2.dr partini ckd batam 2013 97

7/27/2019 2.Dr Partini CKD Batam 2013 97

1/43

Curriculum Vitae

Nama: Partini Pudjiastuti Trihono

Pendidikan:

Dokter umum: FKUI 1979

Spesialis Anak: FKUI 1989

Master of Medicine (Paediatrics): University ofMelbourne 1996

Pediatric Nephrology course: Royal ChildrenHospital Melbourne 1996

Spesialis Anak Konsultan: IDAI 1999

Doktor: FKUI 2007

Jabatan sekarang:

Ketua Program Studi IKA FKUI

Ketua Divisi Nefrologi Departemen IKA FKUI

Wakil Ketua Kolegium IKA Indonesia


2/43

CHRONIC KIDNEY DISEASE:DIANOSIS AND MANAGEMENT

Partini Pudjiastuti TrihonoDepartment of Child Health

Faculty of Medicine University of Indonesia

Batam, 8 June 2013


3/43

Definition of CKD

NKF-KDOQI CPG

Structural or functional abnormalities of the kidneys for >3

months, as manifested by either:

1. Kidney damage, with or without decreased GFR, as defined

bypathologic abnormalities

markers of kidney damage, including abnormalities inthe composition of the blood or urine or abnormalities

in imaging tests

2. GFR


4/43

Stage 1 Kidney damage w/normal GFR

GFR >= 90ml/min/1.73 m

Stage 2 Kidney damage w/ mildGFR decrease

60-89mild

Stage 3 Moderate GFR decrease 30-59moderate

Stage 4 Severe GFR decrease 15-29severe

Stage 5 Kidney failure (ESRD) < 15 or on dialysis

Classification of CKD

NKF - K/DOQI (KIDNEY DISEASE OUTCOME QUALITY INITIATIVE) -Am J Kidney Dis 2002


5/43

PROGRESSION OF CHRONIC KIDNEY DISEASE

Systemic

hypertensionReduced nephron mass

INTRAGLOMERULAR HYPERTENSION

Increased filtration pressure

ProteinuriaPodocyte

injury

Tubulointerstitial

hypoxia

Glomerular

hypertrophy

Hyperfiltration

Vasoactive

signaling

Proinflamatory

signaling

Matrix deposition

FIBROSIS


6/43

Causes of CKD

Glomerulonephritis

Primary: nephrotic syndrome, focal segmental glomerulosclerosis

Secondary: SLE, Henoch-Schonlein

Familial nephropathy

Alport syndrome, congenital nephrotic syndrome

CAKUT (congenital anomalies in kidney and urinary tract)

Bilateral renal dyslasia, hypoplasia, polycystic kidney disease

Reflux nephropathy

Obstructive uropathy PUJO, VUJO, calculi

Miscelaneous Bilateral Wilms tumor

Renal cortical necrosis


7/43

Risk Factors for CKD

VUR associated with recurrent UTI and renal scarring

Obstructive uropathy

Prior history of acute nephritis or nephrotic syndrome

History of renal failure in perinatal period

Family history of polycystic kidneys or genetic renal conditions

Renal dysplasia or hypoplasia

Low birth weight infants

History of Henoch-Schonlein purpura

Presence of diabetes, hypertension

Systemic lupus erythematosus, vasculitis


8/43

DIAGNOSIS


9/43

Modes of presentation of CKD

Antenatal ultrasoundscanning

Abdominal mass

Urinary tractinfection

Enuresis

Failure to thrive

Short stature

Lethargy and pallor

Hematuria

Nephrotic syndrome

Hypertension

Congestive cardiac

failure Seizures

Failure to recover fromacute renal failure

Screening siblings ofindex cases


10/43

Simple assessment of GFR in children

Schwartz formula:

GFR= body height (cm) x K

Pcr (mg/dL)

K= 0.45 for babies < 1 year old

K= 0.55 for boys and girls 1-13 year old

K= 0.57 for girls > 13 year old

K= 0.70 for boys > 13 year old

This equation gives the GFR in ml/min./1.73 m2 BSA Theproblem is, the Schwartz formula does not work so goodin children with very high plasma creatinine levels.


11/43

Chronic renal failure

Main consequences

Mechanism Example Clinical Manifestation s

Decreased

excretion

Uremic toxins

Salt and water

Phosphate

Acid

Potassium

Uremic syndrome

Volume overload, hypertension

Hyperparathyroidism

Metabolic acidosis

Hyperkalemia

Decreased

biosynthesis

Erythropoietin

Activation of vitamin D

Anaemia

Osteomalacia,

Hyperparathyroidism

Altered

metabolism

Dyslipidaemia

Glucose intolerance

Atherogenesis


12/43

Uremic Syndrome: manifestations

Cardiovascular Hypertension Cardiomyopathy Arrhythmias Cardiac failure

Arteriosclerosis Pericarditis

Central Nervous System Insomnia Fatigue/spasm

Tremor asterixis, myoclonus Confusion, stupor, coma Encephalopathy EEG changes

Coagulation System Bleeding Hypercoagulation

Respiratory System Pneumonitis, uremic lung

Lung edema Endocrinology and

metabolism Glucose intolerance Abnormal lipid metab. Abnormal amino acids metab, Malnutrition

Hypoalbuminemia Muscle wasting Growth retardation Hypothermia


13/43

Peripheral Nervous System Polyneuropathy Paresis Autonomic neuropathy Hypotension

Hematology and Immunology Anemia Susceptible to infection Granulocyte dysfunction Lymphocyte dysfunction Immunodeficiency Malignancy

Musculo-sceletal System Osteodystrophy, osteomalacia Hyperparathyroidism Pain and fracture Carpal Tunnel syndrome Amiloidosis Myopathy Muscle weakness

Skin Skin dry Pruritus Hyperpigmentation Bleeding

Delayed wound healing

Gastrointestinal System Anorexia Nausea, vomiting Hiccup Stomatitis

Gastritis Parotitis Colitis Bleeding Fetor uremicum

Uremic Syndrome: manifestations


14/43

Diagnosis and Assessment Severity

Investigations Urinalysis Blood: complete blood peripheral, urea,

creatinine, Ca, PO4, alkaline phosphatase,PTH, iron, ferritin, blood gas

Radiology: CXR, bone age ECG Kidney ultrasound: renal size, anomalies,

obstruction MSU, DMSA (not helpful if GFR


15/43

PRINCIPAL MANAGEMENT

1. Early detection and prompt treatmentkidney diseases

2. Slowing progression of CKD3. Prevention and management of

complications


16/43

100

10

0

No Treatment

Current Treatment

Early Treatment

4 7 9 11

Time (years)

GFR

(mL/min/1

.732)

Kidney Failure

Early treatment can make adifference

[email protected]


17/43

Stage Description GFR Evaluation Management

At increasedrisk

Test for CKD Risk factor management

1

Kidneydamage with

normal orGFR

>90

DiagnosisComorbidconditions

CVD and CVD

risk factors

Specific therapy, based on diagnosisManagement of comorbid conditions

Treatment of CVD and CVD risk factors

2

Kidneydamage with

mild GFR60-89

Rate ofprogression

Slowing rate of loss of kidney function 1

3Moderate

GFR30-59 Complications Prevention and treatment of complications

4 Severe GFR 15-29 Preparation for kidney replacement therapyReferral to Nephrologist

5 Kidney Failure


18/43

Fluid and salts intake Nutrition Proteinuria

Hypertension Anemia Metabolic acidosis Infection

Secondary hyperparathyroidism Ca and P metabolisms/bone and mineral

disorder

Slowing progression and treatmentof complications


19/43

Maintain hydration

Beware of polyuria

Adequate hydration: attention to fluid intake and

urine output Correct electrolyte disturbances

Hyponatremia

Hypo / hyperkalemia

Hyperhosphatemia Hypo / hypercalcemia

Fluids and salt intake


20/43

Nutritional and dietary management

Adequate calorie intake formaintenance and catch-up growth

Adequate protein intake for growth(RDA, higher biologic value protein)

Low phosphate intake

Salt / potassium restriction

Vitamins and trace elementssupplementation


21/43

Proteinuria

Screening:Test first morning urine sample Protein >+1: do protein to creatinine ratio

Monitoring: protein to creatinine ratio on

first morning urine sample Spot urine for albumin/creatinine ratio (mg:mg)

Normal = 2

Treatment: ACEI: captopril, enalapril

ARB : losartan

both


22/43

ACEI +/- ARB

Beware of hypotension, deteriorationof kidney function, hyperkalemia

Decrease in GFR, usually within 4weeks:

Decrease < 30%: acceptable

Decrease 30%-50%: dose adjustment

Decrease > 50%: drug withdrawal


23/43

Hypertension

Treatment should be aggressive

Target: BP level < 90th centile for specificage, sex, and height

Hypertension related to hypervolemia diuretics thiazide or furosemide

Others anti-hypertensive agents:

ACEI +/- ARB

Ca channel blocker: amlodipine, nifedipine

Selective -blocker: atenolol

Vasodilators: hydralazine


24/43

Etiology of anemia in CKD:MULTIFACTORIAL

Erythropoietin deficiency Erythropoiesis inhibitor Secondary hyperparathyroidism Blood loss Deficiency of hematinic agents (Fe,folic acid, B12) Shorter erythrocytes lifespan Primary renal diseases Cytokine inflammation Infection Aluminium toxicity


25/43

GFR < 60 mL/m/1.73 m2

Hb level

Hb < 11 g/dL

Complete peripheral bloodIron index

Normal Iron deficiency Refer to

hematologist

Treat with r-EPOIron supplement

Anemia correctedAnemia persisted

No No

GUIDELINE NKF - K/DOQI

Am J Kidney Dis, 2002 (mod)


26/43

Indikasi : Hb < 10 g/dl atau Ht 30 % (PERNEFRI) Dosages: start with 50 unit/kg SC, twice a week

Pre-requisite:1. Adequate iron storage: feritin serum >100 g/L

transferin > 20%2. No infection/inflammation3. No hyperparathyroidisms4. Avoid iron overload

TREATMENT ANEMIA WITH r-HuEPO


27/43

Packed Red Cell Transfusion

Indications

1. Acute bleeding

2. Hb< 7 g/dl but r-EPO is not available

3. Hb


28/43

Acid base status

Maintenance of acid base balance is important

Metabolic acidosis associated with

Failure to thrive, muscle degradation, bone

demineralization, hyperkalemia Correction:

Reducing protein intake ( S- containingamino acids)

Reduce endogenous acid production Sodium bicarb. supplementation (dose

adjusted to BGA)


29/43

Feedback Loops in 2nd Hyperparathyroidism

Ca = calcium; CVD = cardiovascular disease; P = phosphorus.Courtesy of Kevin Martin, MB, BCh.

PTH

Bon e Disease

Fractures

Bone pain

Marrow fibrosisErythropoietin resistance

1,25DCalcitriol

Renal Failur e

PTH

Systemic Toxic i ty

CVD

Hypertension

Inflammation

Calcification

Immunological

25D

Ca++

Decreased Vitamin D Receptorsand Ca-Sensing Receptors

Serum P


30/43

Ca and PO4 metabolism in CKD

Monitor Ca, PO4, alkaline phosphatase,PTH, Xray renal osteodystrophy view (kneeor wrist)

Restrict dietary phosphate Phosphate binder

CaCO3 50-100 mg/kg BW taking during meals

Ca acetate

Sevelamer

Vitamin D3 (1,25 diOH cholecalciferol)

Calcium supplement (watch carefully for

hypercalcemia)


31/43

Target ranges for blood biochemicalparameters in children with CKD

Camg/dL

Pmg/dL

Ca x P PTHpg/mL

ALPmg/dL

Age 1-12 yrs

CKD 2-3 9-10.2 4-6


32/43


33/43

Vaccination of Patients with ChronicRenal Disease


34/43

Factors affecting renal diseaseprogression

CKD

Progression

Hypertension Proteinuria

Renal

anemia,dyslipide

mia

Altered

mineralhomeostasis


35/43

Anemia of Renal Failure

[email protected]


36/43

KDOQI RECOMMENDATION

Ca

Maintain in normal range

PO4

CKD stage 5:

> 12 year 3.4-5.5 mg/dL

1-12 year 4 6 mg/dL

PTH

CKD stage 4: 70-110 pg/ml

CKD stage 5: 200-300 pg/ml

Ca x PO4

> 12 year : 55 mg2/dL2

< 12 year : 65 mg2/dL2


37/43

Growth

Possible factors contributing to growth retardation in CRF

Inadequate energy intakeInappropriate protein intakeDisturbance of water and electrolyte balanceMetabolic acidosisRenal osteodystrophyHypertensionInfectionAnemiaHormonal abnormalities

Corticosteroid therapyPsychosocial factors

Recombinant human growth hormone when optimal management fails


38/43

Vaccination of Patients with ChronicRenal Disease

Recommended:

BCG

Hepatitis B

Varicella zoster

Pneumococcus

Influenza


39/43


40/43

Chronic Kidney Disease

Common condition

Most etiology:

Glomerulonephritis

Reflux nephropathy Obstructive uropathy

Significant morbidity

Expensive

Effective treatment can slow progression Teamwork: primary physicians, pediatricians,

renal specialists

Infection Congenital UT anomalies


41/43

CKD

death

Stages in Progression of Chronic KidneyDisease and Therapeutic Strategies

Complications

Screeningfor CKD

risk factors

CKD riskreduction;

Screening for

CKD

Diagnosis& treatment;

Treat

comorbid

conditions;

Slow

progression

Estimateprogression;

Treat

complications;

Prepare for

replacement

Replacementby dialysis

& transplant

NormalIncreased

risk

Kidney

failureDamage GFR

AJKD 2002: 39(2)


42/43

Chronic kidney disease

Hyperparathyroidism

Phosphate retention FGF23 1,25(OH)2D3

PTH resistanceof bone

Hypocalcemia Acidosis

Parathyroid Careceptor expression

Parathyroid 1,25(OH)2D3receptor expression

Pathophysiology

of2nd

h

yperparathyroidism


43/43

Recommended target ranges forserum PTH and Ca-Po4 product

Targetrange

Chronic Kidney Disease Stage

II III IV VSerum PTHlevel

35-70pg/ml

35-70pg/ml

70 -110pg/ml

200-300pg/ml

Ca-PO4

productlevel

Age < 12 years < 65 mg2/dL2

Age > 12 years < 55 mg2/dL2

2.dr partini ckd batam 2013 97

Documents