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8/3/2019 04. Chronic Kidney Diseases Slide - Residen & Coass1
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Klasifikasi hipertensi pada kehamilan :
Gestational hypertension
Hypertension chronic in pregnancy
Preeclampsia
Superimposed preeclampsia
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Gestational hypertension
Normotensi hamil hipertensi partus - normotensi
Hypertension chronic in pregnancy
Hipertensi hamil hipertensi partus hipertensi
Preeclampsia
Normotensi n- hamil hipertensi proteniuri partus -normotensi
Superimposed preeclampsia
Hipertensi hamil hipertensi- proteinuri partus hipertensi
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C H R O N IC H R O N I
CC
K I D N E YK I D N E Y
D I S E A S ED I S E A S E
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The Relationship of Blood Urea Nitrogen (BUN) o
Serum Creatinine Concentration to
Glomerular Filtration Rate.
ken lines indicate that there is a family of curves rather than a single one for
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Methods of Glomerular Filtration
Rate (GFR) Measurement
Inulin Clearance
Alternative Filtration Markers
125I-Iothalamate, 51Cr-EDTA, 99mTc-DTPA and
non-radioactive iohexol
Plasma Creatinine
Creatinine ClearancePredictive Creatinine Clearance (the Cockroft-Gault Formula
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Creatinine ClearanceCreatinine Clearance
Ccr =Ucr x V
Pcr
Pcr = Plasma concentration of creatinineUcr = Urine concentration of creatinineV = Urine flow rate
V : 24 hr collectionOver night collectionTime collection
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EXAMPLESEXAMPLES
Patient 1 :
In a 68 years old dibetic female weighing 50 kg with aplasma creatinine level of 5.0 mg/dl the creatinineclearance would be:
(140-68) x 50 x 0.85
-------------------------- = 8.5 ml/minute
72 x 5.0This woman is ready to start maintenance dialysis
Patient 2 :A 30 year old 70 kg male with with a plasma creatinine
value of 5.0 mg/dl has, by the formula, a creatinineclearance of 21 ml/minute and does not yet requiredialysis therapy
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Patients with chronic kidney disease should be evaluateto determine :
Diagnosis (type of kidney disease)
Comorbid conditions
Severity, assessed by level of kidney function
Complications, related to level of kidney functions
Risk for loss of kidney function
Risk for cardiovascular disease
Evaluation and Treatment
Am J Kidney Dis 2002 ; 39 (suppl 1
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Treatment of chronic kidney disease should include :
Spesific therapy, based on diagnosis
Evaluation and management of co-morbid conditions
Slowing the loss of kidney function Prevention and treatment of cardiovascular disease
Prevention and treatment of complications of decreased kidney function
Preparation for kidney failure and kidney replacement therapy
Replacement of kidney function by dialysis and transplantation, if sign an
symptoms of uremia are present
Am J Kidney Dis 2002 ; 39 (suppl 1
Evaluation and Treatment
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Individuals at increased risk for CKD should be
tested at the time of a health evaluations to
determine if they have CKD.
Diabetes
Hypertension
Autoimmune diseases
Systemic infections
Exposure to drugs or procedures associated with acute
decline in kidney function
Recovery from acute kidney failure
Age > 60 years
Family history of kidney disease Reduced kidney mass (includes kidney donors and
transplant recipients)
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Measurements should included :
Serum creatinine for estimation of GFR
Assessment of proteinuria
Urinary sediment of urine dipstick for red blood
cells and white blood cells
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Progression of renal disease :Progression of renal disease :
A irreversible decline in GFR because
of structural damage to the renal
vasculature, tubules or interstitium.
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Definitions of Progression, Remission, andDefinitions of Progression, Remission, and
Regression of Proteinuric Chronic NephropathyRegression of Proteinuric Chronic Nephropathy
VariableVariable ProgressionProgression RemissionRemission RegressionRegression
Proteinuria
Glomerular filtration rate
Renal structural changes
1g/24 h
Declining
Worsering
< 1g/ 24 h
Stable
Stable
< 0.3g / 24 h
Increasing
Improving
Ruggenenti P, et al. Lancet2001 ; 357
Pi t l l f l l h t i i th
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Systemic HypertensionPrimary Renal Disease
Renal Ablation
Aging
Diabetes Mellitus
Dietary Factor
ENDOTHELIAL INJURYRelease of vasoactive factors
Vascular lipid deposition
Intracapillary throbosis
MESANGIAL INJURYAccumulation of macromolecules
Matrix production
Cell proliteration
EPITHELIAL INJURY
ProteinuriaPermeability to water
GLOMERULAR SCLEROSIS
GLOMERULAR HYPERTENSION
Pivotal role of glomerular hypertension in the
initiation and progression of structural injury
Brenne
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THE MECHANISM OF PROGRESSION OFTHE MECHANISM OF PROGRESSION OF
CHRONIC KIDNEY DISEASECHRONIC KIDNEY DISEASE
1.1. HYPERTENSIONHYPERTENSION
2.2. PROTEINURIAPROTEINURIA
3.3. ANGIOTENSIN-IIANGIOTENSIN-II
4.4. HYPERGLYCEMIA.HYPERGLYCEMIA.
5.5. PROTEIN INTAKEPROTEIN INTAKE
6.6. SODIUM INTAKESODIUM INTAKE
7.7. WATER INTAKEWATER INTAKE
8.8. HYPERLIPIDEMIAHYPERLIPIDEMIA
9.9. SMOKINGSMOKING
10.10. NSAIDNSAID
11.11. ANEMIAANEMIA
12. HYPERINSULINEMIA12. HYPERINSULINEMIA
13. HOMOCYSTEINEMIA13. HOMOCYSTEINEMIA
14. HYPERPHOSPHATEMIA14. HYPERPHOSPHATEMIA
15. POTASSIUM DEPLETION15. POTASSIUM DEPLETION
16. HYPERCOAGULATION16. HYPERCOAGULATION
17. GENDER17. GENDER
= LEVEL 1
= LEVEL 2
= LEVEL 3
Hebert LA, et al : Kidney Int2001;
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Aims of Dietary protein restriction :
To slow the progression of kidney disease
Minimize accumulation of uremic toxins Preserve protein nutritional status
(GFR mL/min) :
>50 : No restriction recommended
25 50 : 0.6 to 0.75 g/kgBW
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ADEQUACY OF HD (2)ADEQUACY OF HD (2)
DOQI recommends that Kt/V > 1.3
These recommendations are based on thrice weeklydialysis; twice weekly dialysis cannot be adequateunless there is substantial residual renal function
(glomerular filtration rate 5 10 ml/min).
A URR > 65% is equivalent to Kt/V > 1.2DOQI recommends a target of 70% (equivalent to
Kt/V of 1.3)
Goals for renoprotection approach in CKD patient (1)
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Goals for renoprotection approach in CKD patient (1)
BP control
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Antihypertensive therapy
First step, ACE inhibitor or ARB
Second step, diureticIn stage 3, loop diuretic
Third step, CCB or BB
Fourth step, BB or CCB if not used before.Consider other alternatives such as alpha blocker or
centrally acting drugs.
Goals for renoprotection approach in CKD patient (2)
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T H A N KT H A N K
Y O UY O U