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 CHRONIC KIDNEY DISEASE (CKD)(Penyakit Ginjal Kronik)

Criteria :Kidney damage for 3 monthstructural and functional abnormalitywith or without decreased Glomerular Filration Rate (GFR)manifest by either abnormality of :pathologyblood compositionurine compositionimaging testGFR < 60 ml/min for 3 month, with or without kidney damage

Explanation :Structural abnormality e.g. single kidney, kidney/ureter stone, cystic kidney, proteinuriaProstate hypertrophy, etcGFR : calculated by Kockroft Gault FormulaBlood composition e.g. ureum, creatininUrine composition e.g. proteinuria, haematuriaImaging e.g. BNO (plain photo abdomen), USG etc

Kidney disease 3 month :GFR (Cockroft Gault) 60 ml/mnt/1.73 m2Kidney damage (+)- CKDKidney damage (-) - normal< 60 ml/mnt/1.73 m2- CKD

CASE 1.Man, 60 years old, Bw, 70 kg, Serum Creatinine 1.3 mg/dl for 4 monthHe doesnt have any kidney damage

DOES HE HAVE CKD ?

Three month later, that man has haematuria, prostate hypertrophyThe 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 abnormalityDOES SHE HAVE CKD ?

STAGES OF CKDChronic 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

StageDescriptionGFR (mL/min/1.73 m2)IKidney damage with normal or GFR 90IIKidney damage with mild GFR60-89IIIModerate GFR30-59IVSevere GFR15-29VKidney failure < 15 or dialysis

ETIOLOGY OF CKDEtiology of CKD are :Diabetes MellitusChronic GlomerulonephritisChronic PyelonephritisHypertensionUrinary tract stoneObstruction (tumor, prostate)Immunological disease (SLE)Congenital (polycystic kidney)MalignancyOthers :pregnancychronic liver disease

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

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

Patophysiology of hypertension in CKD- 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 kidneyAngiotensin IAngiotensin Converting Enzyme (ACE)Renin Angiotensin Aldosterone SystemSuprarenal cortexAldosteronAngiotensin II

PATHOPHYSIOLOGY OF ANEMIA IN CKD

Erythropoitin insufficiency - decreased of erythropoitin secreted by the kidney

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:Diagnosis (type of kidney disease)Comorbid conditions;Severity; assessed by level of kidney function;Complications, related to level of kidney function;Risk for loss of kidney function;Risk for cardiovascular disease

COMPLICATION OF CKD1. Cardiac diseases- coronary artery disease- congestive heart disease- acute left heart failure

2. Metabolic acidosis

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 diseaseWhat should be doneHow oftenAge > 50 YearsDiabetesHigh Blood PressureSmokingObesityFamily history of kidney diseaseBlood pressureUrine dipstick (mircoalbuminuria if diabetes present)eGFREvery 12 months

Treatment for chronic kidney disease should include:Specific therapy, based on diagnosisEvaluation and management of comorbid conditions;Slowing the loss of kidney functionPrevention and treatment of cardiovascular disease;Prevention and treatment of complications of decreased kidney functionPreparation for kidney failure and kidney replacement therapy;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/1.73m2Unexplained decline in kidney function (>15% drop in eGFR over three months)Proteinuria > 1 g/24 hrsGlomerular haematuria (particularly if proteinuria present)CKD and hypertension that is hard to get to targetDiabetes with eGFR < 60 mL/min/1.73m2Unexplained anaemia (Hb

Who does not usually need to be referred to a Nephrologists?CKD stage 2 and 3Stable eGFR 30-89 mL/min/1.73m2Minor proteinuria (

STAGES OF CKD: A CLINICAL ACTION PLANChronic 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

StageDescriptionGFR (mL/min/1.73 m2)Actions*IKidney damage with normal or GFR 90Diagnosis and treatment. Treatment of comorbid conditions, Slowing progression, CVD risk reductionIIKidney damage with mild GFR60-89Estimating progressionIIIModerate GFR30-59Evaluating and treating complicationsIVSevere GFR15-29Preparation for kidney replacement therapyVKidney failure < 15 or dialysisReplacement (if uremia pesent)

CaseMan 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 Cmcontracted the right kidney

Urine culture and sensitivity test for the cause of infectionManagement ?Stone management (urologic approach)AntibioticSlowing the progression