Chronic Kidney Disease:

Tufts-New England Medical Center

National Kidney Foundation

Definition of CKD
Structural or functional abnormalities of
the kidneys for >3 months, as
manifested by either:
1. Kidney damage, with or without decreased
GFR, as defined by
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 month with

or without kidney damage

CKD Risk Factors

Diabetes Mellitus
Hypertension
Cardiovascular
Disease
Obesity
Metabolic Syndrome
Acute Kidney Injury
Malignancy

Kidney Stones
Autoimmune
diseases
Nephrotoxics like
NSAIDS

Etiologi of CKD
Diabetic Kidney Disease
Glomerular diseases (autoimmune diseases, systemic
infections, drugs, neoplasia)

Vascular diseases (renal artery disease, hypertension,

microangiopathy)

Tubulointerstitial diseases (urinary tract infection, stones,

obstruction, drug toxicity)

Cystic diseases (polycystic kidney disease)

Diseases in the transplant (Allograft nephropathy, drug
toxicity, recurrent diseases, transplant glomerulopathy)

Prevalence of CKD and Estimated Number of

Adults with CKD in the US (NHANES 88-94)
Stage

Description

GFR
(ml/min/1.73 m2)

Kidney Damage with

Normal or GFR

Prevalence*
N
(1000s)

90

5,900

3.3

Kidney Damage with

Mild GFR

60-89

5,300

3.0

Moderate GFR

30-59

7,600

4.3

Severe GFR

15-29

400

0.2

Kidney Failure

< 15 or Dialysis

300

0.1

*Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes
approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated
from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For
Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two
measurements.

Prevalence of Abnormalities at each level of GFR

*>140/90 or antihypertensive medication

p-trend < 0.001 for each abnormality

Clinical Practice Guidelines for the Detection,

Evaluation and Management of CKD

Stages in Progression of Chronic Kidney

Disease and Therapeutic Strategies
Complications
Complications

Normal
Normal

Screening
for CKD
risk factors

Increased
Increased
risk
risk
CKD risk
reduction;
Screening for
CKD

Damage
Damage

GFR
GFR

Kidney
Kidney
failure
failure

Diagnosis
Estimate
Replacement
& treatment; progression;
by dialysis
Treat
Treat
& transplant
comorbid complications;
conditions;
Prepare for
Slow
replacement
progression

CKD
CKD
death
death

CKD - Management

Diagnostic work up to decide underlying etiology

Treatment of Hypertension and Dyslipidemia
Treatment of Anemia
Treatment of Hyperphosphatemia
Avoidance of Dehydration & Nephrotoxic agents
Proper Dosing of Drugs
Preparation for Renal Replacement Therapy

Definition of ESRD vs Kidney Failure

ESRD defined term that indicates
chronic treatment by dialysis or
transplantation
Kidney Failure: GFR < 15 ml/min/1.73
m2 or on dialysis.

CKD - Manifestations
Abnormal Sodium-Water metabolism
Edema, Hypertension
Abnormal Acid-base abnormalities
Metabolic Acidosis due to uremia
Abnormal hematopoesis
Anemia of CKD
Cardiovascular Abnormalities
LVH, CAD, Diastolic Dysfunction
Abnormal Calcium-Phosphorus metabolism
Hyperphosphatemia, pruritus, arthralgia
Hyperparathyroidism
Renal Osteodystrophy

Importance of Proteinuria in CKD

Interpretation

Explanation

Marker of kidney
damage

Spot urine albumin-to-creatinine ratio >30 mg/g or

spot urine total protein-to-creatinine ratio >200 mg/g
for >3 months defines CKD

Clue to the type

(diagnosis) of CKD

Spot urine total protein-to-creatinine ratio >5001000 mg/g suggests diabetic kidney disease,
glomerular diseases, or transplant glomerulopathy.

Risk factor for adverse Higher proteinuria predicts faster progression of

outcomes
kidney disease and increased risk of CVD.
Effect modifier for
interventions

Strict blood pressure control and ACE inhibitors are

more effective in slowing kidney disease
progression in patients with higher baseline
proteinuria.

Hypothesized
surrogate outcomes
and target for
interventions

If validated, then lowering proteinuria would be a

goal of therapy.

Akut kidney injury

HB normal
Oliguric type
Non oliguric type (30-60%) prognosis
lebih baik
Umumnya reversible
Mortalitas tinggi: 40-60%

Penyebab AKI
Pre-renal : Hypovolemic, hypotensi,
dehydrasi, syok
Renal (Intrinsic renal failure) ATN
(acute tubular nephrosis) or VMN
(vascular membrane nephrosis)
Post-renal : obstruksi, batu, prostat,
trauma, keganasan.

Anamnesis

Riwayat tindakan / operasi

Hipotensi shock
Hipertensi (accelerated / malignant)
Drugs
Renal disease

Clinical Course of AKI

Onset Phase : oliguria, ureum creatinin
meningkat, gangguan elektrolit
Oliguric Phase : fluid overload, edema
ankle/pulmo, hyperkalemia cardiac,
arythmia, hyponatremia, acidosis,
kussmaul respiration.

Acute uremic syndrome

CVS : hipertensi, arythmia, CHF,
pericarditis
Gastroinstestinal : anorexia, nausea,
vomithing, diarhea, bleeding, pancreatitis
CNS : cunfussion, twitching, asterixis,
soporosus coma
Hemopoetic system : bleeding, anemia

Management of AKI
Phase oliguri : cairan <500 cc/h, monitor
elektrolit : kalium, asupan kalori. Dialisis
Phase diuretik : keseimbangan cairan
dan elektrolit
Post diuretik : cairan / elektrolit
Prognosis : tergantung penyebab, usia,
comorbid, infeksi, multi organ

RRT
Preparation for Renal Replacement Therapy
Education for Options of Dialysis & Renal
Transplantation for Renal Replacement
Hemodialysis Vs Peritoneal Dialysis
Timely placement of vascular access or PD
catheter.

Integrated Renal Replacement

Therapy
Transplantasi

RRT

Hemodialisis

Peritoneal Dialisis

RRT
Indications (Absolute):

Uncontrolled hyperkalemia and acidosis

Uncontrollable hypervolemia (pulmonary edema)
Pericarditis
somnolence (advanced encephalopathy)
Bleeding diathesis

Indications (Relative):

Nausea, vomiting and poor nutrition

Metabolic acidosis
Lethargy and Malaise
Worsening kidney function <10 ml or <15 ml in diabetics

CKD - RRT
Transplantation:
Graft survival better
with living donor
kidneys.
Immunosuppresion is
almost always a must.

CKD - RRT
Transplantation:
Diseases like FSGS may reccur early in the
transplanted kidney.
Increased risk for infection, cardiovascular disease.
Contraindications:

Malignancy (recent or metastatic)

Current infection
Severe extra renal disease
Active use of illicit
drugs(narcotics,stimulant,depressant,hallucinogens)

HD

VS

PD

Keunggulan
Keunggulan
Dilakukan dalah waktu lebih singkat
Kimia darah lebih stabil
Lebih efisien terhadap pengeluaran zatHematocrite lebih tinggi
zat BM rendah
Pengendalian tekanan darah lebih
Terjadi sosialisasi di senter dialisis
mudah
Cairan dialisat sebagai sumber nutrisi,
pada penderita DM, insulin bisa
Kelemahan
diberikan intraperitoneal
Membutuhkan heparin
Membutuhkan vascular access
Kelemahan
Gangguan hemodinamik
Peritonitis
Pengendalian tekanan darah yang lebih
Obesitas
sulit
Hiperglikemi
Dibutuhkan disiplin diet dan jadwal
pengobatan yang teratur
Malnutrisi / protein loss
Hernia
Back pain