Uremic Syndrome

Acute Kidney Injury

Chronic Kidney Disease
Epidemiologi
 Epidemiologi Gagal Ginjal
● Di dunia Prevalensi PGK sekitar 10% dari populasi umum
● Prevalensi PGK stadium akhir sekitar 0,2% dari populasi

● Prevalensi PGK di Indonesia sebesar 2% (449.800 orang)

● Prevalensi terendah sebesar 1% dan tertinggi sebesar 4 %
Sumber : Riskesdas, 2013

● Prevalensi PGK sebesar 3,8%

● Prevalensi terendah sebesar1,8% dan tertinggi sebesar 6,4
%
Sumber : Riskesdas 2018
Edgar V. Nephrology Secrets, 3rd Edition
 CKD

PARENCHYMAL OBSTRUCTIVE

• GN • urolithiasis
• Diabetic Nephropathy • Prostate
• Nephrosclerotic/hypertension • Ureteric Stricture
• Policystic
• Lupus
• TBC
 Definition of
Chronic Kidney Disease

AJKD 2002: 39(2)

Summary of KDIGO 2012 CKD
 NKF-KDOQI recommendation

Adults

MDRD (modification of diet in renal disease) equation:

GFR (ml/min/1.73 m2) = 186 X (SCr) -1.154 X (Age) -0.203 X
(0.742 if female) X (1.210 if black)

Children
Schwartz equation: GFR (ml/min) = 0.55 x length/Scr

Counahan-Barratt equation: GFR (ml/min/1.73m2)= 0.43 X

Length/Scr
 Pivotal Rote of Glomerular Hypertension
in the Initiation and Progression
of Structural Injury.

Systemic Primary Renal Aging, Diabetes

Hypertension Disease Renal Melitus, Dietary
Ablation Factors

GLOMERULAR HYPERTENSION

ENDOTHELIAL INJURY MESANGIAL INJURY EPITHELIAL INJURY

Release of vasoactive
factors Accumulation of macromolecules Proteinuria
Vascular lipid deposition ↑Matrix production ↓ Permeability to water
Intracapillary thrombosis ↑ Cell proliferation

GLOMERULAR SCLEROSIS

Anderson S. Brenner. Q J Med 1989 ; 70 : 185-189.)

 Proteinuria
Interstitium
Protein leakage
•Gene expression
Protein load to for inflamation
Proximal tubules •Transdifferentiation
to myofibloblast

Glomerular Hypertension Fibrosis

Proliferation
Hypertension
Ang II TGF ß 1, etc Matrix synthesis

PROGRESSION of CKD
Eknoyan G, ASN Symp,Philadelphia,2002
Stage and Stage5 N=372,000
prevalence of CKD
GFR <15*
in individuals older
N=400,000
than 20 years Stage 4
GFR 15-29*

Stage 3
GFR 30-59*

N=7,600,00

Stage 2
GFR 60-89*
N=5,300,000

Stage 1
GFR>90*
N=5,900,000

*GFR measurement in mL/min/1.73 m2 7

Fig 1. Rate of glomerular filtration rate (GFR) decline in normals and in hypothetical
patients with onset of progressive renal disease at age 25

Kidney International 2001 591211-1226DOI: (10.1046/j.1523-1755.2001.0590041211.x)

Copyright © 2001 International Society of Nephrology Terms and Conditions
● In normal “healthy” individuals, the eGFR will fall by
up to 10 ml/min (ie 10%) per decade

● An 80 year old man will have an expected eGFR of

50-60 ml/min
 RISK FACTORS FOR CKD
PROGRESSION

GENETIC HYPERLIPIDEMIA GENDER

HYPERGLYCEMIA CIGARETTES ANEMIA

RAAS ACTIVITY HOMOCYSTEIN HYPOKALEMIA

HYPERTENSION SALT INTAKE HYPERPHOSPHATEMIA

PROTEINURIA PROTEIN INTAKE ENDOGENOUS

INSULIN EXCESS

Hebert et aL: KI 2001 59:1211-26

 GFR ( mL/min/1,73 m2)

“Original study performance using hematocrit

from Radtke et el, Blood 1979;54:877-884.
 CARDIAC REMODELLING RESULTING FROM
ANEMIA AND HYPERTENSION
LVEDV :<90 ml/m2

CONCENTRI
C
ION LVH
NS
RTE
P E DILATED LVH
HY
CK WITH HEART
An
D em
ia FAILURE

ECCENTRI
2
Normal LVM :126 g/m C
LVH

LVEDV :<90 ml/m2

LVH = left venticuler hypertrophy; LVM=LV mass; LVEDV=LV end diastolic volume

Lopez-Gomez et al.Kidney Int.1998;54:992-SEB; London et al. Adv Ren Replace

Ther. 1997;4:194-211. Casele et al.Ann Intern Medicine.1986;10:173-176
Anemia associated with increased risk of stroke
In CKD patients/
Eknoyan G, ASN Symp,Philadelphia,2002
 Calcitriol Decline and iPTH Elevation
as CKD Progresses
50 CKD Stage 1 Stage 2 Stage 3 Stage 4
5.6 million 5.7 million 7.4 million 300,000
400
1,25(OH)2D3 (pg/mL)

40

iPTH (pg/mL)
Calcitriol

300
30
Low-Normal
25
Calcitriol
20 200

10 100
High-Normal 65
PTH
0
105 95 85 75 65 55 45 35 25 15
eGFR (mL/min/1.73 m2)
N = 150.
iPTH = intact PTH.
Adapted from Martinez et al. Nephrol Dial Transplant. 1996;11(suppl 3):22-28.
© 2005 The Johns Hopkins University School of Medicine.
Synergistic effect of CKD,CHF and
Anemia as risk factors for Death
2 yr mortality (n~ 200,000 5% Medicare sample)

Collins, Adv studies in Med 2003

Eknoyan G, ASN Symp,Philadelphia,2002
 Who are at risk?
● Those who are hypertensive, diabetic, obese,
renal stone.
● Those with family history of:
hypertension, diabetes, and renal disease/
failure
 Infection / UTI

Dehydration

Acute on
Chronic Obstructive

Electrolyte Disturb.

Severe Hypertension
 CKD

STAGE 1 STAGE 2 STAGE 3-4 STAGE 5

Decrement Renal Renal failure ESRD

of recidual insufficiency
renal function
risk
risk
risk

Tx
Tx Tx
 Decisions in renal
replacement
● Pre-dialysis care

● Active treatment
- Peritoneal dialysis (PD)
- Haemodialysis (HD)
- Transplantation

● Conservative (non-dialytic) care. Symptom

management.
• Blood pressure and proteinuria control
• Correction of hyperglycaemia
• Dietary management
• Correction of calcium-phosphate
disorders
• Correction of hyperlipidaemia
• Correction of anemia and acidosis
• Cessation of smoking
• the importance of early referral to a
nephrologist
 Decisions in renal
replacement
● Pre-dialysis care
Treat: hypertension
hyperglycemia To target
hyperlipidemia
anemia
Diet: Low Protein

Anti RAAS antihypertensives

Am J Kidney Dis 2002 39:376-82
Early Treatment Makes a Difference
 MANAGEMENT
CKD

CONSERVATIVE RRT

Diet : Water + salt

Protein
Calori
Phosphate, K+

Risk-factors management

Symptomatic Medicament :
 MANAGEMENT
CKD

Consernative
RRT

DIALYSIS TRANSPLANT

• Hemodialisa
• Peritoneal
• CAPD
• IPD
• Hemofiltration
• Hemodiafiltration
Indication : vide AKI
 Diabetes:
The Most Common Cause of ESRD
Primary Diagnosis for Patients Who Start Dialysis

Other Glomerulonephritis

10% 13%
No. of patients
No. of dialysis patients (thousands)

700 Projection
Diabetes Hypertension
95% CI
600 50.1% 27%

500

400

300 520,240
281,355
200
243,524
100 r2=99.8%

0
1984 1988 1992 1996 2000 2004 2008

United States Renal Data System. Annual data report. 2000.

 Cardiovascular Mortality in the
General Population and in ESRD
Annual mortality
(%) Treated by Dialysis
Dialysi
100
s

10
General
1
population

Mal
0.1 e
Femal
e
Blac
0.01 k
White
25–3 35–4 45–5 55–6 65–7 75–8 ≥8
4 4 4 4
Age 4 4 5
(years)
 MANAGEMENT
CKD

CONSERVATIVE DIALYSIS TRANSPLANT

• Cadaver
Kidney
• Living
Donor
• Related
• Un
related
( Renal Replacement Therapy)

a. Dialysis
1. Peritoneal dialysis
(continuous ambulatory peritoneal dialysis
= CAPD)

2. Hemodyalisis (HD)

b. RENAL TRANSPLANTATION
Donor : Living (related, un-related)
Cadaver

Resipien
Tissue Type - HLA-Match
Long term use of imuno-suppressive drugs
to cope with rejection
 Messages to Take Home
● Kidney Disease is a silent killer-(no signs or
symptoms until you loose >70% of your kidney
function,
● The risk of dying from a cardiovascular event, if
you’ve lost 50% or more of your kidney function,
is similar to that having had a heart attack.
● Proteinuria reduction needs to be a key part of
blood pressure management.

©2006. American College of Physicians. All Rights Reserved.

 Terima
kasih….wassalam