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Gangguan sistem urologi fokus gagal ginjal

Gangguan sistem urologi fokus gagal ginjal. Dr. Eddy Susatyo, SpPD FinaSIM RSU dr. Sutrasno Rembang. STRUCTURE OF THE KIDNEYS. Chronic Kidney Disease ?. Definition of CKD. Kidney damage for >3 months

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Gangguan sistem urologi fokus gagal ginjal

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  1. Gangguan sistem urologifokus gagal ginjal Dr. Eddy Susatyo, SpPD FinaSIM RSU dr. Sutrasno Rembang

  2. STRUCTURE OF THE KIDNEYS

  3. Chronic Kidney Disease ?

  4. Definition of CKD • Kidney damage for >3 months • Defined by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR)‏ • Reduced GFR for >3 months • New staging for chronic kidney disease (CKD) is primarily based on kidney function. National Kidney Foundation (NKF). Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.

  5. Prevalence of CKD

  6. How About the Function of Renal ?

  7. Fungsi ginjal Regulasi volume cairan tubuh Regulasi keseimbangan elektrolit Regulasi keseimbangan asam basa Regulasi tekanan darah (RAAS) Ekskresi sampah metabolik Regulasi erithropoesis Metabolisme vit D Sintesis prostaglandin

  8. Brain ADH Renin Angiotensin II Kidney Na+ excretion H2O excretion Lung Ang II Angiotensin I Adrenal Angiotensinogen Aldosteron RAAS Hepar

  9. The Most Common Causes of CKD • Glomerulonefritis • Penyakit ginjal herediter • Hipertensi • Uropathy obstruktif • Infeksi • Nefropati diabetik

  10. Other Glomerulonephritis 10% 13% Diabetes Hypertension 50.1% 27% The Most Common Causes of CKD Other Glomerulonephritis Primary Diagnosis for Patients Who Start on Dialysis

  11. Pe Reabs Na Hipertrofisel renal Pe eksrsisametab Ggnkonstentrasiurin Pe ekskrkalium Penurunan GFR Ggnfsekskresi Pe ekskr PO4 Pe ekskr ion H CKD GgnReproduksi GgnImun Ggnfs non ekskresi  prod eritropoetin Pe abs Ca

  12. JENIS PEMERIKSAAN PENUNJANG • Urinalisis • Evaluasi Fungsi Ginjal • Evaluasi Serologis • Pemeriksaan Radiologis • Biopsi Ginjal

  13. Abbreviated MDRD Study Equation GFR (mL/min/1.73 m2) = 186.3 X SCr-1.154 X Age-0.203 X 0.742 (if female) X 1.210 (if African American) Equations for Estimating GFR Cockcroft-Gault Equation (140 – Age) X Weight in kg Ccr = (mL/min)‏ = 0.85 if female 72 X SCr MDRD = Modification of Diet in Renal Disease; Ccr = creatinine clearance. Levey et al. Ann Intern Med. 2003;139:137-147.

  14. CKD Stage Description GFR Prevalence Patients/ Nephrologist 1 Kidney damage normal incr. GFR 90 5,900,000 1180 2 Mild decr. in GFR 60-89 5,300,000 1060 3 Mod dec. in GFR 30-59 7,600,000 1520 4 Severe decr in GFR 15-29 400,000 80 5 Kidney failure <15 300,000 70 (145-160by 2010)* CKD Progresses in Stages Defined by Kidney Function: GFR 20 Million People With CKD (1 in 9 adults) in the United States,Many More at Risk *Estimated maximal load of kidney failure patients/nephrologist.Adapted from NKF. Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.; Coresh et al. Am J Kidney Dis. 2003;41:1-12; and Wish. Nephrol News Issues. 1999;13:23, 27, 53.

  15. Clinical Features – CKD 3-5 • Unintentional weight loss • Nausea, vomiting General ill feeling • Fatigue; Headache; Frequent hiccups • Generalized itching (pruritus) • Increased or decreased urine output • Need to urinate at night, polyuria • Easy bruising or bleeding

  16. Clinical Features – CKD 3-5 • Blood in the vomit or in stools • Decreased alertness; Muscle cramps • Seizures; Agitation; Hypertension • Peripheral sensory neuropathy • Breath fetor; Loss of appetite; • Uremic frost on the skin • Uremic pericarditis, CHF

  17. STAGES OF CKD INCREASED RISK NORMAL DAMAGE LOW GFR RENAL FAILURE CKD DEATH COMPLICATIONS

  18. Susceptibility Risk Factors Progression Factors Complications • Diabetes • Hypertension • Older age • Family history of CKD • Racial or ethnic minority • Other: low income, minimal education, kidney-mass reduction, known kidney disease • Higher level of proteinuria • Higher BP • Poor glycemic control • Smoking • Hyperlipidemia • Drug use • CVD • Anemia • Altered bone & mineral metabolism Considerations for Patients with CKD? Levey et al. Ann Intern Med. 2003;139:137-147. USRDS. 1999 Annual Data Report. Available at: www.usrds.org.

  19. What Are Progression Factors for CKD? • Elevated creatinine may indicate CKD, but not all creatinine elevation is irreversible • Key progression factors include • Elevated blood pressure (BP)‏ • Proteinuria • Poorly controlled glucose in patients with diabetes • Excess protein intake. • NSAIDs, contrast, aminoglycosides, other Levey et al. Ann Intern Med. 2003;139:137-147.

  20. + DM, - CKD - DM,+CKD + DM,+ CKD 2-year Follow-Up of Medicare Patients: Focus on Diabetes, CKD or Both Medical Cohort CKD identified as ICD-9-CM diagnosis code, includes CKD from diabetes, hypertension, obstructive uropathy, and other diagnosis codes reported on USRDS ESRD registration forms. ESRD = end-stage renal disease; DM = diabetes mellitus; ICD-9-CM = International Statistical Classification of Diseases, 9th Revision, Clinical Modification.Collins et al. Kidney Int. 2003;64(suppl 87):S24-S31.

  21. LVH Increases With CKD Progression LVH at Baseline (%)‏ 80 60 40 20 0 50-75 25-50 <25 Dialysis Start eGFR (mL/min/1.73 m2)1 eGFR = estimated glomerular filtration rate. 1. Levin et al. Am J Kidney Dis. 1999;34:125-134. 2. Foley et al. J Nephrol. 1998;11:239-245.

  22. 10 15 15 8 17 62 8 9 43 5 20 14 Anemia Rates Increase as Levels of CKD Severity Progress 100 Anemia Prevalence (%)‏ Hgb Values 80 11-12 g/dL 10-11 g/dL 60 <10 g/dL 40 20 0 <2 2-2.9 3-3.9 ≥4 Creatinine (mg/dL)‏ Chronic Kidney Disease (CKD) Progression Hgb = hemoglobin. Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.

  23. Complication Intervention Target Goals Diabetes Glycemic control preprandial glucose 90-125 mg/dL A1C <7% Hypertension BP control < 130/80 mm Hg Secondary HPT PTH control CKD stage 3 = 35-70 pg/mL 4 = 70-110 pg/mL Dyslipidemia Maintain lipids to target LDL-C <100 mg/dL (70?) TG <150 mg/dLHDL-C >40 mg/dL Anemia Reach Hgb goal 11-12 g/dL Malnutrition Dietary modification Adequate energy intake 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.

  24. CKDStage Description GFR (mL/min/1.73 m2)‏ Action* Risk At increased risk 90 with CKD risk factors Evaluate for CKD Reduce/control CKD risk factors 1 Kidney damage with normal or  GFR 90 Diagnose and treat comorbid conditions Address progression factors Reduce/control CVD risk factors 2 Kidney damage with mild  GFR 60-89 Estimate progression *All actions for prior stages 3 Moderate  GFR 30-59 Evaluate and treat complications *All actions for prior stages 4 Severe  GFR 15-29 Prepare for kidney replacement Evaluate and treat complications 5 Kidney failure <15 or dialysis Kidney replacement if uremia present Summary: Clinical Actions for Progressive Stages of CKD *Actions for each progressive stage of CKD also include all the actions for prior stages. NKF. Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.

  25. Cause of death in dialysis patients

  26. Decisions in renal replacement • Pre-dialysis care • Active treatment- Peritoneal dialysis (PD)- Haemodialysis (HD)- Transplantation • Conservative (non-dialytic) care. Symptom management.

  27. Penatalaksanaan CKD Ditujukan untuk mengurangi gejala klinik , mencegah komplikasi , mencegah progresifitas CKD, mempersiapkan initiasi dialisis Uremia : diit protein 0,6 – 0,8 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

  28. How Do We Know if a Patient is Adequately Dialyzed? • K/DOQI Guidelines • Define Adequate Dialysis as: • KT/V = 1.2 or greater • URR = 65% or greater

  29. URR% - Urea Reduction Ratio : the percentage of urea removed during the treatment KT/V: Formula utilizing dialyzer urea clearance, treatment time and total body fluid

  30. Example URR • Initial (predialysis) urea level: 50 mg/dL • The postdialysis urea level: 15 mg/dL • The amount of urea removed: 50 mg/dL–15 mg/dL = 35mg/dL • URR% = Ur pre – Ur post x 100% • Ur Pre • 35/50 = 70/100 = 70% • Recommended a minimum URR of 65 percent. • The URR is usually measured only a month.

  31. How About Acute kidney injury in Sepsis ?

  32. Critical ill patient potentially AKI

  33. AKI in ICU  5 –25% Mortality AKI 40-80%

  34. Klasifikasi/staging AKI modifikasi RIFLE Mehta RL. Nephrology Self Assesment Program , Vol 6, No 5, Sept 2007 Murray PT, Palevsky PM. Nephrology Self Assesment Program , Vol 6, No 5, Sept 2007

  35. Sepsis Ischemic insult Nephrotoxic insult Ischemia-reperfusion Endotoxin release Complement activation + Anti-inflamatory mediators Pro-inflamatory mediators - Oxygen free radicals Arachidonic acid metabolities Cellular activation (PMN, endothelial cells…) Nitric oxide Proteases Heat shock proteins Chemokines Endothelins Platelet activating factor  Urinary KIM-1, NAG  Serum creatinine Acute kidney injury  GFR  Urine output Pathogenic mechanism of sepsis related acute kidney injury

  36. Effects of ischemia on renal tubules in the pathogenesis of ischemic AKI Schrier et al, J Clin Invest 2004, 114:5-14

  37. Renal Protection • Renal protection, there is damage before any symptom • MAP> 65 mmHg • CVP 8-12 mmHg (no ventilator) • 12-15 mmHg (ventilator) • Urine > 0,5ml/BW/hour • SaO2 >70% • Koloid ,albumin ?

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