Introduction

Three primary renal function :

1. Excretory
2. Endocrin
3. metabolic
In chronic kidney disease
many organic compounds accumulation
amino acid & protein metabolic products
(urea, creatinine, guanidine compounds, uric acid)
Toxic effects ! Uremia
 Batasan Penyakit Ginjal Kronik
Kriteria :

1. Kerusakan ginjal 3 bulan, yaitu kelainan struktur atau fungsi

ginjal, dgn atau tanpa penurunan laju filtrasi glomerulus
berdasarkan :
Kelainan patologik atau
Petanda kerusakan ginjal spt kelainan pd komposisi
darah atau urin, atau kelainan pd pemeriksaan pencitraan
2. Laju filtrasi glomerulus < 60 ml/men/1.73 m2 selama 3
bulan, dgn atau tanpa kerusakan ginjal.
 Potential Risk Factors for Susceptibility to and
Initation of Chronic Kidney Disease

Clinical Factors Sociodemographic Factors

Diabetes Older age

Hypertension US ethnic minority status : African
Autoimmune diseases American, American Indian, Hispanic, Asian
Systemic Infections or Pasific Islander
Urinary tract infections Exposure to certain chemical and
environmental conditions
Urinary stones
Low income/ education.
Lower urinary tract obstruction
Neoplasia
Family history of chronic kidney diseases
Recovery from acute kidney failure
Reduction in kidney mass
Exposure to certain drugs
Low birth weight
 Types and Examples of Risk Factors for Chronic
Kidney Disease
Increase susceptibility to
Susceptibility factors
kidney damage
Directly initiate kidney
Initiation factors
damage
Cause worsening kidney
damage and faster decline in
Progression factors
kidney function after
initiation of kidney damage
Older age, family history
Diabetes, high blood pressure,
autoimmune disease, systemic
infections, urinary tract
infections, urinary stones, lower
urinary tract obstruction, drug
toxicity.
Higher level of proteinuria,
higher blood pressure level,
poor glycemic control in
diabetes, smoking.
 Penatalaksanaan penderita dgn
risiko CKD

Seleksi pendrt dgn risiko CKD

Evaluasi thd kemungkinan terjadi CKD
Evaluasi marker CKD
Modifikasi faktor risiko
 Evaluasi pasien dgn risiko tinggi GGK

Tekanan darah
Ureum, kreatinin, asam urat
Gula darah, HBA1C
Urine rutin ( albumin, eritrosit, leukosit, pH )
USG, renogram
Rasio Albumin/kreatinin
 Potentially Modifiable Risk Factors for Development and Progression
of Chronic Disease According to Stage

Poor physical functioning

Poor Social Functioning

Elevated Homocystein
Thrombogenic factors

Vocational disability
Other Uremic Toxin
Oxidative stress
Dyslipidemia

Menopause
Proteinuri

Smoking
Anemia
Stage Description

At increased risk
1 Kideny damage
with normal or
GFR

2 Kidney damage
with mild GFR
3 Moderate GFR
4 Severe GFR
5 Kideny failure
 Rencana Kerja Berdasarkan Stadium
Penyakit Ginjal Kronik
LFG (ml/men./
Stadium Deskripsi Aksi
1.73 m3)
1 Kerusakan ginjal dgn 90 Diagnosis & pengobatan, Terapi
LFG normal penyakit penyerta,
Penghambatan progresifitas,
Penurunan risiko PKV

2 Kerusakan ginjal dgn 60 - 89 Perkiraan progresifitas

LFG ringan

3 Sedang LFG 30 - 59 Evaluasi & pengobatan

komplikasi
4 Berat LFG 15 - 29 Persiapan terapi pengganti
ginjal
5 Gagal ginjal < 15 Terapi pengganti ginjal
(atau dialisis)

LFG = Laju Filtrasi Glomerulus; PKV = Penykt Kardiovaskular

 Pemeriksaan Penunjang
Penyakit Ginjal Kronik

Kadar kreatinin serum utk menghitung laju filtrasi

glomerulus.
Rasio protein thd kreatinin atau albumin thd
kreatinin dlm contoh urin pertama pd pagi hari
atau urin sewaktu.
Pemeriksaan sedimen urin atau dipstick utk melihat
adanya sel darah merah dan sel darah putih.
Pemeriksaan pencitraan ginjal, biasanya dgn
ultrasonografi.
Kadar elektrolit serum (natrium, kalium, klorida dan
bikarbonat)
 Klasifikasi Diagnosis Penyakit Ginjal Kronik

Penyakit Tipe Utama (Contoh)

Penyakit Ginjal Diabetik Diabetes Tipe 1 dan 2

Penyakit Ginjal NonDiabetik Penyakit Glomeruler (Penyakit otoimun,

infeksi sistemik, neoplasia)
Penyakit Vaskuler (Penyakit pembuluh darah
besar, hipertensi, mikroangiopati)
Penyakit Tubulointerstitial (ISK, batu,
obstruksi, toksisitas obat)
Penyakit Kistik (Penyakit Ginjal Polikistik)

Rejeksi kronik, Toksisitas obat, Penykt

Penykt Ginjal Transplant rekuren, Glomerulopati transplan
 Evaluasi Penderita CKD

Diagnosa dini
Penyakit penyerta
Tentukan stadium CKD
Komplikasi CKD berdasar stadium CKD
Penatalaksanaan pnykt penyerta
Menghambat progresifitas
Risiko thd pnykt kardiovaskular
 Deteksi Dini GGK

Intervensi yg Pencegahan
Modifikasi Persiapan
Menghambat Komplikasi
Komorbiditas RRT
progresifitas Uremik

Penyakit
ACEI/ ARB Malnutrisi Pendidikan
Jantung

Kendali Penyakit Informasi pilihan

Anemia
tek. darah Vaskuler RRT

Kendali Neuropati Pemasangan akses

ODR
Gula darah (pd DM) Tepat waktu

Restriksi Retinopati Memulai dialisis

Asidosis
Protein ? (pd DM) Tepat waktu

Optimalisasi perawatan GGK

 Terapi
Terapi spesifik thd diagnosis CKD
Terapi penyakit penyerta
Menghambat progresifitas CKD
Pencegahan thd pnykt kardiovaskular
Persiapan thd gagal ginjal
Persiapan terapi pengganti
Terapi pengganti
 Chronic kidney diseases ( CKD )

* Renal injury destruksi nefron yang bersifat

chronic progressive , irreversible

* Penurunan jumlah massa nefron menyebabkan

perubahan struktur dan hiper fungsi dari sisa nefron

* Respon mekanisme predisposisi sklerosis nefron

CKD
* uremia sindrom klinik yg mengenai seluruh
organ/ sistem
 Chronic kidney disease

Pathophysiology
Nitrogen and Lipid Metabolism
Pts are often hypercatabolic and have a
decrease capacity to eliminate nitrogenous end
products of protein catabolism.
Hypertriglyceridemia and, decreased HDL are
common in pts with CRF.
High incidence of premature atherosclerosis
 Chronic kidney disease
Clinical
Fluid, Electrolyte, and Acid Base Disorders
Sodium and Volume Homeostasis

Total body contents of Na+ and water are

increased modestly.
Hyponatremia secondary to volume overload
is common
Management in a edematous pt with CRF and
not on dialysis requires diuretics and dietary
restriction of salt and water.
 Chronic kidney disease

Fluid, Electrolyte, and Acid-Base Disorders

Metabolic Acidosis
With advancing renal failure, total daily acid
excretion and buffer production fall below the
level needed to maintain balance of H+ ions
 Chronic kidney disease
Bone, Phosphate, and Calcium Disorders
Renal (Uremic) Osteodystrophy
Present in 35-90% of pts with advanced renal
failure
Osteomalacia (low turnover)
Osteitis Fibrosia Cystica (high turnover)
Secondary Hyperparathyroidism
Subperiostial erosions (esp terminal
phalanges, long bones, and distal clavicles)
Dialysis-related amyloid bone disease
 Chronic kidney disease
Hematologic Abnormalities
Normochromic Normocytic Anemia
Depressed erythropoiesis
Retained toxins effect on bone marrow
Diminished biosynthesis of erythropoietin
(Relative EPO deficiency)
Abnormal Hemostasis
Defective platelet function
Increased guanidinosuccinic acid
Enhanced Susceptibility to Infection
Impaired leukocyte function
 Chronic kidney disease

Neuromuscular Abnormalities
Disturbances of CNS function
Inability to concentrate, drowsiness, etc
Peripheral Neuropathy
Restless Legs Syndrome
Indication for dialysis
GI Abnormalities
Anorexia, N/V
PUD is common
 Chronic kidney disease

Endocrine Abnormalities
Secondary Hyperparathyroidism
Ammenorrhea
Impaired insulin metabolism
Dermatologic Abnormalities
Pallor
Ecchymosis, hematomas
Pruritus
Uremic Frost
 Chronic kidney disease
Cardiovascular and Pulmonary Disorders
Fluid retention in uremia often results in CHF and/or
pulm edema

Hypertension is probably the most common

complication of ESRD
Fluid Retention
Resultant LVH or dilated cardiomyopathy

Pericarditis
Caused by retained metabolic toxins
Higher incidence of atherosclerosis

Cardiovascular disease (no : 1 cause of death)

 Penatalaksanaan CKD
Ditujukan untuk mengurangi gejala klinik , mencegah komplikasi ,
mencegah progresifitas CKD, mempersiapkan initiasi dialisis

Uremia : diit protein 0,8 0,6 gr / kg bb / hari

Hiperkalemia : diit rendah kalium ; 60 80 meq/hari
Asidosis metabolik : diit rendah protein / fosfat; HCO3

Stop rokok
Kontrol lipid ( preparat statin )
HbA1C < 7 %

Hipertensi
Anemia
Osteodistrofi renal
Komplikasi kardiovaskular
hypertension

K/DOQI, 2004 / ADA, 2003 / JNC 7, 2003 : Target BP 130/80 mmHg

Lifestyle modification : DASH diet, exercise, etc
Agent is ARB, ACE-inh (initial) : Hypertension Diabetic Kidney Disease and
Nondiabetic Kidney Disease

Hypertension and Antihypertensive Agents in Diabetic Kidney Disease

(K/DOQI)

Clinical Target BP Preffered Agents for Other Agents to Reduce

Assessment CKD CVD Risk and Reach
Target BP

BP >130/80 mmHg <130/80 mmHg ACE inhibitor or A Diuretic preffered, A

ARB then beta blocker or
calcium chanel
blocker dh la

BP <130/80 mmHg ACE inhibitor or A

ARB
BP < 125 / 75 mmHg ( ekskresi protein > 1 gr / hari )
 Anemia

Target hematocrit pre-dialysis , hemodialysis

Relieve symptom, low risk side effect :

Hb 9,5 g% / Ht 29 - Hb 11g% / Ht 33% ( Pernefri/NKF-DOQI)

- erithropoetin
- preparat - iron ( bila kadar serum iron kurang )

Defisiensi Eritropoetin pada GGK

improvements in the quality of life, cardiacfunction,

physical work capacity, cognitive function, and sexual
function have been reported at a hematocrit
of 36% to39%.
 Faktor Risiko terjadinya Aterosklerosis pada
pasien GGK

Faktor Risiko Konvensional Faktor Risiko Spesifik

Umur Hiperparatiroid
Laki-laki Anemia
Hipertensi Hiperhomosisteinemia
Diabetes Hiperfibrinogenemia
Merokok Uremic dyslipidemia
Hiperlipidemi Oxidative stress
Obesitas Carbonyl stress
Hiperhomosisteinemia Chronic inflamatory state
Menopause
Physical inactivity
Faktor faktor yg mempengaruhi
progresifitas GGK

Underlying disesase yg berjalan terus

kontrol gula darah yg tidak baik
Infeksi
Hipertensi
Proteinuria persisten
Diit tinggi protein & fosfat
Hiperlipidemi
Anemia, penyakit kardiovaskular, merokok
Payah jantung, obat-obat nefrotoksik

Faktor faktor yg lain

Strategi pengelolaan GGK
Berdasarkan clearance creatinin pengelolaan GGK dibagi :

1. Konservatif , creatinin clearance

* > 10ml/mnt (non diabetic)
* > 15ml/mnt untuk diabetik nefropati
2. technical treatment, creatinin clearance
< 10ml/mnt (non diabetic)
< 15ml/mnt untuk diabetik nefropati
Indikasi technical treatment adalah :

1. GGK stadium akhir ( ESRD )

2. Creatinin clearance > 10ml/mnt (non diabetic)

> 15ml/mnt untuk diabetik nefropati :

- neuropati perifer progresif

- kecenderungan perdarahan
- sirkulasi overload yang resisten terhdap obat
- malnutrisi
- osteodistrofi renal (ada fraktur)
Terima kasih