Chronic kidney disease

Bahan Presentasi Divisi Ilmiah

Kimia Klinik
 Definition of Chronic Kidney Disease

Criteria
1. Kidney damage for ≥ 3 months, as defined by structural or
functional abnormalities of the kidney, with or without
decreased GFR, manifest by either :
• Pathological abnormalities; or
• 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 mounths, with or without

kidney damage
• The distinction between acute, subacute and
chronic kidney disease is arbitrary. Clearly, a
rise in the plasma creatinine concentration or
an abnormality on the urinalysis that has
developed within days to weeks represents an
acute process, whereas evidence of renal
disease extending for months to years is a
chronic process that may be associated with
acute exacerbations.
 Differentiation of acute from chronic
kidney disease
• History Long-standing history suggests
CKD
• Renal osteodystrophy Ro” evidence of osteitis fibrosa
cystica or osteomalacia suggests
CKD
• Renal size (length)
-small (<9 cm) CKD
-normal AKI
-enlarged(>12 cm) Diabetec nephropathy
Amyloidosis
Obstructive uropathy
HIV
PKD
• Renal biopsy Histologic diagnosis
 K/DOQI 2003
Tahapan Penyakit Ginjal Kronik
GFR
Tahap Keterangan
(mL/men/1.73m2)
1 Kerusakan ginjal dengan GFR 90
normal atau 
2 Kerusakan ginjal dengan  60 – 89
GFR ringan
3  GFR sedang 30 – 59
4  GFR berat 15 – 29
5 Gagal ginjal < 15 (atau dialisis)
Penyakit ginjal kronik didefinisikan sebagai kerusakan ginjal atau GFR < 60
mL/men/1.73m2 selama > 3 months. Kerusakan ginjal didefinisikan sebagai kelainan
patologis atau adanya petanda adanya kerusakan, termasuk kelainan dalam test darah
atau urin atau pemeriksaan radiologis
Penyebab CKD terbanyak yang membuat pasien menjalani
renal replacement therapy (transplant,HD,CAPD)

Penyakit %

Diabetes mellitus 40
Hypertension 25
Glomerulonephritis 15
Polycystic kidney disease 4
Urologic 6
Unknown & miscellaneous 10
 Screening for CKD
• Rationale : early detection, early intervention, reduced
associated complications, high prevalence silent kidney disease
• Whom ? Diabetes, hypertension, autoimmune diseases, urinary
tract infection or obstruction, heart failure, cirrhosis, family of
ESRD, family of nephropathy (DM,HT,glomerulonephritis)
• How ?
- standart urine dipstick (spot urine): proteinuria
hematuria, lekosituria
- serum creatinine
- blood pressure
- ultrasound imaging(obstruction,stones,infection,PKD)
- serum electrolytes
- urinary concentration
 The risk for loss of kidney function
Type Definition Examples
Susceptibility Increased susceptibility to Older age, family history
factors kidney damage
Initiation factors Directy initiate kidney damage Diabetes, high blood
pressure, autoimmune
diseases, systemic
infections, urinary tract
infections, urinary stones,
lower urinary tract
obstruction, drug toxicity
Progression Cause worsening kidney Higher lavel of proteinuria,
factors damage and faster decline in higher blood pressure
kidney function after initiation level, poor glycemic
of kidney damage control in diabetes,
smoking
Endstage Increase morbidity and Lower dialysis dase (KW),
factors mortality in kidney failure temporary vascular
access, anemia, low serum
albumin, late referral
 Otak : - letargi, malaise
Manifestasi - bingung
- koma
- kejang Konjungtiva : - kemerahan
Klinik Uremia - kalsifikasi
- perubahan fundus karena hipertensi
Wajah : - pucat
- warna keabu-abuan
- uraemic frost
Mulut : - napas uremik
Tekanan vena jugularis :
- tinggi atau rendah

Jantung : - pembesaran jantung

Dada : - hiperventilasi karena asidosis
- perikarditis - edema paru, efusi

Abdomen : - ginjal & kandung kemih teraba

Tekanan darah : - meningkat - bruits ginjal
- turun saat berdiri
Lengan & tangan :
- lecet
- bekas garukan
- lekonikia
- tremor
- flap
- myoclonic jerks
Urin : - simptom penyakit ginjal
- poliuri, frekuensi, nokturi

Genital : - impotensi
- libido menurun Perifer : - edema tungkai
- amenore, mandul - neuropati perifer
- deformitas tulang pd anak
- peningkatan penyakit vaskuler
Manifestasi klinik CKD (biasanya manifes
pada KK<30 ml/minute ):

Anemia
Hipertensi
Overload syndrome
Uremia
 Perjalanan CKD
• Kerusakan ginjal bersifat irreversible
• Penurunan fungsi ginjal bersifat progresif (4
ml/m pertahun)
• Kerusakan ginjal lebih lanjut bisa
diperlambat/dihambat dengan melakukan
intervensi terhadap faktor-faktor yg
mempercepat kerusakan ginjal
 Koreksi faktor reversibel & correctable

 Faktor pre renal : hipovolemia ,dekompensasi kordis,hipotensi,

stenosis arteri renal
 Faktor post renal : membebaskan obstruksi post renal oleh karena
batu, prostat, keganasan rongga pelvis
 Mengobati penyakit dasar faktor renal : DM, hipertensi, Wegener’s
granulomatosis, lupus nefritis dll
 Eradikasi infeksi kuman t.u yg di traktus urogenitalis : ISK, sepsis
 Measures to prevent the progression of CKD
patients ?
• Life style modification : ideal BW,healty
eating,restrict dietary salt intake,cease
smoking,moderate alcohol consumption,increase
physical activity
• BP below 130/80. Hypertensive diabetics and
micro/macroalbuminuria treated with ACE I or ARB
• Glycemic control : HbA1c <7%
• Reduction of proteinuria : ACEI,ARB
Measures to prevent the progression
of CKD
• Dietary protein restriction : 0,6 – 0,8 g/kg BB
• Lipid lowering : cholesterol total
<200,LDL<100,HDL>45,TG<150
• Avoidance of nephrotoxic agents:
NSAID,aminoglycoside,radiocontrast media
Adjust doses depend on clearance creatinine
• Early referral to nephrologist :creatinine clearance
<30 ml/m,rapid progression of renal failure,doubt to
diagnosis or prognosis
• Others : Ca x P <55 mg/dl, PTH <3xN, fluid
balance,acidosis
Pengobatan Khusus Gejala & Keluhan
GGK
1. Anemia
- Fe
- asam folat
- eritropoetin
- transfusi
2. Gatal
- diet rendah protein
- difenhidramin
3. Mual
- diet rendah protein
4. Hiperuricemia : alupurinol
5. Hiperkalemi : glukose dan insulin,diit rendah kalium,cation
exchange resin
6. Asidosis : nabic infus dan tablet
7. Overload syndrome : balans cairan, diuretik
 Should be referred to nephrologist

• When creatinine clearance <30 ml/min/1.73m2

• Patients at risk of rapid progression
• In whom doubt exists as to their diagnosis and
prognosis
 Kapan dilakukan renal replacement
therapy ?

 Klirens kreatinin < 15 ml/m (DM)

 Klirens Kreatinin < 10 ml/men (non DM)
 Sindroma Uremik
 Hiperkalemia
 Asidosis Metabolik
 Kelebihan Cairan (overload)
 Modalitas renal replacement therapy
• Hemodialisis (HD)
• Chronic ambulatory peritoneal dialysis (CAPD)
• Kidney transplant
HD
CAPD
KIDNEY
TRANSPLANT