AHA, 2018

Theraphy for CKD

 Old Classification of CKD as Defined by Kidney
5 Disease Outcomes Quality Initiative (KDOQI)
Modified and Endorsed by KDIGO
Stage Description Classification Classification
by Severity by Treatment
1 Kidney damage with GFR ≥ 90
normal or increased GFR
2 Kidney damage with GFR of 60-89 T if kidney
mild decrease in GFR transplant

3 Moderate decrease in GFR GFR of 30-59 recipient

4 Severe decrease in GFR GFR of 15-29 D if dialysis

5 Kidney failure GFR < 15 D if dialysis

m²
 DIABETES
MELLITUS TYPE 2
12
Diabetic foot ulcer
KLASIFIKASI ULKUS DIABETIK
Hypertension
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Initiation of lifestyle changes and antihypertensive drug treatment

Blood pressure (mmHg)
Other risk factors, asymptomatic High normal SBP Grade 1 HT SBP Grade 2 HT Grade 3 HT
organ damage or disease 130−139 140−159 or DBP SBP 160−179 SBP ≥180
or DBP 85−89 90−99 or DBP 100−109 or DBP ≥110
• Lifestyle changes for • Lifestyle changes for
• Lifestyle changes
several months several weeks
No other RF • No BP intervention
• Then add BP drugs • Then add BP drugs
• Immediate BP drugs
targeting <140/90
targeting <140/90 targeting <140/90
• Lifestyle changes for • Lifestyle changes for
• Lifestyle changes
• Lifestyle changes several weeks several weeks
1−2 RF • No BP intervention • Then add BP drugs • Then add BP drugs
• Immediate BP drugs
targeting <140/90
targeting <140/90 targeting <140/90
• Lifestyle changes for
• Lifestyle changes • Lifestyle changes
• Lifestyle changes several weeks
≥3 RF • No BP intervention • Then add BP drugs
• BP drugs targeting • Immediate BP drugs
<140/90 targeting <140/90
targeting <140/90

• Lifestyle changes • Lifestyle changes • Lifestyle changes

• Lifestyle changes
OD, CKD stage 3 or diabetes • No BP intervention
• BP drugs targeting • BP drugs targeting • Immediate BP drugs
<140/90 <140/90 targeting <140/90

Symptomatic CVD, CKD stage ≥4 or • Lifestyle changes • Lifestyle changes • Lifestyle changes
• Lifestyle changes
• BP drugs targeting • BP drugs targeting • Immediate BP drugs
diabetes with OD/RFs • No BP intervention
<140/90 <140/90 targeting <140/90

BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; DBP, diastolic blood pressure; HT, hypertension; OD, organ damage; RF, risk factor; SBP, systolic blood
pressure.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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ANEMIA
INDIKASI TRANSFUSI MENURUT AMERICAN SOCIETY OF
ANESTHESIOLOGY
PAD
CLI
ALI
Indikasi ABI
ABI Limitations

● Incompressible arteries (elderly patients, patients

with diabetes, renal failure, etc.)
● Resting ABI may be insensitive for detecting mild
aorto-iliac occlusive disease
● Not designed to define degree of functional
limitation
● Normal resting values in symptomatic patients
may become abnormal after exercise
● Note: “Non-compressible” pedal arteries is a
physiologic term and such arteries need not be
“calcified”
Indikasi ABI
● Pasien dengan luka akibat gangguan pembuluh darah di ekstremitas bawah
● Untuk mendiagnosis penyakit arteri pada pasien dnegan suspek penyakit arteri
ekstremitas bawah
● Claudicatio intermitten
● Usia diatas 70 tahun
● Usia diatas 50 tahun dengan riwayat pengguna tembakau dan diabetes
● Menenrukan adekuat aliran darah terutama ekstremitas bawah
● Pada penyakit campuran arteri dan vena
● Menilai potensi healing pada luka
ABI
Exercise ABI Testing

● Confirms the PAD

diagnosis
● Assesses the functional
severity of claudication
● May “unmask” PAD when
resting the ABI is normal
● Aids differentiation of
intermittent claudication
vs. pseudoclaudication
diagnoses
 Exercise ABI Testing: Treadmill

● Indicated when the ABI is

normal or borderline but
symptoms are consistent
with claudication;
● An ABI fall post-exercise
supports a PAD diagnosis;
● Assesses functional capacity
(patient symptoms may be
discordant with objective
exercise capacity).

.
The Ankle-Brachial Index

Lower extremity systolic pressure

ABI = Brachial artery systolic pressure
• The ankle-brachial index is 95% sensitive and 99% specific for PAD
• Establishes the PAD diagnosis
• Identifies a population at high risk of CV ischemic events
• The “population at risk” can be clinically and epidemiologically defined:
 Age less than 50 years with diabetes, and one additional risk
factor Age 50 to 69 years and history of smoking or diabetes
 Age 70 years and older
 Leg symptoms with exertion (suggestive of claudication) or
ischemic rest pain
 Abnormal lower extremity pulse examination
 Known atherosclerotic coronary, carotid, or renal artery
disease

• Toe-brachial index (TBI) useful in individuals with non-

compressible pedal pulses
Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34;
Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14
Toe-Brachial Index Measurement

● The toe-brachial index

(TBI) is calculated by
dividing the toe pressure
by the higher of the two
brachial pressures.
● TBI values remain
accurate when ABI
values are not possible
due to non-compressible
pedal pulses.
● TBI values ≤ 0.7 are
usually considered
diagnostic for lower
extremity PAD.
 ACC/AHA Guideline for the Management of PAD:
Steps Toward the Diagnosis of PAD

Individuals Age 50 to 69 years and history of smoking or diabetes

“at risk” Age ≥ 70 years
Abnormal lower extremity pulse examination
for PAD Known atherosclerotic coronary, carotid, or renal arterial disease

Obtain history of walking impairment and/or limb ischemic symptoms:

Obtain a vascular review of symptoms:
• Leg discomfort with exertion
• Leg pain at rest; nonhealing wound; gangrene

No leg “Atypical” Classic Chronic critical Acute limb

pain leg pain claudication limb ischemia ischemia
(CLI) (ALI)

Perform a resting ankle-brachial index measurement

Diagnosis and Treatment Diagnosis and Diagnosis and Diagnosis and Diagnosis and
of Asymptomatic PAD Treatment of Treatment of Treatment of Treatment of Acute Limb
and Atypical Leg Pain Asymptomatic Claudication Critical Limb Ischemia
PAD and Atypical Ischemia
Leg Pain

Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

 Recommendations for Antiplatelet and
Antithrombotic Drugs
I IIa IIb III Antiplatelet therapy is indicated to reduce the risk of MI, stroke,
and vascular death in individuals with symptomatic atherosclerotic
lower extremity PAD, including those with intermittent
MODIFIE claudication or CLI, prior lower extremity revascularization
D (endovascular or surgical), or prior amputation for lower extremity
ischemia.

I IIa IIb III Aspirin, typically in daily doses of 75 to 325 mg, is

recommended as safe and effective antiplatelet therapy to
reduce the risk of MI, stroke, or vascular death in individuals
MODIFIE
with symptomatic atherosclerotic lower extremity PAD,
D including those with intermittent claudication or CLI, prior
lower-extremity revascularization (endovascular or surgical),
or prior amputation for lower-extremity ischemia.
Recommendations for Antiplatelet and
Antithrombotic Drugs
I IIa IIb III Clopidogrel (75 mg per day) is recommended as a safe and
effective alternative antiplatelet therapy to aspirin to reduce the
risk of MI, ischemic stroke, or vascular death in individuals
with symptomatic atherosclerotic lower-extremity PAD,
MODIFIED including those with intermittent claudication or CLI, prior
lower-extremity revascularization (endovascular or surgical), or
prior amputation for lower-extremity ischemia.

I IIa IIb III Antiplatelet therapy can be useful to reduce

the risk of MI, stroke, or vascular death in
asymptomatic individuals with an ABI ≤0.90.
NEW
Recommendations for Antiplatelet and
Antithrombotic Drugs
I IIa IIb III
The usefulness of antiplatelet therapy to reduce the risk of MI,
stroke, or vascular death in asymptomatic individuals with
borderline abnormal ABI, defined as 0.91 to 0.99, is not well
NEW established.

I IIa IIb III The combination of aspirin and clopidogrel may be

considered to reduce the risk of cardiovascular events in
patients with symptomatic atherosclerotic lower-extremity
PAD, including those with intermittent claudication or CLI,
NEW
prior lower-extremity revascularization (endovascular or
surgical), or prior amputation for lower-extremity ischemia
and who are not at increased risk of bleeding and who are at
high perceived cardiovascular risk.
Recommendations for Antiplatelet and Antithrombotic Drugs

I IIa IIb III

In the absence of any other proven indication for
warfarin, its addition to antiplatelet therapy to reduce
No
Benefit
the risk of adverse cardiovascular ischemic events in
MODIFIE
D individuals with atherosclerotic lower extremity PAD is
of no benefit and is potentially harmful due to
increased risk of major bleeding.
Skor DVT
HIPONATREMIA
CKD
CKD (CHRONIC KIDNEY FAILURE)
JAZAKUMULLAH.
TERIMAKASIH