GAGAL GINJAL

Sebuah Komplikasi pada

Kasus Urologi
Dr. Elyanawati Sp.PD
Bagian Penyakit Dalam
Ciputra Hospital Tangerang

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
pathologic abnormalities
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, with or without

kidney damage

Incidence and Prevalence of End-Stage

Renal Disease in the US

Cardiovascular Mortality in the General Population

and in ESRD Treated by Dialysis
Annual mortality (%)
100

Dialysis

10

General population

1
0.1

Male
Female

0.01

Black
White
2534 3544 4554 5564 6574 7584
Age (years)

85

STAGES

K/DOQI GUIDELINES
STAGES 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

The Leading Causes of ESRD

Primary Diagnosis For Patients Who Start Dialysis
Other
10%

700
600

Glomerulonephritis
13%
Hypertension
27%

Diabetes
50.1%

No of Patients
Projection
95% CI

500

Number of
400
Dialysis
Patients
300
200
100
0

520,240
281,355
243,524
R2 = 99.8%
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

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

ETIOLOGY
Etiology
glomerulonephritis
Obstruction
Diabetic nephropaty
Lupus nephritis
Polycystic KD
Hypertension
Unknown
Centre nephrology in Indonesia
Sidabutar RP ( 1989 ) *

1989 *

1996

40,12%
36,7%
6,13%
4,17%
2,12%
2,09%
9,32%

46,19%
12,85%
18,65%
0,16%
1,41%
8,46%
15,2%

2000
39,64%
13,44%
17,54%
0,23%
2,51%
15,72%
10,93%

Classification of CKD by Diagnosis

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)

Marker Kidney Damage

Sedimen urin abnormal
Silinder, Lekosit, Hematuri
Sel tubulus
Proteinuri
ureum kreatinin eGFR
Imaging
Hidronefrosis
Besar ginjal tak sama
Polikistik
ginjal mengecil

(140 Umur) X BB
Klirens Keatinin (ml/men.) = ---------------------------------- X (0.85 jika
wanita)
72 X Kreatinin serum

Early Treatment Makes

a Difference

Brenner, et al., 2001

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 kardiovaskuler

Chronic Renal Disease :

Initial Treatment Recommendations
Renal Insufficiency
CLcr < 60 mL/min
Crserum > 1.4 mg/dL*

Microalbuminuria
(only abnormality)

Proteinuria

Diabetes Mellitus

130/80

130/80

ACE Inhibitor
(or ARB)
Start
And
Titrate
To maximum
Tolerable
Dose

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
Assessment

BP >130/80 mmHg

BP <130/80 mmHg
BP < 125 / 75 mmHg

Target BP

<130/80 mmHg

Preffered Agents for

CKD

ACE inhibitor or ARB

ACE inhibitor or ARB

( ekskresi protein < 1 gr / hari )

Other Agents to Reduce

CVD Risk and Reach
Target BP
Diuretic preffered, then
beta blocker or calcium
chanel blocker dh la

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 )

improvements in the quality of life, cardiacfunction,

physical work capacity, cognitive function, and sexual
function have been reported at a hematocrit
of 36% to39%.

Clinical Practice Guidelines for the Detection,

Evaluation and Management of CKD

Clinical Practice Guidelines for

Management of Hypertension in CKD
Type of Kidney Disease

Blood Pressure
Target
(mm Hg)

Preferred Agents
for CKD, with or
without
Hypertension

Other Agents
to Reduce CVD Risk
and Reach Blood
Pressure Target

ACE inhibitor
or ARB

Diuretic preferred,
then BB or CCB

Diabetic Kidney Disease

Nondiabetic Kidney
Disease with Urine Total
Protein-to-Creatinine
Ratio 200 mg/g
Nondiabetic Kidney
Disease with Spot Urine
Total Protein-to-Creatinine
ratio <200 mg/g
Kidney Disease in Kidney
Transplant Recipient

<130/80

None preferred

Diuretic preferred,
then ACE inhibitor,
ARB, BB or CCB
CCB, diuretic, BB,
ACE inhibitor, ARB

At
increased
risk
Kidney Damage
and normal
or GFR
Stage 1

Kidney Damage
and mild
GFR
Stage 2

90

60

Moderate
GFR

Severe
GFR

Kidney Failure

Stage 3

Stage 4

Stage 5

30

15

GFR

Primary care
physician

Nephrologist

Other specialists (as needed)

END STAGE RENAL DISEASE

Definition of ESRD vs Kidney Failure

ESRD is a federal government defined
term that indicates chronic treatment by
dialysis or transplantation
Kidney Failure: GFR < 15 ml/min/1.73 m 2
or on dialysis.

Indikasi Dialisis
GFR < 10 ( < 15 pada DM )
Sindroma uremikum
Overhidrasi
Asidosis Metabolik
Hiperkalemia
Infeksi

Others Choices
CAPD
Transplantation

Keuntungan & Kerugian HD vs PD

Keuntungan
HD

Sangat efisien
Mendpt follow-up medis
Protein loss lewat dialisis ( - )

Kerugian
Risiko tinggi pd Pendrt Ggn
kardiovaskuler berat
Sering memerlukan perbaikan
AV fistula iskemik pd tangan
Sering terjadi episode
hipoglikemik & hipotensi
Hiperkalemi
Membran biokompatibel X darah sitokin
inflamasi progresifitas
Heparin perdarahan retina

CAPD

Toleransi kardiovaskuler
Tanpa AV fistula
Kalium serum terkontrol
Kadar gula terkontrol insulin
intraperitoneal
Hipoglikemi jarang terjadi

Risiko peritonitis & risiko infeksi

pd kateter sama dgn nonDM
Protein loss melalui dialisa
Terjadi tekanan
intraabdominal hernia &
leakage cairan

SUMMARY
The

prevalence of chronic kidney disease (CKD) has

increased in Indonesia and worldwide by the year

Urology disorder is one of the most common caused
of CKD in Indonesia
To prevent progression to ESRD :
treatment primary disease, blood pressure control,
nephroprotective drugs, tight blood glucose control,
decrease proteinuria & low protein diet

TERIMA KASIH