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Nama: Partini Pudjiastuti Trihono Pendidikan: Dokter umum: FKUI 1979 Spesialis Anak: FKUI 1989 Master of Medicine (Paediatrics): University of Melbourne 1996 Pediatric Nephrology course: Royal Children Hospital 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
Partini Pudjiastuti Trihono Department of Child Health Faculty of Medicine University of Indonesia
Definition of CKD
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
Classification of CKD
Stage 1 Kidney damage w/ normal GFR GFR >= 90 ml/min/1.73 m
Stage 2 Stage 3
Kidney damage w/ mild 60-89 GFR decrease mild Moderate GFR decrease 30-59 moderate
Stage 4
Stage 5
15-29 severe
< 15 or on dialysis
NKF - K/DOQI (KIDNEY DISEASE OUTCOME QUALITY INITIATIVE) - Am J Kidney Dis 2002
INTRAGLOMERULAR HYPERTENSION
Glomerular hypertrophy
Proteinuria
Vasoactive signaling
Matrix deposition
Proinflamatory signaling
FIBROSIS
Causes of CKD
Glomerulonephritis
Familial nephropathy
Obstructive uropathy
Miscelaneous
DIAGNOSIS
K= K= K= K=
babies < 1 year old boys and girls 1-13 year old girls > 13 year old boys > 13 year old
This equation gives the GFR in ml/min./1.73 m2 BSA The problem is, the Schwartz formula does not work so good in children with very high plasma creatinine levels.
Decreased biosynthesis
Altered metabolism
Atherogenesis
Bleeding Hypercoagulation
Insomnia Fatigue/spasm Tremor asterixis, myoclonus Confusion, stupor, coma Encephalopathy EEG changes
Glucose intolerance Abnormal lipid metab. Abnormal amino acids metab, Malnutrition Hypoalbuminemia Muscle wasting Growth retardation Hypothermia
Skin
Gastrointestinal System
Anorexia Nausea, vomiting Hiccup Stomatitis Gastritis Parotitis Colitis Bleeding Fetor uremicum
Musculo-sceletal System
Osteodystrophy, osteomalacia Hyperparathyroidism Pain and fracture Carpal Tunnel syndrome Amiloidosis Myopathy Muscle weakness
PRINCIPAL MANAGEMENT
1. Early detection and prompt treatment kidney diseases 2. Slowing progression of CKD 3. Prevention and management of complications
GFR (mL/min/1.732)
10 0
Kidney Failure
4 7 9 11
Time (years)
dfschaffner@BeckmanCoulter.com
ASN
Clinical Practice Guidelines for the Detection, Evaluation and Management of CKD
Stage Description At increased risk Kidney damage with normal or GFR Kidney damage with mild GFR Moderate GFR Severe GFR Kidney Failure
1
GFR
Evaluation Test for CKD Diagnosis Comorbid conditions CVD and CVD risk factors Rate of progression Complications
Management Risk factor management Specific therapy, based on diagnosis Management of comorbid conditions Treatment of CVD and CVD risk factors
>90
60-89
3 4 5
Prevention and treatment of complications Preparation for kidney replacement therapy Referral to Nephrologist Kidney replacement therapy
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.
Proteinuria
Screening:Test first morning urine sample
Protein >+1: do protein to creatinine ratio
Treatment:
ACEI: captopril, enalapril ARB : losartan both
Hypertension
Treatment should be aggressive Target: BP level < 90th centile for specific age, 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
Hb < 11 g/dL
Complete peripheral blood Iron index Normal Treat with r-EPO No Iron deficiency No Refer to hematologist
Anemia persisted
Pre-requisite:
1. 2. 3. 4.
Adequate iron storage: feritin serum >100 g/L transferin > 20% No infection/inflammation No hyperparathyroidisms Avoid iron overload
!!
Correction: Reducing protein intake ( S- containing amino acids) Reduce endogenous acid production Sodium bicarb. supplementation (dose adjusted to BGA)
PTH
PTH
Ca++
Bone Disease Fractures Serum P Bone pain Marrow fibrosis Erythropoietin resistance
1,25D Calcitriol
25D
Renal Failure
Ca = calcium; CVD = cardiovascular disease; P = phosphorus.
Courtesy of Kevin Martin, MB, BCh.
Vitamin D3 (1,25 diOH cholecalciferol) Calcium supplement (watch carefully for hypercalcemia)
CKD 5
Age > 12 yrs CKD 2-3 CKD 4 CKD 5
8.8-9.7
4-6
<65
200-300
100-450
Hypertension
Protein uria
dfschaffner@BeckmanCoulter.com
KDOQI RECOMMENDATION
Ca
PO4
3.4-5.5 mg/dL 4 6 mg/dL
PTH
CKD stage 4: 70-110 pg/ml CKD stage 5: 200-300 pg/ml > 12 year : 55 mg2/dL2 < 12 year : 65 mg2/dL2
Ca x PO4
Growth
Possible factors contributing to growth retardation in CRF
Inadequate energy intake Inappropriate protein intake Disturbance of water and electrolyte balance Metabolic acidosis Renal osteodystrophy Hypertension Infection Anemia Hormonal abnormalities Corticosteroid therapy Psychosocial factors
Recombinant human growth hormone when optimal management fails
Significant morbidity Expensive Effective treatment can slow progression Teamwork: primary physicians, pediatricians, renal specialists
Normal
Increased risk
Damage
GFR
Kidney failure
CKD death
Diagnosis Estimate Replacement & treatment; progression; by dialysis Treat Treat & transplant comorbid complications; conditions; Prepare for Slow replacement progression
Phosphate retention
FGF23
1,25(OH)2D3
Hyperparathyroidism
Parathyroid Ca receptor expression Parathyroid 1,25(OH)2D3 receptor expression
35-70 pg/ml
35-70 pg/ml
70 -110 pg/ml
200-300 pg/ml
Age < 12 years < 65 mg2/dL2 Age > 12 years < 55 mg2/dL2