ORGAN INTOXICATION
disorders, electrolyte
imbalances
Removal from In-vivo neutralisation
blood of toxins*
Acute RRT (Dialytic therapy) compartment
* ASAIO J
 Indications for acute dialysis
1. Creatinine clearance < 25 ml/min :
a. uremia
b. Progressive fluid overload
c. uncontrolled hyperkalemia or me-
tabolic acidosis
2. Creatinine clearance <15 ml/min, BUN
>100 mg/dl
 CVVH Continuous veno-venous hemofiltration

heater

PV
Advantage
no arterial access
BLD

blood flow sufficient

SAD
good elimination of
high-flux

V
large molecules
heparin
V exact filtration

PA

Disadvantages
complex machinery

UF R expensive