CKD

INTRODUCTION
Chronic Kidney Disease (CKD) is a patophysiologic

process with various etiology which cause decrease
renal function progressively where the renal
dysfunction is irreversible and lasting until renal
replacement therapy is needed.
1

Recent evidence indicates that the outcomes can be
improved by early diagnosis and treatment.
3

EPIDEMIOLOGI
Data from the ItalKid study,
incidence : 12.1 cases per year per million (age
range, 8.8-13.9 y).
prevalence : 74.7 per million.
more common in children >6 years than in those <6
years.
In Indonesia, there is no prevalence of CKD in
children nationally
DEFINITION
A patient has CKD if either of the following criteria are present :
1. Kidney damage for >3 month, as defined by structural or functional abnormalities of
the kidney, with or without decrease GFR, manifested by 1 or more of the following
features:
Abnormalities in the composition of the blood or urine
Abnormalities in imaging tests
Abnormalities on kidney biopsy
2. GFR <60 mL.min/1.73 m
2
for >3 month, with or without the other signs of kidney
damage described above.
Kidney Disease Outcomes Disease Initiative, 2012. Clinical Practice Guideline for Chronic
Kidney Disease : Evaluation, Clasification and Stratification.
Tabel 1. Criteria for definition of CKD
STAGING
Stage GFR
(mL/min/1.73
m
2
)
Description Action Plan
1 >90 Kidney damage with normal
or increased GFR
Treat primary and comorbid conditions,
slow CKD progression, CVD risk
reduction
2 60-89 Kidney damage with mild
reduction of GFR
Estimate rate of progression
3 30-59 Moderate reduction of GFR Evaluate and treat complications
4 15-29 Severe reduction of GFR Prepare for kidney replacement therapy
5 <15 End Stage renal failure Kidney replacement therapy
Kidney Disease Outcomes Disease Initiative, 2012. Clinical Practice Guideline for Chronic Kidney Disease :
Evaluation, Clasification and Stratification.
ETIOLOGI
<5 years old >5 years old
Hipoplasia
Displasia
Obstructive uropathy
Congenital nephrotic syndrom
Focal segmental
gromerulosclerosis
Renal vein trombosis
Glomerulonephritis
Inherited disorder (juvenile
nephropthisis, alport
syndrome, polycystic kidney
disease)
Metabolic disorder
(cystinosis, hyperoxaluria)

ETIOLOGI
Diagnosis Incidence
Obstructive uropathy 22%
Aplasia/hypoplasia/dysplasia 18%
Glomerulonephritis 10%
Reflux nephropathy 8%
Tabel 3.Common Cause of Chronic Kidney Disease in Children
North American Pediatric Renal Trial and Collaborative Studies 2006
Dilys A. Whyte and Richard N Fine, 2008. Chronic Kidney Disease in Children.
PATOFISIOLOGI
Figure 1. Cycle of the chronic kidney disease
Wassner SJ, Baum M (1999). Chronic Renal Failure. Physiology and Management. In: Barrat TM, Avner ED,
Harmon WE, Editors. Pediatric Nephrology, 4
th
edition. Baltimore: Lippincott Williams & Wilkins, pp. 1155-1182.
Clinical Manifestation
Unspecific symptoms such as dizziness, letargis,
anorexia, nausea.
5
Failure to thrive, polyuria
dehydration, urinary tract infection.
In physical examination we found a pallor, limp, and
hypertension. The condition last for along time and
more day more severe.
Clinical Manifestation
Clinical manifestation is the result of :
1. Fluid and electrolyte imbalance
2. overacumulation of uremic toxin.
3. Hormonal dysfunction (decrease of erytropoeitin
and vitamin D3)
4. unresponse of end organ with growth hormone.

LABORATORY FINDING
Laboratory findings could be found :
9

complete blood countnormochromic, normocytic
anemia.
Renal Function Test serum ureum and creatinine.
Electrolitehyperkalemia, hyponatremia (if volume
overloaded), acidosis, hypocalcemia,
hyperphosphatemia.
Urinalisis proteinuria and hematuria if caused by
glomerulonephritis in heavy proteinuria could be found
hypoalbuminemia.
Where k is :
1. 0.33 for low-birhtweiht infant <1 year old
2. 0.45 for term infant <1 year old whose weight is
appropriate for gestational age
3. 0.55 for children (1-13 years old)
4. 0.57 for adolescent girls (13-21 years old)
5. 0.70 for adolescent boys (13-21 years old)
TREATMENT
Treatment of CKD should include:
1. Specific therapy, based on diagnosis
2. Evaluation and management of comorbid conditions
3. Slowing the loss of kidney function
4. Prevention and treatment of cardiovascular disease
5. Prevention and treatment of complications of decreased
kidney function (eg, hypertension, anemia, acidosis, growth
failure)
6. Preparation for kidney failure therapy
7. Replacement of kidney function by dialysis and
transplantation,

PROGNOSIS
About 70% of children with chronic kidney disease
develop ESRD by age 20 years.
Children with ESRD have a 10-year survival rate of
about 80% .
The most common cause of death in these children is
cardiovascular disease, followed by infection.
Chief Complaint : Loss of consciousness
History:
This has been happened by the patient + 4 days ago. Patient didnt respond when
family asking for conversation. Patient be more quite even the patient spoke, that
was incoherent. Patient is a oldterm patient in nephrology division pediaetric
departemen. Last month, the patient was recommended for hospitalization, but
the patient refused.
History of vomit suffered by patient + 3 day, frequency five times per day, volume +
spoon. The content is what patient eat and drink. Now, the vomit was denied.
Diare wasnt found. last defecation three days ago. History of pale faeces was
denied. Last urination 2 days ago. History of urine like a tea was denied.
Fever wasnt found, history of fever also denied
History of seizure was found five months ago, frequency once a day. As soon as the
patient hospitalized at RSUP HAM.
History of weight loss was found, history of appetite loss was found

Name : F.A.Z
Age : 15 y.o.
Sex : Male
Date of Admission: August, 12
th
2014
History
History
History of previous illness : -
History of drugs : Spironolakton, Furosemide
Physical Examination
Generalized status
Body weight: 40 kg, Body length: 165 cm
Body weight according to age : 40/56 = 71%
Body height according to age : 165/170 =97%
Body weight according to body height : 40/51 = 78%
Interpretation : Undernutrition

Presens status
Consciousness: GCS : 13 (E
4
V
4
M
5)
, Blood pressure 140/100 mmHg, HR: 98
bpm, RR: 24 bpm, body temperature: 36,8
o
C, body weight : 40 kg, body
height : 165 cm
Anemic (+); Icteric (-); Cyanosis (-); Edema (-). Dyspnea (-).
Localized status
Head :
Eye: isochoric pupil (3mm/3mm), light reflex (+/+) , conjunctiva palpebral
inferior pale (+/+), icteric sclera (-).

Nose: nasal septum : no deviation, mucosa color dark pink,
polyps (-), sinus tenderness (-), discharge (-).
Ear : External auditory canal: no discharge, tympanic membrant:
intact, no inflammation,
Mouth: lips : color is red, fissures; Bucal : dark pink, glistening;
tounge : dark pink, papilla athropy (-), tremor (-)
Teeth and gums : twenty teeth, caries (-).
Tonsil : difficult to assess
Neck :
Lymph node enlargement (-), Neck rigidity (-)
Thorax:
Inspection : Symmetrical fusiformis, epigastrial retraction (-
), RR: 20 x/i, reguler
Palpation : SF right = left, normal
Percussion : Sonor
Auscultation : rales (-/-) , stridor (-/-).
Extremities:
Extremitas superior : Pulse 98 bpm, regular, adequate
pressure and volume, warm, CRT < 3", spastic (-/-).
Extremitas inferior : Pulse 98 bpm, regular, adequate pressure
per volume, warm, CRT < 3", spastic (-/-).

Urogenital:
Male, within normal limit.

Abdomen:
Inspection : Symmetrical fusiformis
Palpation : Soepel, Liver and spleen unpalpable
Percussion : Tympani
Auscultation : Normoperistaltic
Laboratory Findings (August 12
th
2014):
Parameters Value Normal Value
Complete Blood Count
Hemoglobin 7.20 gr% 13.2 17.3 gr%
Hematocrite 17.40 % 43 49 %
Erithrocyte 2.37 x 10
6
/mm
3
4.20 4.87 x
10
6
/mm
3

Leucocyte 11.37 x 10
3
/mm
3
4.5 11 x 10
3
/mm
3

Platelet 420.000 /mm
3
150 - 450/mm
3

MCV 73.40 fl 85 95 fl
MCH 30.40 pg 28 - 32 pg
MCHC 41.40 gr% 33 - 35 gr%
RDW 13.20 % 11.6 14.8 %
MPV 8.00 fl 7.0 10.2 fl
PCT 0.34%
PDW 7.8%
Hitung Jenis
- Neutrofil 86.90% 37-80
- Limfosit 9.70% 20-40
- Monosit 3.30% 2-8
- Eosinofil 0.10% 1-6
- Basofil 0.000% 0-1
- Neutrofil absolute 9.88 1,9-5,4
- Limfosit absolute 1.10 3,7-10,7
- Monosit absolute 0.38 0,3-0,8
- Eosinofil absolute 0.01 0,2-0,5
- Basofil absolute 0.00 0-0,1
Interpretation : Metabolic Acidosis
Parameters Value Normal Value
Analisa Gas Darah
pH 7.31 7.35 7.45
PCO2 27.9 mmHg 38 42
PO2 151.7 mmHg 85 100
Bikarbonat 29.5 mmol/L 22 26
Total CO2 15.1 mmol/L 19 25
Kelebihan Basa (BE) -5.0 mmo/L (-2) (+2)
Saturasi O2 99.3% 95 100
Carbohydrate Metabolism
Blood Glucose ad random 149.00 mg/dL < 200
Renal Function Test
Ureum 178.00 mg/dL < 50
Creatinine 4.97 mg/dL 0,17 0,42
Elektrolit
Kalsium 8.9 mg/dL 9.2 11.0 mg/dL
Natrium 98 mEq/L 135 155 meq/L
Kalium 1.7 mEq/L 3,6 5,5 mEq/L
Klorida 56 mEq/L 96 106 mEq/L
Radiologic imaging July 8
th
2014
KV is too high, good
inspiration, middle trachea,
both costophrenicus angels
is sharp, smooth
diaphragm, Cardio Thoracic
Ratio is more than 50%,
bones and soft tissues in
normal condition,
Result : Cardiomegaly
Working Diagnosis:
Chronic Kidney disease Stage IV

Management:
Oxygen 1 2 L/i nasal canule (+),
nasogastric tube (-)
IVFD D5% 5 gtt/i
Spironolakton 2 x 25 mg
Diet 1995 kkal + 80 g protein

Diagnostic Planning:
Chest X-ray
Complete blood count
Glucose ad random
Electrolyte (Na, K, Cl)
Blood gas analysis
Urin analysis
USG Doppler Of Kidney and Bladder

Follow up August 12
th
2014
S
Loss of consciousness
O
A
Chronic Kidney Disease Stage IV
Sens: GCS 14 , Temp: 36.8
o
C. Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-)
Head Right Eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (+).
Icteric sclera (-). Light reflex (+).
Left eye: Pupil diameter 3 mm. Inferior palpebra conjunctiva pale (+).
Icteric sclera (-). Light reflex (+)..
Neck Lymph node enlargement (-)
Thorax Simetris fusiformis. Retraction (-) epigastrial; intercostals, suprasternal.
HR: 98 bpm, reguler; murmur (-)
RR: 28 x/i, regular, rales (-)
Abdomen Soepel, Rapid turgor. normoperistaltic. Liver, spleen and renal
unpalpable.
Extremities Pulse 98 x/i, regular, adequate p/v, warm, CRT < 3. Blood Pressure
140/100 mmhg
Genital Male; within normal limit.

P
Management:
O2 1-2 L/i
IVFD D5% 5 gtt/I mikro
Spironolakton 2x25 mg
Hiponatremia correction
Fast Correction = (120-98) x 40 x 0.6 = 501.6 mEq (finished in 6 hours. With NaCl
3% = 501.6/513 =977cc = 160 gtt/I micro
Slow correction = (135-125) x 40 x 0.6 = 240 mEq/L
Maintanance = 2 -4 mEq/L = 80 160 mEq/L
Total = 320 400 mEq
With IVFD D5% NaCl 0.9% = 320/154 x 1000 = 2077 cc 155 gtt/I micro,
finished in 18 hours
Hipocalemia correction
1.7 mEq/L with 0.75 mEq/kgBB, 30 mEq KCl in 90 cc D5%, finished in 3 hours =
40 gtt/I micro

Planning :
Electrolit test repetition post correction, full blood, and AGD
Dipstick result
Uro/Bil/Ket/Blood/Pro/Nit/Leu/Glu/Sg/pH
-/+/-/-/+/-/+/-/1.005/6.5
Follow up August 13
th
2014
S
limp (+), nausea and vomit (-), Fever (-)
O
A Chronic Kidney Disease Stage IV
Alert : Compos Mentis , Temp: 36,7
o
C. Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe
(-)
Abdomen Soupel, Rapid turgor. normoperistaltic. Liver, spleen and renal
unpalpable.
140/100 mmhg

P
Management:
O2 1-2 L/I
Diet 1995 kkal + protein 32 gram

Planning :
Electrolit and AGDA repetition test ( if correction of hipocalemia and
hiponatremia finished).

Water Balance
Input :Diet = 1.500 cc Output : OUP = 900 cc
IVFD = 30 cc BAB = 0
Total = 1.524 cc IWL = 190 cc
Total = 1.090 cc
B = I - O
= 434 cc
K6JB = HS + BC
= 1010 cc
Follow up August 14
th
2014
S
O
o
(-)
unpalpable.
130/90 mmhg

P Management:
O2 - 1 L/I nasal kanul
IVFD D5% 5 gtt/I micro

Water Balance
Input :
Diet = 600 cc
IVFD = 150 cc
Total = 750 cc

B = I - O
= -40cc
K6JB = HS + BC
= 335 cc
Output :
OUP = 600 cc
BAB = 0
IWL = 190 cc
Total = 790 cc
Follow up August 15
th
2014
S
O
Alert : Compos Mentis , Temp: 37
o
C. Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-
)
unpalpable.
130/90 mmhg

P
Management:

Planning
USG Doppler of kidney and bladder

Electrolit correction result
Ca/Na/K/Cl = 7.7/121/1.8/93 mEq/L
Full blood count result
Hb/Ht/RBC/WBC/Plt = 6.7/18.9/2.31x10
6
/9.5x10
3
/431x10
3

Water Balance
Input : Diet = 600 cc Output : OUP = 600 cc
IVFD = 150 cc BAB = 0
Total = 750 cc IWL = 190 cc
Total = 790 cc
B = I - O
= -40cc
K6JB = HS + BC
= 335 cc
Follow up August 16
th
2014
S
O
o
)
unpalpable.
130/90 mmhg

P
Management:

Planning
Tranfussion PRC 3 cc/kgbb in 24 hours
Water Balance
IVFD = 0 cc BAB = 0
Total = 500 cc
B = I - O
= 400 cc
K6JB = HS + BC
=875 cc
Follow up August 17
th
2014
S
O
o
)
unpalpable.
120/80 mmhg

P
Management:
IVFD D5% 5 gtt/I
Planning

Water Balance
IVFD = 0 cc BAB = 0
Total = 500 cc
B = I - O
=400 cc
K6JB = HS + BC
= 875 cc

Follow up August 18
th
2014
S
O
o
C. Anemic (+). Icteric (-). Edema (-). Cyanosis (-) Dyspnoe (-)
unpalpable.
120/80 mmhg

P
Management:
Planning
Repeat electrolit and AGDA
Water Balance
Input : Diet = 900 cc Output : OUP = 70 cc B = I - O
IVFD = 300 cc BAB = 200 cc = 200 cc
Total = 1200 cc IWL = 100 cc K6JB = HS + BC
Total = 1.000 cc = 475 + 200 cc
= 675 cc
Dipstik
Uro/Bil/Ket/Blo/Pro/Nit/Leu/Glu/SG/pH
-/+1/-/-/+2/+3/-/-/1.010/7.0
Follow up August 19
th
2014
S
O
o
(-)
unpalpable.
120/80 mmhg

P
Management:
IVFD D5% 5 gtt/I
Planning
Water Balance
IVFD = 50 cc BAB = 0 = - 250 cc
Total = 600 cc = 725 cc
Follow up August 20
th
2014
S
O
Alert : Compos Mentis , Temp: 37.5,8
o
C. Anemic (+). Icteric (-). Edema (-). Cyanosis (-)
Dyspnoe (-)
unpalpable.
120/80 mmhg

P
Management:
IVFD D5% 5 gtt/I
Water Balance
IVFD = 300 cc BAB = 200 cc = 200 cc
Total = 1.000 cc = 475 + 200 cc
= 675 cc
Dipstik
Uro/Bil/Ket/Blo/Pro/Nit/Leu/Glu/SG/pH
-/+/-/-/+/-/+/-/1.005/6.5
DISCUSSION
Patients with chronic kidney disease (CKD) stage 1-3 are frequently
asymptomatic. Generally, these disturbances become clinically manifest with
CKD stages 4-5 (GFR < 30 mL/min/1.73 m
2
) associated with positive
symptoms. In patients we found GFR 23,24 mL/min/1.73 m
2.
It shows chronic
kidney disease stage 4.
Anemia, which in CKD develops primary as a result of
decreased renal synthesis of erythropoietin, manifests as
fatigue, reduced exercise capacity, impaired cognitive and
immune function, and reduced quality of life. Anemia is also
associated with the development of cardiovascular disease, the
new onset of heart failure, the development of more severe
heart failure, and increased cardiovascular mortality. In
patients we found of laboratorium result with Hb 7.20 g%. It
shows anemia.
Typical physical findings in persons with uremia are those
associated with fluid retention, anemia, and acidemia. Severe
malnutrition can contribute to muscle wasting, while
electrolyte abnormalities may cause muscle cramping, cardiac
arrhythmias, and mental status changes.
Hyponatremia is decrease in serum Na concentration < 136
mEq/L caused by an excess of water relative to solute. Common
causes include diuretic use, diarrhea, heart failure, and renal
disease. Clinical manifestation are primarily neurologic (due to
an osmotic shift of water into brain cells causing edema),
especially in acute hyponatremia, and include headache,
confusion, and stupor, seizures and coma may occur.
Correction Hiponatremia

Fast Correction = (120-98) x 40 x 0.6 = 501.6 mEq (finished in 6 hours.
With NaCl 3% = 501.6/513 =977cc = 160 gtt/I micro
Slow correction = (135-125) x 40 x 0.6 = 240 mEq/L
Maintanance = 2 -4 mEq/L = 80 160 mEq/L

Total = 320 400 mEq
With IVFD D5% NaCl 0.9% = 320/154 x 1000 = 2077 cc 155 gtt/I micro,
finished in 18 hours
Kalium concentration in patient is 1.7 mEq/L. The normal
potassium level is 3.5-5.0 mEq/L. Low potassium is defined as a
potassium level below 3.5 mEq/L.

Hypocalemia correction:
< 2.5 mEq/L : 0.75 mEq/kg body weight with ratio D5% 1 : 3 and
finished in 3 h.
2.5 3 mEq/ L : 0.5 mEq /kg body weight with ratio D5% 1 : 3,
and finished in 2 h.
3.5 mEq/L : 0.25 mEq/kg body weight with ratio D5% 1 : 3, and
finished in 1 h.

In patients potassium concentration is 1.7 mEq/L with calculated
potassium correction :
1.7 mEq/L with 0.75 mEq/kgBB, 30 mEq KCl in 90 cc D5%, finished in
3 hours = 40 gtt/I micro
CONCLUSION
A boy age 15 years suffering from stage chronic
kidney disease stage 4 with GFR 23.24 mL/min/1.73
m
2.

CKD

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INTRODUCTION

Chronic Kidney Disease (CKD) is a patophysiologic

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