Chronic Kidney Disease

Syafrizal Nasution and Oke Rina

H.Adam Malik Hospital
 Case
 AE is a 21 year-old man with nephrotic
syndrome. He complains of mild fatigue but
is otherwise asymptomatic. Five years
before he complain anasarca edema and
proteinuria.
 Doctor had trial steroid and proteinuria (-)
but relaps again
 On physical examination:
 Weight 40 kg with BP 120/80 mm Hg
 Labs
 Five years ago, his serum Cr: 0.5 mg/dL
 Three years ago, his serum Cr: 0.9 mg/dL
 One year ago, sCr: 1.81 mg/dL
 Lab Data
 CBC (January 2011)  SMA-7
 Hb 15.9  Ureum 33
 WBC 19.35  Cr: 1.29
 HCT 45.4  Renal ultrasound: …?
 PLTs 329

 Urine: protein (++),

eritrosit (-), cast
granular
 Calculations
 Cockcroft-Gault
 Men: CrCl (mL/min) = (140 - age) x wt (kg)
 SCr x 0.81

 Women: multiply by 0.85

 MDRD
 GFR (mL/min per 1.73 m2) = 186 x (SCr x 0.0113)-1.154 x
(age)-0.203 x (0.742 if female) x (1.12 if African-American)
 Back to the case…

 History medications: (five years ago)

 Predvison
 Captopril
 Cyclosporin A
 History medication : (three years ago)
 Metil prednisolon
 Captopril
 Cellcept
 Metabolic changes with CKD
 Hemoglobin/hematocrit 
 Bicarbonate 
 Calcium
 Phosphate 
 PTH 
 Triglycerides 
 Metabolic changes…
 Monitor and treat biochemical abnormalities
 Anemia
 Metabolic acidosis
 Mineral metabolism
 Dyslipidemia
 Nutrition
 Metabolic acidosis
 Muscle catabolism

 Metabolic bone disease

 Sodium bicarbonate
 Maintain serum bicarbonate > 22 meq/L
 0.5-1.0 meq/kg per day
 Watch for sodium loading
 Volume expansion
 HTN
 Mineral metabolism
 Calcium and phosphate metabolism
abnormalities associated with:
 Renal osteodystrophy
 Calciphylaxis and vascular calcification

 14 of 16 ESRD/HD pts (20-30 yrs) had

calcification on CT scan
 3 of 60 in the control group
NEJM 2000; 342(20): 1478-83
 Nutrition
 Think about uremia
 Catabolic state
 Anorexia
 Decreased protein intake

 Consider assistance with a renal dietician

 Follow-up Visit
 Two weeks later, the patient returns and
complains of fatique and hematemesis
 His BP today is 159/75 mm Hg

 He refused dialysis  go back to his home

 He died 10 days after came home in another
hospital
 New laboratories (dari Adam
Malik)
 Hb
 Leuco
 Ureum: ?
 Creat:?
 Evaluation for CKD
 Blood  Urine
 CBC with diff  Urinalysis with
 SMA-7 with Ca2+ and microscopy
phosphorous  Spot urine for
 PTH microalbumin
 HBA1c  24-urine collection for
 LFTs and FLP protein and creatinine
 Uric acid and Fe2+
studies  Ultrasound
 Key points
 The serum creatinine level is not enough!
 Target BP for CKD
 <130/80 mm Hg
 <125/75 mm Hg in proteinuria
 HTN and proteinuria are the two most
important modifiable risk factors for
progressive CKD