Chronic Kidney Disease

Erlieza Roosdhania
Bagian Penyakit Dalam RSU RA Kartini
Jepara
2016

Kriteria CKD

Klasifikasi

Patofisiologi

Staging
Stage

Description

GFR

Kidney damage with normal or

inc GFR

90

Kidney damage with mild

reduction in GFR

60-89

Moderate dec in GFR

30-59

Sever dec in GFR

15-29

Kidney Failure

<15 or dialysis

Staging CKD

CKD Risk Factors*

Modifiable
Diabetes
Hypertension
History of AKI
Frequent NSAID
use

Non-Modifiable

Family history of
kidney disease,
diabetes, or
hypertension

Age 60 or older (GFR

declines normally
with age)

Race/U.S. ethnic
minority status
*Partial list
AKI, acute kidney injury

Manifestasi klinis CKD

Signs of uremia
Pericarditis
Encephalopathy
Perpheral neuropathy
Restless leg syndrome
GI symptoms: N V D , anorexia
Skin : dry skin, pruritis, echymosis
Fatigue, inc somnolence
Platelet dysfunction
Sexual dysfunction

Biopsi ginjal

Biopsi diperlukan pada kasus seperti

SLE yang prognosisnya sangat

tergantung kerusakan ginjal saat
terdiagnosa.
Biopsy tidak diperlukan pada pasien
dengan hasil USG ginjal yang
contracted, karena akan memperberat
luka pada ginjal dan memperburuk
fungsi ginjal..

Penatalaksanaan

Old Classification of CKD as Defined by Kidney Disease

Outcomes Quality Initiative (KDOQI) Modified and
Endorsed by KDIGO
Stage

Description

Kidney damage with

Classification Classification
by Severity
by Treatment
GFR 90

normal or increased GFR

2

Kidney damage with

GFR of 60-89

T if kidney

mild decrease in GFR

transplant

Moderate decrease in GFR

GFR of 30-59

recipient

Severe decrease in GFR

GFR of 15-29

D if dialysis

Kidney failure

GFR < 15

D if dialysis

Note: GFR is given in mL/min/1.732 m

National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification, and Stratification. Am J Kidney Dis 2002;39(suppl 1):S1-S266

KDIGO, Kidney
Disease: Increasing
Global Outcomes

Who Should be Involved in the

Patient Safety Approach to CKD?

Kidney
damage and
normal or GFR

Kidney
damage and
mild

Moderate
GFR

Severe
GFR

Kidney
failure

GFR

Stage 1
GFR

Stage 2
90

Stage 3
60

Primary Care Practitioner

30

Stage 4

Stage 5

15

Nephrologist
Consult?

Patient safety
The Patient (always)
and other subspecialists (as needed)

Penatalaksanaan

Terapi non farmakologis

menghambat perburukan ginja

a.Pembatasan protein :
-Pasien non dialisis 0,6 -0,75 gram /kg BB/hr sesuai CCT dan toleransi
pasien
- Pasien hemodialisis 1 -1 2 gram/kgBB ideal/hari - Pasien hemodialisis
1 -1,2 gram/kgBB ideal/hari
-Pasien peritoneal dialisis 1,3 gram/kgBB/hr
b. Pengaturan asupan kalori : 35 kal/kgBBideal/hr
c. Pengaturan asupan lemak : 30 -40% dari kalori total dan
mengandung jumlah yang sama antara asam lemak bebas jenuh
dan tak jenuh
d. Pengaturan asupan KH : 50 -60% dari total kalori
e. Garam NaCl : 2 -3 gr/hr
f. Kalsium : 1400-1600 mg/hr g. Kalsium : 14001600 mg/hr
g. Besi : 10 -18 mg/hr
h. Magnesium : 200 300 mg/hr
i. Asam folat pasien HD : 5 mg

Terapi farmakologis

menghambat perburukan ginjal

a.Kontrol tekanan darah :

-Penghambat ACE atau antagonis reseptor angiotensin evaluasi
kreatinin dan kalium serum, bila terdapat peningkatan kreatinin >
35% atau timbul hiperkalemi harus dihentikan
-Penghambat kalsium
-Diuretik
b. Pada pasien DM, kontrol GD hindari pemakaian metformin dan
obat
obat sulfonil urea dengan masa kerja panjang.
Target HbAIC untuk DM tipe 1 adalah 0,2 diatas nilai normal
tertinggi, untuk DMTipe2 adalah 6%
c. Koreksi asidosis metabolik dengan target HCO3 20 22 mEq/l
d. Kontrol dislipidemia dengan target LDL < 100 mg/dl, dianjurkan
golongan satin

Penatalaksanaan penyakit penyerta

Hipertensi
o
o
o
o

Pengurangan BB dan
Dit rendah garam 2g/day
Pilihan :ACE inhibitor / angiotensin II
receptor blocker (ARB)
Goal TD <130/80 mm Hg; pada pasien
dengan proteinuria > 1-2 g/d goal TD
< 125/75 mm Hg

Second-line antihypertensive agents

include calcium(HERBESSOR 30 mg
OD, AmLODIP 10mg OD) channelblocking agents.

Hiperkalemia
IV calcium gluconate 10 % in 10 ml normal

saline selama 10-20 mins

Salbutamol (SALBO 5mg) nebulizer
Low potassium diet
4 amp of 25 % dextrose water with 12-14 units
of insulin
Lasix 40mg OD if systolic more than 90 mmHg
Stop spironolakton
Emergency dialysis in case of potentially lethal
hyperkalemia

Edema paru

high flow Oxygen with face mask

Lasix 120-250mg IV over 1 hour
Hemodylisis or hemofiltration in
unresponsive cases
CPAP

Gangguan metabolisme tulang

Dit rendah fosfat hingga 1000 mg/d .
Oral phosphorus binders, such as calcium

carbonate(Qalsan D) (650 mg/tablet) or

calcium acetate(LOPHOS) (667 mg/capsule),
block absorption of dietary phosphorus and given
in TDS or QID at the beginning of meals.
These should be titrated to a serum phosphorus
of < 4.6 mg/dL in stage 34 of CKD (GFR of 1559
mL/min) and
< 4.65.5 mg/dL in ESRD patients

Hipokalsemia
Maximal elemental calcium doses of 1500 mg/d (eg,nine
tablets of calcium acetate),

doses should be decreased if serum calcium rises above 10

mg/dL

Typical calcitrio dosing is 0.25 or 0.5 mcg orally daily or

every other day initially. Cinacalcet is a calcimimetic agent

that targets the calcium-sensing receptor on the chief cells
of the parathyroid gland and suppresses PTH production.
Cinacalcet, 3090 mg PO x OD, can be used if elevated
serum phosphorus or calcium levels prohibit the use of
vitamin D analogs

Manajemen Anemia
Serum ferritin < 100200 ng/mL or iron
saturation < 20% is suggestive of iron
deficiency.

Iron therapy should be withheld if the serum

ferritin is > 500800 ng/mL, or Hb is 12 even if

the iron saturation is < 20%.
Ferrous sulphate, gluconate or fumarate 325
mg from OD to TDS may be given,
Erythropoiten 50IU/Kg once or twice a week

SIDE EFFECTS of
ERYTHROPOETIN
Allergic reactions
Hypertension
Hyperviscosity
Pure red cell aplasia

Treating Acidosis

serum bicarbonate level should be

maintained at > 21 mEq/L

Administration of bicarb should

begin with 2030 mEq/d divided into

two doses per day and titrated as
needed

Drugs which require dose reduction

or complete cessation

Antivirals
Benzodiazepines
Colchicine
Digoxin
Exenatide
Fenofibrate
Gabapentin
Insulin
Lithium
Metformin*
Opioid analgesics
Saxagliptin
Sitagliptin
Sotalol
Spironolactone
Sulphonylureas (all)
Vildagliptin

Slowing CKD Progression: ACEi or ARB

Risk/benefit should be carefully assessed in the elderly and

medically fragile
Check labs after initiation
o If less than 25% SCr increase, continue and monitor
o If more than 25% SCr increase, stop ACEi and evaluate
for RAS
Continue until contraindication arises, no absolute eGFR
cutof
Better proteinuria suppression with low Na diet and diuretics
Avoid volume depletion
Avoid ACEi and ARB in combination1,2
o Risk of adverse events (impaired kidney function,
hyperkalemia)
1) Kunz R, et al. Ann Intern Med. 2008;148:30-48.
2) Mann J, et al. ONTARGET study. Lancet.
2008;372:547-553.

Modification of Other CVD

Risk Factors in CKD

Smoking cessation
Exercise
Weight reduction to optimal targets
Lipid lowering therapy
o In adults >50 yrs, statin when eGFR 60
ml/min/1.73m2; statin or statin/ezetimibe
combination when eGFR < 60 ml/min/1.73m2
o In adults < 50 yrs, statin if history of known
CAD, MI, DM, stroke
Aspirin is indicated for secondary but not primary
prevention
Kidney Disease: Improving Global
Outcomes (KDIGO) CKD Work Group.
Kidney Int Suppls. 2013;3:1-150.

Common Medications Requiring Dose

Reduction in CKD

Allopurinol
Gabapentin
o CKD 4- Max dose 300mg
qd
o CKD 5- Max dose 300mg
qod
Reglan
o Reduce 50% for eGFR< 40
o Can cause irreversible EPS
with chronic use
Narcotics
o Methadone and fentanyl
best for ESRD patients
Lowest risk of toxic
metabolites

Renally cleared beta blockers

o

Atenolol, bisoprolol,
nadolol

Digoxin

Some Statins
o

Lovastatin, pravastatin,
simvastatin. Fluvastatin,
rosuvastatin

Antimicrobials
o

Antifungals,
aminoglycosides, Bactrim,
Macrobid

Enoxaparin

Methotrexate

Key Points on Medications in

CKD patients at high risk for drug-related adverse
CKD

events
Several classes of drugs renally eliminated
Consider kidney function and current eGFR (not just
SCr) when prescribing meds
Minimize pill burden as much as possible
Remind CKD patients to avoid NSAIDs
No Dual RAAS blockade
Any med with >30% renal clearance probably needs
dose adjustment for CKD
No bisphosphonates for eGFR <30
Avoid GAD for eGFR <30

Indications for Referral to Specialist Kidney Care

Services for People with CKD
Acute kidney injury or abrupt sustained fall in GFR
GFR <30 ml/min/1.73m2 (GFR categories G4-G5)
Persistent albuminuria (ACR > 300 mg/g)*
Atypical Progression of CKD**
Urinary red cell casts, RBC more than 20 per HPF sustained and
not readily explained
Hypertension refractory to treatment with 4 or more
antihypertensive agents
Persistent abnormalities of serum potassium
Recurrent or extensive nephrolithiasis
Hereditary kidney disease
*Significant

albuminuria is defined as ACR 300 mg/g (30 mg/mmol) or AER 300 mg/24 hours,
approximately
equivalent to PCR 500 mg/g (50 mg/mmol) or PER 500 mg/24 hours
**Progression of CKD is defined as one or more of the following: 1) A decline in GFR category
accompanied by a 25%
or greater drop in eGFR from baseline; and/or 2) rapid progression of CKD defined as a sustained decline in
eGFR of more than 5ml/min/1.73m2/year. KDOQI US Commentary on the 2012 KDIGO Evaluation and
Management of CKD