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CHRONIC KIDNEY DISEASE (CKD)

(Penyakit Ginjal Kronik)

Definition :
CKD is a group of kidney disease with specification :
chronic (more than 3 month)
progressive: become worst time to time
persistent : can not become to completely
remission

Criteria :
1. Kidney damage for 3 month
structural and functional abnormality
with or without decreased Glomerular Filration
Rate (GFR)
manifest by either abnormality of :
pathology
blood composition
urine composition
imaging test
2. GFR < 60 ml/min for 3 month, with or without kidney
damage

Explanation :
Structural abnormality e.g. single kidney,
kidney/ureter stone, cystic kidney,
proteinuria
Prostate hypertrophy, etc
GFR : calculated by Kockroft Gault Formula
Blood composition e.g. ureum, creatinin
Urine composition e.g. proteinuria, haematuria
Imaging e.g. BNO (plain photo abdomen), USG etc

Kidney disease 3 month :

GFR (Cockroft Gault)

< 60 ml/mnt/1.73 m2
- CKD

60 ml/mnt/1.73 m2

Kidney damage (-)


- normal

Kidney damage (+)


- CKD

CASE 1.
Man, 60 years old, Bw, 70 kg, Serum Creatinine 1.3 mg/dl
for 4 month
He doesnt have any kidney damage
DOES HE HAVE CKD ?

Three month later, that man has haematuria, prostate


hypertrophy
The other conditions still similar
DOES HE HAVE CKD ?

CASE 2.
Woman, 44 years old, Bw. 50 kg, creatinine serum 1.5 mg/dl
She doesnt have any kidney abnormality
DOES SHE HAVE CKD ?

STAGES OF CKD
Stage

Description

GFR
(mL/min/1.73 m2)

Kidney damage with normal or GFR

90

II

Kidney damage with mild GFR

60-89

III

Moderate GFR

30-59

IV

Severe GFR

15-29

Kidney failure

< 15 or dialysis

Chronic Kidney Disease is defined as either kidney damage or GFR < 60


mL/min/1.73 m2 for 3 months.
Kidney damage is defined as pathologic abnormalities or markers of
damage, including abnormalities in blood or urine test or imaging studies

ETIOLOGY OF CKD
Etiology of CKD are :
1.

Diabetes Mellitus

2.

Chronic Glomerulonephritis

3.

Chronic Pyelonephritis

4.

Hypertension

5.

Urinary tract stone

6.

Obstruction (tumor, prostate)

7.

Immunological disease (SLE)

8.

Congenital (polycystic kidney)

9.

Malignancy

10. Others :
pregnancy
chronic liver disease

CLINICAL MANIFESTATION :
Symptom :
Not specific : - lethargic, weakness. nausea, vomiting, headache,
- edema, dyspneu on effort

Physical examination :
Hypertension, anemic, edema
Sign of complications e.g. heart hypertrophy, ascites

Patophysiology of hypertension in CKD


1. - Sodium retention
- fail of the kidney for excreted water and sodium
excess

2. - Acceleration of Renin Angiotensin System activity


- increased secretion of renin

Angiotensinogen
(produced by liver)
Renin
(produced by kidney

Angiotensin I

Angiotensin
Converting Enzyme
(ACE)
Suprarenal cortex

Angiotensin II

Aldosteron
Renin Angiotensin Aldosterone System

PATHOPHYSIOLOGY OF ANEMIA IN CKD


1. Erythropoitin insufficiency
- decreased of erythropoitin secreted by the kidney
2. Iron deficiency
- chronic bleeding
- low intake
3. Others
- haemolysis / decreased of erythrocyte live spend
- depressed of bone marrow by uraemic substances

Patients with chronic kidney disease should be


evaluated to determine:
1. Diagnosis (type of kidney disease)
2. Comorbid conditions;
3. Severity; assessed by level of kidney function;
4. Complications, related to level of kidney function;
5. Risk for loss of kidney function;
6. Risk for cardiovascular disease

COMPLICATION OF CKD
1. Cardiac diseases
- coronary artery disease
- congestive heart disease
- acute left heart failure
2. Metabolic acidosis
3. Electrolyte imbalance
- hyper / hypokalemia
- hyper / hyponatremia
4. Renal osteodystrophy (renal bone disease)

Early detection of CKD using kidney health check


Who is at higher risk
of kidney disease

What should be
done

How often

Age > 50 Years

Blood pressure

Every 12 months

Diabetes
Smoking

Urine dipstick
(mircoalbuminuria if
diabetes present)

Obesity

eGFR

High Blood Pressure

Family history of
kidney disease

Treatment for chronic kidney disease should include:


1. Specific therapy, based on diagnosis
2. Evaluation and management of comorbid conditions;
3. Slowing the loss of kidney function
4. Prevention and treatment of cardiovascular disease;
5. Prevention and treatment of complications of decreased
kidney function
6. Preparation for kidney failure and kidney replacement
therapy;
7. Replacement of kidney function by dialysis and
transplantation, if signs and symptoms of uremia are
present

Who may be consider for referral to a Nephrologists?


Anyone with:

eGFR < 30 mL/min/1.73m2

Unexplained decline in kidney function


(>15% drop in eGFR over three months)

Proteinuria > 1 g/24 hrs

Glomerular haematuria
(particularly if proteinuria present)

CKD and hypertension that is hard to get to target

Diabetes with eGFR < 60 mL/min/1.73m 2

Unexplained anaemia (Hb<100 g/L)


with eGFR < 60 mL/min/1.73m2)

Who does not usually need to be referred


to a Nephrologists?
CKD stage 2 and 3
Stable eGFR 30-89 mL/min/1.73m2
Minor proteinuria
(<0.5 g/24 hrs with no haematuria)
Controlled blood pressure

STAGES OF CKD: A CLINICAL ACTION PLAN


Stage

Description

GFR

Actions*

(mL/min/1.73 m2)

Kidney damage with

90

Diagnosis and treatment. Treatment of


comorbid conditions, Slowing
progression, CVD risk reduction

60-89

Estimating progression

normal or GFR
II

Kidney damage with mild


GFR

III

Moderate GFR

30-59

Evaluating and treating complications

IV

Severe GFR

15-29

Preparation for kidney replacement


therapy

Kidney failure

< 15 or dialysis

Replacement (if uremia pesent)

Chronic Kidney Disease is defined as either kidney damage or GFR < 60 mL/min/1.73 m2 for 3
months. Kidney damage is defined as pathologic abnormalities or markers of damage, including
abnormalities in blood or urine test or imaging studies
* Includes actions from proceeding stages

Case
Man 44 yrs, came with chief complain lethargic,
anorexia, edema in both of extremity. The complain up
and down since around 4 month. He had an operation
of kidney stone one year ago.
The patient look pale, blood pressure 180/110 mmHg,
edema in both extremity.
Hb. 5.6 mg/dl, BUN 48 mg/dl, serum creatinine 4,2
mg/dl. Hematuria 20 30 /hpf, leukosuria full,
proteinuria +
What is the assessment of that case ?
What other examination do we need ?

Imaging test :
Plain photo abdomen :
opaque stone in left kidney
USG
stone in pielum of left kidney, 4X3 Cm
contracted the right kidney

Urine culture and sensitivity test


for the cause of infection
Management ?
- Stone management (urologic approach)
- Antibiotic
- Slowing the progression