Gagal Ginjal (2) : Institute of Health Sciences Banyuwangi

GAGAL GINJAL
Masroni, S.Kep., Ns. MS (in Nursing)

(2)
Institute of Health Sciences Banyuwangi
2019
Key points
1. Classification of chronic kidney
disease (CKD) by albuminuria and
eGFR
KDIGO: Classification of Kidney Disease by
albuminuria and Association with Adverse
Outcomes
Levey AS et al, Kidney Int 80: 17-28, 2011

KDIGO: Classification of Kidney Disease by eGFR
and Association with Adverse Outcomes
Levey AS et al, Kidney Int 80: 17-28, 2011

National Kidney Foundation’s (NKF’s) Kidney Disease
Outcomes Quality Initiative (KDOQI) classification
Stage 0 - No CKD
Stage 1 CKD
Stage 2 CKD
Stage 3 CKD
Stage 4 CKD
Stage 5 CKD
MDRD
Levey AS et al, Ann Intern Med 139: 137-147, 2003

Alberta Kidney Disease Network classification
Risk category 0
Risk category 1
Risk category 2
Risk category 3
Risk category 4
MDRD
Tonelli M et al, Ann Intern Med 154: 12-21, 2011

Contoh soal (1):
Ny. L, berusia 25 tahun, dengan berat badan 45 kg,
dengan kadar kreatinin plasma 0,98 mg/dl. Berapakah
nilai laju filtrasi glomerulus (LFG) Ny. L?
Contoh soal (2):

Tn. K, berusia 30 tahun, dengan berat badan 55 kg,
dengan kadar kreatinin plasma 2.00 mg/dl. Berapakah
nilai laju filtrasi glomerulus (LFG) Tn. K?
Nilai normal untuk bersihan kreatinin ialah:
Laki-laki = 97-137 mL/menit/1,73 m2 atau = 0,93-1,32 mL/detik/m2
Wanita = 88-128 mL/menit/1,73 m2 atau = 0,85-1,23 mL/detik/m2
Alberta Kidney Disease Network classification
Tonelli M et al, Ann Intern Med 154: 12-21, 2011

Take home
1. This risk classification system identifies
fewer patients as having advanced CKD
than the NFK staging system
2. This system could reduce unnecessary
referral for care, at the cost of not referring
or delaying referral for some patients who
go on to develop ESRD or die
Kidney Disease: Improving Global Outcomes (KDIGO)
classification
Low risk
Moderate risk
High risk
Very high risk
CKD-
EPI
KDIGO, Kidney Int Suppl 3: 1-150, 2013
classification
Low risk
Moderate risk
High risk
Very high risk

classification
Low risk
Moderate risk
High risk
Very high risk

Key points
disease (CKD) by eGFR and
albuminuria
2. Renal impairment is common. Every
second/third patient in our clinic might
have signs of renal impairment
The RIACE (Renal Insufficiency and
Cardiovascular Events) study
15,773 patients with type 2 diabetes from Italy
Stages of “Diabetic eGFR strata NKF’s KDOQI

nephropathy” (ml/min/1.73 m2) CKD stages
Normo 73,1% ≥90 29,6% No CKD 62,5%
Micro 22,2% 60-89 51,7% Stage 1
6,7%
≥90*
Macro 4,7% 30-59 17,1% Stage 2
12,0%
<30 1,7% 60-89*
Stage 3
MDRD
30-59
17,1%
Stages 4, 5
<30
1,7%
* Plus “kidney damage”
Penno G et al. J Hypertens 29: 1802-1809, 2011
Renal dysfunction is common in
patients with T2DM
The RIACE Study: 15,773 patients
No CKD
with T2DM
1.7% CKD stage 1
CKD stage 2
CKD stage 3
17.1% CKD stages 4/5
12.0% Approximately 40% of

62.5%
patients with T2DM show
signs of CKD (stages 1-5)
6.7%
Approximately 20% of
patients with T2DM show
signs of renal failure (eGFR
<60 ml/min/1.73 m2)
Renal dysfunction is common in
patients with T2DM
The RIACE Study: 15,773 patients
with T2DM
Albuminuria
Normal Mild Severe
(micro) (macro)
>90 Stage 0 Stage

Stage1-2
1
(no CKD) albuminuric phenotype
62.5% 18.7%
60-89 Stage 2
eGFR
ml/min/
1.73 m2 45-59
Stage 3/5 Stages 3/5
NON Stagealbuminuric
3
MDRD albuminuric CKD
30-44 CKD phenotype
phenotype
10.6% 8.2%
15-30 Stage 4

“Natural” history od Diabetic Retinopathy in
type 1 and type 2 diabetes: new paradigms
No-albuminuric Renal
Patients DM Follow-up Renal impairment with
renal no albuminuria
n. % years impairment impairment nor retinopathy
UKPDS
Diabetes 55: 1832-1839, 2006
4,006 100 15 28% 67% (51%) ---
DCCT/EDIC
1,439 100 19 6.2% 24% ---
Diabetes Care 33: 1536-1543, 2010 (type 1)
MacIsaac RJ et al.,
Diabetes Care 27: 195-200, 2004
301 100 --- 36% 39% 29%
Kramer HJ et al., NHANES III
JAMA 289: 3273-3277, 2003
1,197 100 --- 13% 36% 30%
Thomas MC et al., NEFRON
Diabetes Care 32: 1497-1502, 2009
3,893 100 --- 23% 55% ---
Ninomiya T et al., ADVANCE

J Am Soc Nephrol 20: 1813-1821, 2009
10,640 100 --- 19% 62% ---
Bakris GL et al., ACCOMPLISH

Lancet 375: 1173-1181, 2010
11,482 60 --- 9.5% 46.8% ---
Tube SW et al., ONTARGET/
TRASCEND 23,422 37 --- 24% 68% ---
Circulation 123: 1098-1107, 2011
RIACE Study Group, RIACE

J Hypertens 29: 1802-1809, 2011
15,773 100 --- 18.8% 56.6% 43.3%
“Natural” history od Diabetic Retinopathy in
type 1 and type 2 diabetes: new paradigms
Normoalbuminuria
Normal GFR
Cardiovascular events, death

Microalbuminuria
Macroalbuminuria
Reduced eGFR
ESRD
Natural history of diabetic nephropathy: Natural history of diabetic nephropathy:

“non-albuminuric” pathway “albuminuric” pathway
Key points
albuminuria
have signs of renal impairment
3. Albuminuria and eGFR:
complementary measures of (diabetic)
CKD
classification
Low risk
Moderate risk
High risk
Very high risk

Associations of Kidney Disease measures with mortality and
ESRD in individuals with and without diabetes: a meta-analysis
Data for 1,024,977 participants (128,505 with diabetes) from 30 general
population and high-risk cardiovascular cohorts and 13 chronic kidney disease cohorts
Fox CS et al., Lancet 380: 1662-1673, 2012
Data for 1,024,977 participants (128,505 with diabetes) from 30 general
population and high-risk cardiovascular cohorts and 13 chronic kidney disease cohorts
Data for 13 chronic kidney disease cohorts
Risk of coronary events in people with chronic kidney disease
compared with those with diabetes:
a population-level cohort study
1,268,029 participants; median follow-up of 48 months

1,268,029 participants; median follow-up of 48 months;
the Alberta Kidney Disease Network
75,871 1,104,713
12,960 15,368 59,117
eGFR by the CKD-EPI equation Tonelli M et al., Lancet, published online, June 19, 2012
Risk of coronary events in people with chronic kidney disease
compared with those with diabetes:
a population-level cohort study
Tonelli M et al., Lancet, published online, June 19, 2012

The Renal Insufficiency And Cardiovascular Events
(RIACE) Italian multicentre study
4,062 subjects with at least two UAE measurements
Intra-individual CV:
32.5% (14.3-58.9) UAEone value
UAEtwo values
Concordance rate between a
single UAE and the geometric Predictive performance for the
mean of 3 UAE values
mean:
• Two UAE:
normo: 94.6%; Reference line
micro: 83.5%;
macro: 91.1%;
micro/macro: 90.6%;
• Three UAE:
normo: 94.6%;
micro: 84.2%;
macro: 86.8%;
micro/macro: 90.8%.
Pugliese G et al., Nephrol Dial Transplant 26: 3950-3954, 2011
Summary of results and conclusions
 A single UAE value, thought to be encumbered with high intra-

individual variability, is an accurate predictor of the stage of
nephropathy in subjects with type 2 diabetes.
 Multiple UAE measurements may not be necessary for
classification purposes in both clinical and epidemiological
settings.
Pugliese G et al., Nephrol Dial Transplant 26: 3950-3954, 2011

classification

classification

classification

Prevalence of stages 3-5 CKD in type 2 diabetes
MDRD Study: 2,959 (18.8%)
CKD-EPI: 2,715 (17.2%)
CKD-EPI MDRD Study Total Soggetti

CKD Stage CKD stage riclassificati
No CKD 1 2 3 4-5 con la
equazione
No CKD 9,821 234 10,055 CKD-EPI
(62.3%) (1.5%) (63.8%)
1 977 283 1,260 sopra
(6.2%) (1.8%) (8.0%)
sotto
2 75 1,591 77 1,743
(0.5%) (10.1%) (0.5%) (11.1%)
3 44 23 2,342 2 2,411
(0.3%) (0.1%) (14.8%) (0.1%) (15.3%)
4-5 48 256 304
(0.3%) (1.6%) (1.9%)
Total 9,865 1,052 1,897 2,701 258 15,773
(62.5%) (6.7%) (12.0%) (17.1%) (1.7%) (100.0%)
Pugliese G et al., Atherosclerosis 218: 194-199, 2011

Prevalence of stages 3-5 CKD in type 2 diabetes
MDRD Study: 2,959 (18.8%)
CKD-EPI: 2,715 (17.2%)

Summary of results and conclusions
 Estimating GFR in patients with type 2 diabetes using the CKD-

EPI equation provides a better definition of the cardiovascular
burden associated with CKD, in terms of CVD prevalence and
CHD risk score.

Comparison of risk prediction using the CKD-EPI
Equation and the MDRD Study Equation for
Estimated Glomerular Filtration Rate
Distribution of estimated GFR
Data from 1.1 million adults from 25 general population cohorts,
7 high-risk cohorts (of vascular disease), and 13 CKD cohorts
Matsushita K et al, JAMA 307: 1941-1951, 2012

Reclassification across estimated GFR categories

Net reclassification improvements for all-cause
mortality, cardiovascular mortality, and ESRD

Key points
albuminuria
have signs of renal impairment.
CKD
4. Cystatin C
classification

classification

classification

http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm
….. the combined equation improved the classification of measured GFR
….. and correctly reclassified 16.9% of those with an estimated GFR of 45 to
59 ml per minute per 1.73 m2 as having a GFR of 60 ml or higher per minute
per 1.73 m2.
Inker LA et al, N Engl J Med 367: 20-29, 2012

Cystatin C and estimates of renal function: searching for a
better measure of kidney function in diabetic patients
Pucci L et al., Clin Chem 53: 480-488, 2007

Shlipak MG et al, N Engl J Med 369: 932-943, 2013
10.0%
13.7%
9.7%

59 83
88

Key points
albuminuria
have signs of renal impairment.
CKD
4. Cystatin C
5. Measuring GFR
classification

Pucci L et al, Diabet Med 18: 116-120, 2001
We suggest an eight-sample technique to
adequately capture the entire plasma
pharmacokinetic profile. Sampling at 5, 15, 30,
45, 60, 120, 240, and 360 (or longer) min after
bolus iothalamate should adequately capture the
distribution and elimination phase of this drug.
Others have suggested a similar approach
(Pucci L et al. Diabet Med, 2001)
Agarwal R et al, Clin J Am Soc Nephrol 4: 77-85, 2009

Many Thanks...

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GAGAL GINJAL

Masroni, S.Kep., Ns. MS (in Nursing)

Levey AS et al, Kidney Int 80: 17-28, 2011

Levey AS et al, Kidney Int 80: 17-28, 2011

Levey AS et al, Ann Intern Med 139: 137-147, 2003

Tonelli M et al, Ann Intern Med 154: 12-21, 2011

Contoh soal (2):

Tonelli M et al, Ann Intern Med 154: 12-21, 2011

KDIGO, Kidney Int Suppl 3: 1-150, 2013

KDIGO, Kidney Int Suppl 3: 1-150, 2013

Stages of “Diabetic eGFR strata NKF’s KDOQI

12.0% Approximately 40% of

>90 Stage 0 Stage

Penno G et al. J Hypertens 29: 1802-1809, 2011

Ninomiya T et al., ADVANCE

Bakris GL et al., ACCOMPLISH

RIACE Study Group, RIACE

Cardiovascular events, death

Natural history of diabetic nephropathy: Natural history of diabetic nephropathy:

KDIGO, Kidney Int Suppl 3: 1-150, 2013

1,268,029 participants; median follow-up of 48 months

Tonelli M et al., Lancet, published online, June 19, 2012

4,062 subjects with at least two UAE measurements

Summary of results and conclusions

 A single UAE value, thought to be encumbered with high intra-

Pugliese G et al., Nephrol Dial Transplant 26: 3950-3954, 2011

KDIGO, Kidney Int Suppl 3: 1-150, 2013

KDIGO, Kidney Int Suppl 3: 1-150, 2013

KDIGO, Kidney Int Suppl 3: 1-150, 2013

CKD-EPI MDRD Study Total Soggetti

Pugliese G et al., Atherosclerosis 218: 194-199, 2011

Pugliese G et al., Atherosclerosis 218: 194-199, 2011

Summary of results and conclusions

 Estimating GFR in patients with type 2 diabetes using the CKD-

Pugliese G et al., Atherosclerosis 218: 194-199, 2011

Matsushita K et al, JAMA 307: 1941-1951, 2012

Reclassification across estimated GFR categories

Matsushita K et al, JAMA 307: 1941-1951, 2012

Matsushita K et al, JAMA 307: 1941-1951, 2012

KDIGO, Kidney Int Suppl 3: 1-150, 2013

KDIGO, Kidney Int Suppl 3: 1-150, 2013

KDIGO, Kidney Int Suppl 3: 1-150, 2013

Inker LA et al, N Engl J Med 367: 20-29, 2012

Pucci L et al., Clin Chem 53: 480-488, 2007

Shlipak MG et al, N Engl J Med 369: 932-943, 2013

Shlipak MG et al, N Engl J Med 369: 932-943, 2013

KDIGO, Kidney Int Suppl 3: 1-150, 2013

Agarwal R et al, Clin J Am Soc Nephrol 4: 77-85, 2009

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