Chronic Kidney Disease
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Transcript of Chronic Kidney Disease
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CHRONIC KIDNEY DISEASEDisampaikan oleh : Wilda Maula Miftah NurAknowledgement : dr. Mia Melinda, Sp.PD,
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Chronic Kidney Disease (CKD)Penyakit kronis progresif yang ditandai dengan penurunan fungsi dan kinerja nefron secara terus-menerus (terjadi selama beberapa tahun).
Awalnya, nefron yg masih bisa berfungsi dg baik, berusaha mengambil alih tugas dg cara meningkatkan filtrasi & reabsorpsi solut. Namun hal ini akan merusakkan nefron itu sendiri, shg akan berkembang menjadi ESRD dan perlu dialisis / transplantasi.
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Chronic Kidney Disease (CKD)Komplikasi dari CKD timbul akibat :Bahan berbahaya yg seharusnya diekskresiKekurangan vit D aktif & erythropoietin
Sindroma uremik :Komplikasi CKD yg ditandai dg anemia, asterixis, seizure, coma, confusion, pericardial effusion, gatal, renal osteodystrophy
Azotemia: blood urea nitrogen meningkat(BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL)
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CHRONIC KIDNEY DISEASE (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 bypathologic abnormalitiesmarkers of kidney damage, including abnormalities in the composition of the blood or urine or abnormalities in imaging tests2. GFR
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Tahap CKD
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Faktor RisikoChronic Kidney Disease (CKD)Diabetic NephropathyDiabetes most common contributor to ESRDHypertensionCRF with HypertensionGlomerulonephritisPolycystic Kidney DiseaseRapidly progressive glomerulonephrities (vasculitis)
Renal Vascular Disease (i.e., renal artery stenosis)MedicationsAnalgesic Nephropathy (progression after many years)Pregnancy: high incidence of increased creatitine and HTN during pregnancy associated with CRF
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Risk Factors for Renal Disease ProgressionHuether SE, Pathophysiology,4th Edition, 2002, Chapter 35, 1191-1216
Proteinuria > 1.5 g/24 hrDiabetes mellitus (DM) or family history of diabetesProtein to Creatinine ratio > 1 g/gHyperlipidemiaHypertensionSmokingType of underlying renal diseaseHigh protein dietAfrican American racePhosphate retentionMale sexMetabolic acidosisObesity
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CKD vs Acute Kidney InjuryCalsium , PO4 PTHUSG : ukuran ginjal 90 tahunFungsi ginjal berubah cepat (KS atau < 40 mikromol / L selama > 24 jam)Kreatinin serum > 350 mikromol / LKehamilan (meningkatkan KS sampai 20%)Katabolisme bermaknaAmputasi pada tungkai dan lengan massa otot berkurang
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Rumus MDRD untuk Hitung GFRGFR = 186 x (SCr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if African American)
Rumus Modified Diet in Renal Disease yg melibatkan 4 variabel (kreatinin serum, usia, sex, ras) ini dikembangkan pd tahun1999 menggunakan data dr 1,628 px CKD dg GFR 5 - 90 ml /minute / 1.73 m2. Rumus ini memperkirakan GFR yg telah disesuaikan dg luas permukaan tubuh (rumus C&G tidak) & lebih akurat dari pada pengukuran klirens kreatinin dari 24-hour urine collections atau perhitungan dg rumus Cockcroft and Gault.
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Rumus MDRD TerstandarisasiRumus ini di sesuaikan lagi pd thn 2005 agar dapat digunakan dg standardized serum creatinine assay, shg diperoleh nilai kadar kreatinin serum 5 % lebih rendah 5, 6:
GFR = 175 x (Standardized SCr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if African American)
dimana GFR = mL/min/1.73 m2, SCr = serum creatinine (mg/dL), & usia = tahun.
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Keterbatasan MDRDRumus MDRD kurang akurat jika GFR > 60 mL/min/1.73 m2.
Jika GFR < 60 mL/min/1.73 m2, rumus ini akurat utk hampir semua orang tanpa tgt ukuran tubuh. Lebih akurat dr rumus C&G, terutama utk lansia & obesitas
Keterbatasan : (1) hanya memakai kreatinin serum sbg filtration marker; (2) kurang akurat pd GFR yg lebih tinggi; & (3) non-steady state conditions for the filtration marker when GFR is changing.
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MDRD Tidak Dapat Digunakan Tanpa penyakit ginjal, misal pd pasien muda dg DM tipe 1 tanpa microalbuminuria / calon pendonor ginjal
Belum divalidasi pd usia 85 thn, atau pd ras / sub etnis ttt (mis : Hispanics).
Rumus ini tidak memperhitungkan pengaruh nutrisi / obat ttt terhadap kadar kreatinin serumTidak boleh digunakan untuk menghitung penyesuaian dosis; tetapi dapat digunakan scr langsung utk menilai stage CKD
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Perhitungan C&G vs MDRDFor a white female, serum creatinine 1.2 g/dl, weight 125 lbs
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Metode Perkiraan GFR (lanjutan)Klirens UreaJika digunakan iothalamate untuk membandingkan klirens kreatinin (Ccr) dg klirens urea (Curea), maka hasilnya Ccr > GFR krn adanya sekresi kreatinin via tubuler, dan Curea< GFR krn adanya absorpsi urea di tubulerCystatin CProtein BM rendah yg dihasilkan oleh semua sel berinti pd manusiaSerum marker of kidney insufficiency & dpt deteksi kondisi CKD tahap dini Lbh sensitif dr Scr utk deteksi kondisi CKD tahap dini; unggul utk hitung GFR pd anak, px transplan & sirosis
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Proteinurea vs Albuminuria
Metode Pengumpulan UrinNormalMikroalbuminuriaAlbuminuria / Proteinuria KlinisProtein TotalEkskresi 24 jam 300 mg / hari Dipstick Urin sewaktu (spot)< 30 mg/dL-> 30 mg / dLUrin sewaktu (protein : kreatinin) < 200 mg/g-> 200 mg / gAlbuminEkskresi 24 jam< 30 mg/ hr30-300 mg / hari> 300 mg / hariDipstick Urin sewaktu (spot)< 3 mg/dL> 3 mg / dL-Urin sewaktu (protein : kreatinin) < 17 mg/g (pria)< 25 mg / g (wanita)17 250 mg / g (pria)25 355 mg / g (wanita)> 250 mg/g (pria)> 355 mg / g (wanita)
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Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD
Stage
Description
GFR
Evaluation
Management
At increased risk
Test for CKD
Risk factor management
1
Kidney damage with normal or ( GFR
>90
Diagnosis
Comorbid conditions
CVD and CVD risk factors
Specific therapy, based on diagnosis
Management of comorbid conditions
Treatment of CVD and CVD risk factors
2
Kidney damage with mild ( GFR
60-89
Rate of progression
Slowing rate of loss of kidney function 1
3
Moderate ( GFR
30-59
Complications
Prevention and treatment of complications
4
Severe ( GFR
15-29
Preparation for kidney replacement therapy
Referral to Nephrologist
5
Kidney Failure
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Specific Interventions for Complications of CKD A1C = glycosylated hemoglobin; HPT = hyperparathyroidism; PTH = parathyroid hormone; LDL-C = low-density lipoprotein cholesterol; TG = triglycerides; HDL-C = high-density lipoprotein cholesterol; Hgb = hemoglobin.
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K/DOQI guidelines (11 set)Hemodialysis AdequacyPeritoneal DialysisVascular AccessAnemia ManagementNutritionChronic Kidney Disease: Evaluation, Classification, and StratificationDyslipidemiaBone Metabolism and Disease in Chronic Kidney DiseaseBone Metabolism and Disease in Chronic Kidney Disease in ChildrenHypertension and Antihypertensive Agents in Chronic Kidney DiseaseCardiovascular Disease in Dialysis Patients
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Tata Laksana Dasar CKDObati penyakit dasarKendalikan keseimbangan air & garamDiet rendah protein, tinggi kaloriKendalikan gula darahKendalikan keseimbangan elektrolitCegah & obati renal osteodystrophyObati uremiaDeteksi dini infeksi & obatiPengaturan dosis obatDeteksi dini komplikasi & obatiDialisis & transplantasi
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Tata Laksana Dasar CKD (lanjutan)Kendalikan tekanan darahKendalikan gula darahHilangkan sumbatan (obstruksi)Obati infeksi saluran kemihLain-lainAnemiaFeAsam folatEritropoetinGatalDiet rendah proteindifenhidraminMualDiet rendah proteinObati penyakit DasarTx khusus untuk gejala & keluhan uremia
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Daftar PustakaK/DOQI Guidelines, 2002OGallaghan C, Brenner BM. The Kidney at A Glance. 2000. Oxford : Blackwell ScienceAshley C, Morlidge C. Introduction to Renal Therapeutics. 2008. London : Pharmaceutical PressSuzuki H, Saruta T. Kidney and Blood Pressure Regulation. 2004. Basel : KargerSobh MA. Essential of Clinical Nephrology. 2000. Cairo : Dar El ShoroukYogiantoro M. Materi Kuliah S2 Farmasi Klinis Ubaya. 2009RCS 6080. Medical and Psychosocial Aspects of Rehabilitation Counseling
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