Chronic Kidney Disease

BACKGROUND
Chronic Kidney Disease is defined as a
slow lose of renal function over time. This
leads to a decreased ability to remove
waste products from the body and
perform homeostatic functions.
Incidence and Prevalence of End-Stage
Renal Disease in the US
 PATIENT IDENTITY
Nama : Tn. R
Usia : 66 tahun
Jenis Kelamin : laki-laki
Agama : Islam
Alamat : Tunirejo 3/7
Pekerjaan : Petani
No. CM : 05.23.50
Ruang : ICU
Masuk : 13 September 2013
Keluar : 15 September 2013
 HISTORY TALKING

Attack

3 days before
Sesak sangat
berat<
Sesak muncul hingga harus
5 days before tanpa dibawa ke
pengaruh RS
Demam aktivitas, Saat ke RS
setiap malam sesak juga
2 weeks hari, keringat sepanjang mengeluh
before dingin (-), hari muntah
Pergi ke menggigil (-) darah 1 kali
kalimantan
untuk
bekerja
 HISTORY TALKING

History of previous
illness Family history of disease
(-)
Asthma (-)
Hypertension (+) Social economic history
TB (-)
DM (-) Free clinic
Smoking (+)
 Systemic Anamnesis
General : dyspnea (+)
Skin : itching (-), jaundice (-), pale (+)
Head : headache (-)
Eyes : blurred vision (-), red eyes (-), icterics sclera (-/-)
Ears : hearing loss (-), discharge (-)
Nose : nosebleed (-), discharge (-)
Mouth : cyanosis (-), thrush (-)
Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)
Neck : trachea deviation (-), lymph hypertrophy (-)
Chest : dyspneu (+), cough (-), sputum (-), blood (-)
Cardiac : chest pain (-), palpitations (-)
Digestive : nausea (-), vomiting (-),heartburn (-), defecate / micsi (-/-)
Musculo : stiff neck (-), back pain (-)
Extremity : oedem of lower extremity (-), oedem of upper extremity (-)
 PHYSICAL EXAMINATION
General : dyspneu (+)
Awareness : Compos mentis
Vital Sign :
TD : 157/95 mmHg
HR : 107 x / menit
RR : 34 x / menit
T : 38,9 C
Head : Mesocephal, alopesia (-)
Eyes : Anemic Conjuntival (+/+), Icteric Sclera(-/-)
Nose : Simetric, Secret (-), Nostril Breath (-)
Ears : Normal Shape, Discharge (-/-)
Throat : Hyperemic (-), Pain Devour (-)
Mouth : Cyanosis (-), Dry Lips (-),
Neck : Trachea Deviation (-), Lymph Hypertrophy (-)
Extremity : Oedem of lower extremity (-), Oedem of upper extremity (-)

Interpretation : dyspneu, hypertension

 THORAX - PULMONARY
INSPEKSI ANTERIOR
Static RR : 34x/min, Hiperpigmentation
(-), spider nevi (-), atrofi M.
Pectoralis (-), Hemithoraks S=D,
ICS extend (-), Diameter AP < LL
Dinamic Up and down of hemitoraks S=D,
muscle retraction of breathing (-),
retraction ICS (-)
POSTERIOR
RR : 34 x/min, Hiperpigmentation (-
), spider nevi (-), Hemithoraks
Hemithoraks S=D, ICS extend (-),
Diameter AP < LL
Up and down of hemitoraks S=D,
muscle retraction of breathing (-),
retraction ICS (-)

Palpation Palpation pain (-), tumor (-), Palpation pain (-), tumor (-),
enlargement of ICS (-), Stem enlargement of ICS (-), Stem
fremitus is normal fremitus is normal
Percution Sinistra sonor Sinistra sonor
Auskultation Sinistra = Vesicular(N), ronchi (-), Sinistra = Vesicular (N), ronchi (-),
wheezing (-) wheezing (-)

Interpretation : tachypneu
 THORAX - COR
Inspection : Ictus cordis isnt seen.
Palpation : Ictus cordis is palpable in ICS V linea mid clavicula sinistra,
thrill (-).
Percussion : hiposonor (dull) sound
Upper borderline of heart : ICS II linea sternalis sinistra
Waist of heart : ICS III linea parasternalis sinistra
Lower right borderline of heart : ICS VI linea parasternalis dextra
Lower left borderline of heart : ICS VI lateral linea mid clavicula
sinistra
Auscultation :
Katup aorta : SD I-II murni, reguler, AI<A2
Katup trikuspid : SD I-II murni, reguler, T1>T2
Katup pulmonal : SD I-II murni, reguler, P1<P2
Katup mitral : SD I-II murni, reguler, M1>M2
Addition sound : (-)

Interpretation : normal
 ABDOMEN
Inspection : convex of surface(+), sicatric(-), stryae(-),
caput medusa (-).
Auscultation : peristaltic (+) N
Perkusi : tympani, shifting dullness (-), troube space
(+), tympani, Hepar deaf(+), liver span dextra 11 cm, liver span
sinistra 6 cm
Palpation
Superficial : massa (-)
Deeper : abdominal pain (-), hepar isnt palpable, lien
isnt palpable, renal isnt palpable

Interpretation: Normal
 Extremities

Extremities superior inferior

- Oedem -/- -/-
- cold -/- -/-
- reflect physiologist +/+ +/+
- Icteric -/- -/-
 LABORATORY
Hb 7,9 g/dl
Ht 24 %
Leukocyte 1200
Platelet 67.000
SGOT 24
SGPT 22
Ureum 364
Creatinin 13,9
GDS 51
Interpretation : anemic, leukopenia, trombocytopenia, azotemia
 CCT

(140-66) X 60
72X 13,9
= 4440
1000,8
= 4,4
 ECG
13/09/13
 PROBLEM LIST

1. ANEMIA
2. HYPERTENSION
3. AZOTEMIA
 CKD
ASSESMENT Grade V

IP DIAGNOSTIC Ureum creatinin (GFR)

IP THERAPY RL 12 tpm
Inj Cefotaxim 2x1 gr
Inj Furosemid 2x1
Inj Ranitidine 6x1
Inf D5% 2 flash
Bicnat drip 250 mg D5% plus 100 cc bicnat, 12 tts/mnt
Bicnat 3x50
Asam folat 1x1
IP MONITORING Vital sign, complication (acidosis metabolic)

IP EDUCATION Patient education regarding the importance of adherence to

medical therapy is vital, because appropriate treatment of both
hypoxia and underlying medical illness can improve mortality and
morbidity.
 PROGRESS NOTE

word
 REVIEW
Definition :
Structural or functional abnormalities of the
kidneys for >3 months, as manifested by
either:
1. Kidney damage, with or without decreased
GFR, as defined by
pathologic abnormalities
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, with or without kidney
damage
 Epidemiology

CKD affects about 26 million people in

the US
Approximately 19 million adults are in
the early stages of the disease
On the rise do to increasing prevalence of
diabetes and hypertension
Total cost of ESRD in US was
approximately $40 billion in 2008
 Risk Factors

Age of more than 60 years

Hypertension and Diabetes
Responsible for 2/3 of cases
Cardiovascular disease
Family history of the disease.
Race and ethnicity
Highest incidence is for African Americans
Hispanics have higher incidence rates of ESRD
than non-Hispanics.
 Clinical Definition

GFR of less than 60 ml/minute per 1.73m2 per

body surface area (normal is 125ml/min) .
Presence of kidney damage, regardless of
the cause, for three or more months
 Definition of ESRD vs Kidney Failure

ESRD is a federal government defined

term that indicates chronic treatment by
dialysis or transplantation

Kidney Failure: GFR < 15 ml/min/1.73

m2 or on dialysis.
 Symptoms

Hematuria
Flank pain
Edema
Hypertension
Signs of uremia
Lethargy and fatigue
Loss of appetite
If asymptomatic may have elevated serum
creatinine concentration or an abnormal
urinalysis
 Stages in Progression of Chronic Kidney
Disease and Therapeutic Strategies

Complications

Increased Kidney CKD

Normal Damage GFR
risk failure death

Screening CKD risk Diagnosis Estimate Replacement

for CKD reduction; & treatment; progression; by dialysis
risk factors Screening for Treat Treat & transplant
CKD comorbid complications;
conditions; Prepare for
Slow replacement
progression
 Prevalence of CKD and Estimated Number
of Adults with CKD in the US (NHANES 88-94)
Prevalence*
GFR
Stage Description N
(ml/min/1.73 m2) %
(1000s)
Kidney Damage with
1 90 5,900 3.3
Normal or GFR
Kidney Damage with
2 60-89 5,300 3.0
Mild GFR

3 Moderate GFR 30-59 7,600 4.3

4 Severe GFR 15-29 400 0.2

5 Kidney Failure < 15 or Dialysis 300 0.1

*Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes
approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated
from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For
Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two
measurements.
 Pathophysiology

Repeated injury to kidney

 Identify patients in your practice at high risk for Chronic Kidney Disease
- Patients with hypertension - Patients with heart failure
- Patients with diabetes mellitus - Patients with unexplained anemia
- Patients with atherosclerotic coronary, - Patients with a family history of end stage renal disease
cerebral or peripheral vascular disease - First nations peoples

eGFR <30 eGFR 30-60 eGFR >60

Consider reversible factors: Individualized follow up

-Medication - Volume depletion and treatment
-Intercurrent illness - Obstruction CKD is diagnosed in this group only if
other renal abnormalities are present
Repeat tests in 2 - 4 weeks (i.e. proteinuria, hematuria, anatomical)

eGFR <30 eGFR 30-60

Nephrology referral Follow eGFR at 3 months then serially

recommended Assess for persistent significant proteinuria
Implement risk reduction

eGFR < 30 Stable eGFR 30-60

or progressive decline in eGFR and
or persistent significant proteinuria no significant proteinuria
or inability to attain treatment targets
 Clinical Practice Guidelines for the Detection,
Evaluation and Management of CKD
Stage Description GFR Evaluation Management
At increased
Test for CKD Risk factor management
risk
Diagnosis
Kidney
Comorbid Specific therapy, based on diagnosis
damage with
1 >90 conditions Management of comorbid conditions
normal or
CVD and CVD Treatment of CVD and CVD risk factors
GFR
risk factors
Kidney
Rate of
2 damage with 60-89 Slowing rate of loss of kidney function 1
progression
mild GFR
Moderate
3 30-59 Complications Prevention and treatment of complications
GFR
Preparation for kidney replacement therapy
4 Severe GFR 15-29
Referral to Nephrologist
5 Kidney Failure <15 Kidney replacement therapy
1
Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors
(ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot
urine total protein-to-creatinine ratio of greater than 200 mg/g.
MANAGEMENT
 Clinical Practice Guidelines for
Management of Hypertension in CKD
Type of Kidney Disease Blood Pressure Preferred Agents Other Agents
Target for CKD, with or to Reduce CVD Risk
(mm Hg) without and Reach Blood
Hypertension Pressure Target
Diabetic Kidney Disease

ACE inhibitor Diuretic preferred,

Nondiabetic Kidney
or ARB then BB or CCB
Disease with Urine Total
Protein-to-Creatinine
Ratio 200 mg/g
<130/80
Nondiabetic Kidney Diuretic preferred,
Disease with Spot Urine then ACE inhibitor,
Total Protein-to-Creatinine ARB, BB or CCB
ratio <200 mg/g None preferred

Kidney Disease in Kidney CCB, diuretic, BB,

Transplant Recipient ACE inhibitor, ARB
 What Should Patients and Doctors
Know
In general CKD is characterized by a gradual
loss of the kidneys filtration capacity.
Markers Dont tell everything
Genetic variants found so far only account for
1.4% of variance seen in eGFR, and at most the
relative risk for CKD is modified by 20% per loci.
 What Should Patients and Doctors
Know

Genetic Risk does not translate into

clinical risk
Complex interaction with environmental
factors
Would need to calculate a likelihood ratio
in conjunction with a probability of disease
prevalence to gain a better estimate of
clinical risk.
 What Should Patients and Doctors
Know
Prevention
Keep diabetes and blood pressure
controlled
If at risk perform screening tests
Reduce exposure to nephrotoxic drugs
Eat right and exercise
Know your family history
If you have a positive family history ask doctor
to perform common screening tests for kidney
function.
 Sources
Wheeler et al 2009. Sequential Use of
Transcriptional Profiling, Expression Quantitative
Trait Mapping, and Gene Association
ImplicatesMMP20 in Human Kidney Aging.
Padmanabhan S et al. (2010) . Genome-wide
association study of blood pressure extremes
identifies variant near UMOD associated with
hypertension.PLoS Genet. 6(10):e1001177.
Gudbjartsson DF et al. (2010) . Association of
variants at UMOD with chronic kidney disease and
kidney stones-role of age and comorbid
diseases. PLoS Genet. 6(7):e1001039.
Kttgen A et al. (2009) . Multiple loci associated
with indices of renal function and chronic kidney
disease. Nat. Genet. 41(6):712-7.