Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Objectives
Definition
Investigations
CKD
Interventions
Nutrition/dietary
protein intervention
2
Ginjal
Sistem
Filtrasi
Glomerulu
s
Glomerulus
Kapiler Glomerulus
Slit diaphragm
Barier Filtrasi/Penyaring
GBM
Fenestrated endothelium
Penampakan lapisan luar penyaring ginjal yang sehat dengan mikroskop elektron
of the following
No
hematuria
No proteinuria
No parenchymal or structural abnormality
(cyst, scar, hydronephrosis)
Decreased GFR
Staging of CKD
GFR Category
GFR
(ml/min/1.73 m2)
Terms
G1
90
G2
60 89
Mildly decreased
G3a
45 59
G3b
30 44
G4
15 29
Severely decreased
G5
< 15
Normal or High
KIDNEY FAILURE
KDIGO 2012, Kidney International Supplements (2013) 3, 5-14
With Kidney
Damage
Without Kidney
Damage
With
HBP
Without
HBP
With
HBP
Without
HBP
> 90
High BP
normal
60 89
High BP with
GFR
GFR #
30 59
15 29
< 15 or Dialysis
6089 mL/min/1.73 m2
Predictors of Progression
Cause
of CKD
Level of GFR
Level of albuminuria
Age
Sex
Race/ethnicity
Elevated Blood
Pressure
Hyperglycemia
Dyslipidemia
Smoking
Obesity
History
of CVD
Ongoing exposure
to nephrotoxic
agents
16
Normal
Increased Risk
Screening for
CKD risk
factors
CKD risk
reduction,
Screening for
CKD
DM/HT
Damage
3
Diagnosis &
treatment,
Treat comorbid
conditions,
Slow
progression
PROTEINURIA
GFR
Kidney
failure
Estimate
progression, Treat
complications,
Prepare for
replacement
Creatinine
CKD
death
Replacement
by dialysis &
transplant
17
Proteinuria
Care plan
STAGE 1 & 2
Proteinuria plus
eGFR 60+
(to determine eGFR
over 60, hand
calculate GFR using
Cockcroft-Gault
formula)
CKD
Care plan
STAGE 3
eGFR 3059
ml/min
ESKD
Care plan
STAGE 4
eGFR 15-29
ml/min
MODERATE
SEVERE
KIDNEY
KIDNEY
DAMAGE
DAMAGE
STAGE 5
PALLIATIVE CARE
eGFR <15
ml/min
FAILURE
DIALYSIS
HAEMODIALYSIS
PERITONEAL DIALYSIS
TRANSPLANTATION
Chronic
Kidney
Disease
Diagnosis
End Stage
Kidney
Disease
Diagnosis
Kidney
Failure
Investigating CKD
s.Creatinine Concentration
High s.Creatinine
with Normal GFR
Spurious elevation:
Cephalosporin
Alcohol intoxication
Cimetidine or trimethoprim
Increased creatinine
production:
Exogenous: ingestion of
large quantities of meat
Endogenous: Muscular
disorders, or increases in
muscular mass
Normal s.Creatinine
with CKD
Poor production of
creatinine:
Severely
malnourished
patients
Elderly
Small
children
Ladies
of small size
21
Principles Management
Early
recognition of CKD
Estimate
22
Clinical Features
Mild
to Moderate CKD:
Usually
Severe
NO SYMPTOMS
Pale,
23
Complications of CKD
Stage of CKD
Complications
Stage 1
Stage 2
BP
Stage 3
Stage 4
Malnutrition
Metabolic acidosis
Kalium
Stage 5
Azotemia
Volume overload
iPTH
Ca2+/PO4 disturbances
Dyslipidemia
LVH
Anemia
24
http://www.health.gov.bc.ca/gpac/pdf/ckd.pdf
Interventions
25
CV RISK
FACTOR
MODIFICATION
PROTEINURIA
REDUCTION
EVALUATE
CKD
PROGRESSION
VAX
NUTRITIONAL
ASSESSMENT
ANEMIA
MGMT
CKD-MBD
MGMT
GLYCEMIC
CONTROL
LIPID
CONTROL
HTN
27
glucose control in
diabetes
Strict blood pressure
control
RAA system blockade
Treat anemia of CKD
Optimize
nutrition
Treat
associated CVD
and dyslipidemia
Prevent
renal
osteodystrophy (ROD)
Prevent
75
GFR
50
25
10
4
Time (yr.)
29
11
<7%
Delay
Hyperlipidemia
In
CKD:
Mainly
hypertriglyceridemia
Increasing
production
Altering glomerular hemodynamics
Increasing local inflammation
K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease.
Am J Kidney Dis 2003:41(Suppl 3):S1S91.
31
Dyslipidemia Treatment
Smoking
cessation
Aspirin
use
Weight
loss
Aerobic
Exercise
Statins
Fibric Acid
Derivatives
LDL Goal
K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease.
Am J Kidney Dis 2003:41(Suppl 3):S1S91.
32
Anemia
Present
Causes:
Reduced
EPO production
Others: iron deficiency, rapid destruction of RBC,..
Anemia
CHF
Studies
1%
33
7.3
7.0
6.0
6.3
6.0
4.6
5.0
3.6
4.0
3.0
2.0
1.0
1.5
2.0
2.0
2.4
2.4
3.7
3.7
4.7
4.0
2.9
1.0
N
on
e
D
An M o
em nl
ia y
on
ly
C
K
D
D
M
on
/C
D
ly
M
K
D
/A
o
ne
m nly
ia
D
M
on
/C
ly
C
K
H
D
F
/A
on
ne
ly
m
ia
D
on
M
C
/
ly
C
K
H
D
F
/A
on
ne
C
ly
H
m
F/
ia
D
An
M
o
/C
em nly
H
F/
i
An a o
em nly
C
ia
C
H
H
F/
F/ on
C
ly
C
K
K
D
D
/A
ne on
D
l
M
/C mia y
D
H
M
on
F/
/C
ly
C
H
K
F/
D
C
on
K
D
ly
/A
ne
m
ia
0.0
Source: Medicare sample (5%), followup from 1996 to 1997 of enrollees aged >65 y.o.,
adjusted for age, gender and race.
34
CKD
To save the HEART and the KIDNEY,
treat the ANEMIA
CHF
Anemia
35
Hypertension
Role of the Kidney in Hypertension
Renal-Body
37
www.hypertensiononline.org
Interchangeable,
CAPD
Transplant
HD
Hemodialysis
39
Hemodialysate
Artificial
kidney
44
47
Transplantasi Ginjal
Donor
Resipien
Nutrition/Dietary Protein
Intervention
Alternatives to Avoid
Nutritional Intervention
Rationale
AA loads
:
induce glomerular hyperfiltration
Protein
Obesity
Nutrition Therapy
Consult
High
57
K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias
in CKD. AJKD 2003:41(Suppl 3):S1S91.
Progression of CKD :
Proteinuria
PROTEINURIA is the major determinant in the rate of CKD
progression!
Protein, which is excessively filtered by the glomerular
membranes:
Protein-restricted diets
Effect on progression in non-diabetic CKD patients
Protein-restricted diets
Efficacy in delaying the need of dialysis
Study
Year
Treatment
(non-diabetics)
Control
OR
IHLE et al
JUNGERS et al
KLAHR et al
LOCATELLI et al
MALVY et al
ROSMAN et al.
WILLIAMS et al
Total (95%CI)
1989
1987
1994
1991
1999
1989
1991
4 / 34
5 / 10
18 / 291
21 / 230
11 / 25
30 / 130
12 / 33
13 / 38
7/9
27 / 294
32 / 226
17 / 25
34 / 117
11 / 32
101 / 753
141 / 741
(95 % CI)
0,1
0,2
10
Guidelines :
Protein in pre-dialysis patients
For
VLPDs
Thank you
for your attention
68
PANDUAN 1
Tujuan Penatalaksanaan Nutrisi
Pada Penyakit Ginjal Kronik
Tujuan Umum
1.
2.
3.
4.
Tujuan Khusus
PGK Predialisis
Mengurangi akumulasi
produk-produk sisa nitrogen.
Mengurangi gangguan
metabolik terkait uremia.
Memperlambat laju
progresivitas penyakit ginjal.
Mengatur keseimbangan air
dan elektrolit.
Mengendalikan kondisikondisi terkait PGK seperti
anemia, penyakit tulang dan
penyakit kardiovaskular
PGK HD
Mengendalikan kondisi-kondisi
terkait PGK seperti anemia,
penyakit tulang dan penyakit
kardiovaskular
Tujuan Khusus
PGK PD
Transplantasi Ginjal
metabolisme berlebih.
PANDUAN 2
Penilaian Status Nutrisi
Indikator Malnutrisi
1. SGA (B) dan (C)
2. Albumin serum < 3,8 g/dl
3. Kreatinin serum < 10 mg/dl
4. Indeks massa tubuh (IMT) < 20 kg/m2
5. Kolesterol < 147 mg/dL
6. Prealbumin serum < 30 mg/dL
PANDUAN 3
Rekomendasi Asupan Energi,
Protein dan Lemak
2.
3.
4.
Kalori Dialisat
Dekstrosa
1,5% = 86,08
Dekstrosa 2,5% = 144,68
Dekstrosa 4,25% = 243,91
PANDUAN 4
Rekomendasi Vitamin, Air, Mineral
dan Trace Elements
PANDUAN 5
Monitoring dan Evaluasi
SKENARIO
Ny. F, 58 tahun, MRS pada tanggal 11 Januari 2015 di RS Pertiwi
karena mengalami sesak nafas dan hipertensi. Sejak Desember 2014,
Ny. F dinyatakan menderita GGK dan harus menjalani hemodialisa 2
kali seminggu. Gejala yang sering dialami Ny. F antara lain badan
terasa lemas, mual, muntah, nafsu makan menurun, volume BAK
berkurang, dan gatal-gatal. Terapi diet yang diberikan sekarang adalah
diet Rendah Protein RG. Ny. F sudah pernah berkonsultasi dengan ahli
gizi terkait diet yang harus dijalankan. Namun, yang menjadi kendala
utama dalam pengaturan diet Ny. F adalah Ny. F seringkali menolak
pembatasan garam dalam makanan dan masih suka mengkonsumsi
crekers, dan makanan kalengan. Asuhan gizi yang optimal dan
kolaborasi antar tim kesehatan sangat diperlukan untuk membantu
mempertahankan kualitas hidup pasien.
Problem
PGK
stadium V on Reguler HD
Hipertensi stadium 2
Anemia on PGK
Dispepsia
Hipoalbuminemia
Hiponatremia
Hiperkalemia
Normal range
Number of patients
100
80
60
40
20
0
16
18
20
22
24
26
Bicarbonate (mmol/l)
28
30
32
Normal range
1800
Number of patients
1600
1400
1200
1000
800
600
400
200
0
2
2.5
3.5
4.5
5.5
6.5
Potassium (mmol/l)
7.5
8.5
9.5
10
Normal range
1800
Number of patients
1600
1400
1200
1000
800
600
400
200
0
124
126
128 130
132
134 136
138 140
Sodium (mmol/l)
142
144 146
148
150