1. A Comprehensive Approach to Kidney Disease and Hypertension
Dr. Eddy Susatyo, SpPD
SubBag Ginjal dan Hipertensi
Ilmu Penyakit Dalam
RSI ARAFAH/ RSUD Rembang

2. Ginjal Fungsi Ginjal Regulasi volume cairan
Regulasi keseimbangan elektrolit
Regulasi keseimbangan asam dan basa
Regulasi tekanan darah (RAAS)
Regulasi eritropoesis
Ekskresi sampah metabolik
Metabolisme vitamin D
Sintesis prostaglandin

5. Apa penyebab Gagal Ginjal ?

6. Akut
Gagal Ginjal
Kronik

7. Chronic
CKD: Chronic Kidney Disease
Acute
ARF: Acute Renal Failure
AKI: Acute Kidney Injury
Acute Classification
Pre-renal
Renal
Post-renal

9. The CKD problem Clinically silent in the early stages
Cost of renal disease can be extreme to health care service
Effects of renal disease can be extreme on patient
Treatments now available to slow progression
Need an “early warning” system for CKD

10. All global renal diseases affect glomerular filtration rate (GFR)‏
Diseases of the Kidney
Diabetes
Hypertension
Atherosclerosis
Glomerular diseases
Toxins
Gentamicin
NSAIDS
Compound analgesics
Inherited diseases
Tubular disorders
All global renal diseases affect glomerular filtration rate (GFR)‏

12. Glomerular Filtration Rate is the volume of fluid passing through the glomerulus in a given period of time.
Influenced by renal perfusion pressure, renal vascular resistance, glomerular damage, post-glomerular resistance.
“Normal Range” approx mL/min
Approx 170 L per day
A larger healthy person has a higher GFR
Can be reported as mL/min/1.73m2
Values fall with increasing age

13. Other reasons for estimating the GFR
Monitoring progression of CKD
GFR estimates are used for drug dosing decisions
Dosing of renally excreted drugs
Avoiding nephrotoxic drugs
Risk factor for cardiovascular disease mortality
Renal involvement in systemic diseases, such as diabetes mellitus or SLE

14. Estimate of GFR Measured GFR Serum creatinine Creatinine clearance
Formulae based on serum creatinine
Cockcroft and Gault
MDRD
Other
Eg Cystatin C
All based on measurements of serum creatinine

15. Equations for Estimating GFR
Abbreviated MDRD Study Equation
GFR (mL/min/1.73 m2) =  SCr  Age  (if female)  (if African American)
Cockcroft-Gault Equation
(140 – Age)  Weight in kg
Ccr = (mL/min)‏
 0.85 if female
72  SCr
MDRD = Modification of Diet in Renal Disease; Ccr = creatinine clearance.
Levey et al. Ann Intern Med. 2003;139:

17. Definition of CKD Kidney damage for 3 months
Defined by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR)‏
Reduced GFR for 3 months
New staging for chronic kidney disease (CKD) is primarily based on kidney function.
National Kidney Foundation (NKF). Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.

18. Prevalence of CKD

19. The Most Common Causes of CKD
Diabetes
50.1%
Hypertension
27%
Glomerulonephritis
13%
Other
10%
Primary Diagnosis for Patients Who Start on Dialysis

20. STAGES OF CKD COMPLICATIONS CKD DEATH INCREASED RISK NORMAL DAMAGE
LOW GFR
RENAL FAILURE
CKD
DEATH
COMPLICATIONS

21. Bagaimana dengan Anemia Renal ?

22. Anemia Rates Increase as Levels of CKD Severity Progress
100
Anemia Prevalence (%)‏ 62 15 10
Hgb Values 80
11-12 g/dL 43 8 15
10-11 g/dL 60
<10 g/dL 40 20 8 17 14 9 5 20
<2
2-2.9
3-3.9 ≥4
Creatinine (mg/dL)‏
Chronic Kidney Disease (CKD) Progression
Hgb = hemoglobin.
Kausz et al. Dis Manage Health Outcomes. 2002;10:

23. Normal
Gagal Ginjal

28. Chronic kidney disease (CKD)
Anemia is an expected complication of CKD
Treatment
Increased cardiovascular morbidity
recombinant human erythropoietin
(r-HuEPO)
Left Ventricular Hypertrophy
(LVH)
Congestive Heart Failure (CHF)

29. Diambil : Jerome Rossert dkk, Nephrol Dial Transplant (2002) 17: 359–362

31. INFLAMMATION plus CaP deposition
Why are CKD/ESRD Patients Predisposed to CV Disease?
CKD/ESRD
ANEMIA
LVH/CHF
LIPIDS
HTN
INFLAMMATION plus CaP deposition
CV DISEASE AND DEATH
CAD and PVD

32. Why are CKD/ESRD Patients Predisposed to CV Disease?
30-50% of ESRD patients have INFLAMMATION (increased CRP, increased IL-6, decreased albumin)‏
Increased CRP is a primary marker for inflammation predicting cardiovascular disease in normal adults
Increased CRP is the primary marker for increased cardiovascular mortality on dialysis
CKD/ESRD patients have metastatic calcification (coronary arteries) because of secondary hyperparathyroidism and elevated PO4 levels.

33. Bagaimana hubungan antara hipertensi dengan CKD ?

34. Distribution of hypertensives (65-89 years)
ISOLATED SYSTOLIC
ISOLATED SYSTOLIC
COMBINED
COMBINED
ISOLATED DIASTOLIC
ISOLATED DIASTOLIC
Framingham study

35. Factors Affecting Blood Pressure Total Peripheral Resistance=
Cardiac Output X
Amount of blood
ejected per minute
Blood flow through
blood vessels

38. Prevalence of HTN in CKD
80% of patients with glomerulonephritis and 30% of patients with chronic interstitial disease are hypertensive.

41. Klahr S et al, N Engl J Med 330:877, 1994
Aggressive BP Control, Proteinuria and CKD Progression – what is the optimal BP for CKD? * *
Klahr S et al, N Engl J Med 330:877, 1994
GOAL BP<125/75 if >1 gm proteinuria

42. A II Angiotensin II plays a central role in organ damage
Atherosclerosis*
Vasoconstriction
Vascular hypertrophy
Endothelial dysfunction
Stroke
Hypertension
A II
LV hypertrophy
Fibrosis
Remodeling
Apoptosis
Heart Failure MI
Death
GFR
Proteinuria
Aldosterone release
Glomerular sclerosis
Renal Failure
*Preclinical data.
LV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate.

43. Non-ACE pathways (eg, chymase)‏
Renin Angiotensin Aldosterone System
Non-ACE pathways (eg, chymase)‏
Vasoconstriction
Cell growth
Na/H2O retention
Sympathetic activation
Angiotensinogen
AT1
Renin
Angiotensin I
Angiotensin II
ACE
Aldosterone
AT2
Cough, angioedema
Benefits?
Vasodilation
Antiproliferation (kinins)‏
Inactive fragments
 Bradykinin

44. Decreased
vasodilatory
prostaglandins
Increased
angiotensin II
Low GFR

45. How About Renal Osteodystrophy

46. Bone Disease in CKD Metabolic abnormalities Hyperphosphatemia
Hypocalcemia
PTH elevation

47. Bone Disease in CKD Renal Osteodystrophy
Osteomalacia / osteitis fibrosis cystica / osteosclerosis
Metastatic calcification
Vascular!

48. Bone Disease in CKD
Renal Osteodystrophy

50. Matur nuwun