ckd management rsua printout -...

8/7/2018

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CKD in Indonesia and Its Management

Mohammad Yogiantoro

Data presented only for those countries from which relevant information was available; “.” signifies data not reported. All rates are unadjusted. Israel, Japan, and Taiwan are dialysis only. Percent change from 2004-2005 is not reported for countries whose reporting methods changed during this period.

USRDS Annual Report 2008 and 2009

CKD is Growing Globally at 8% Annually and Dialysis Patient Population Doubled Since 2000

CKD Growth Drivers

• Aging population

• No. 1 cause of CKD is diabetes (40%–50%)

• No. 2 cause of CKD is hypertension (20%–30%)

Stage 5 Country Data

Asia Pacific

- Global prevalence of CKD : 11-13% (majority stage III)- RRT : HD, CAPD, renal transplantation- Incidence rate ESRD per million in Indonesia (2002-

2006), increasing from 10.2 to 23.4- 117,162 new case ESRD in USA (2013), incidence rate :

363 per million/year

• Most Px CKD asymptomatic, until developed ESRD

• Early detection reduce incidence (morbidity, mortality, cost)

• Etiology CKD in Indonesia :– Glomerulonephritis (39.87%)

– Diabetic nephropathy (17.54%)

– Hypertension (15.72%)

– Obstructive & infective (13.44%)

– Unknown (10.93%)

– Polycystic kidney disease (2.51%)

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Distribution of dialysis centers and seven geographic areas studied

• CKD growing rapidly, progression to ESRD

• 13 nephrology centers (questionnaire)

• Previous data prevalence ESRD increased

• CAPD as alternative RRT

• High cost

• Covered by government health insurance

• Management approach should shifted from treatment to prevention

Results: Of 9412 subjects recruited, 64.1% were female. Persistent

proteinuria was found in almost 3%. Systolic and diastolic hypertension was

found in 10%, isolated systolic hypertension in 4.8% and isolated diastolic

hypertension in 4.6%. CKD was found in 12.5% (CG), 8.6% (MDRD) or

7.5% (Chinese MDRD) of subjects with either hypertension, proteinuria

and/or diabetes.

Proteinuria, systolic blood pressure and a history of diabetes mellitus

were independent predictors of impaired eGFR.

Obesity and smoking history were found in 32.5% and 19.8%,

respectively.

Conclusion: The present study showed a high prevalence of CKD in

representative urban and semi-urban areas and argues for screening

and treatment of all Indonesians, particularly those at an increased risk of

CKD

PAGE 12 | Present situation of Dialysis in Indonesia

RUMAH SAKIT

PAGE 12 |

Dialysis in Indonesia

Belum ada data menyeluruh

Indonesian Renal Registry (2015) PERNEFRI & DEPKES

Reporting rate : ~ 40%

Hemodialysis, Peritoneal, CRRD, Hybrid

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RUMAH SAKIT

PAGE 13 |

Dialysis in Indonesia (IRR 2015)

89%

7%

4%Cause

Chronic Kidney Disease

Acute Kidney Failure

Acute on ChronicPAGE 14 | Present situation of Dialysis in Indonesia

RUMAH SAKIT

PAGE 14 |


Hypertension, 44%

Diabetes, 22%

Unknown, 3%

Other, 9%

Chronic Pyelonephritis,

7%

Secondary Nephropathy, 7%

Primary GN, 8% Etiology


RUMAH SAKIT

PAGE 15 |


76%

13%

3% 3% 4% 1%0%

10%

20%

30%

40%

50%

60%

70%

80%

Vascular Access Type

Vascular Access Type

Av Shunt Femoral Other

D/T Jugular D/T Subclavia2 D/T Femoral2


RUMAH SAKIT

PAGE 16 |


< 3 mo27%

3 - 6 mo18%

6 - 12 mo33%

12 - 36 mo14%

> 36 mo8%

TIME FROM DIALYSIS TO DEATH (MONTHS) IN 2015

Cause of Death

Cardiovascular 44%

Cerebrovascular 8%

GI Bleeding 3%

Septicemia 16%

other 29%

Majority Death : < 12 months; COD : Cardiovascular, Sepsis


RUMAH SAKIT

PAGE 17 |

Jaminan Kesehatan Nasional (JKN)

1 Januari 2014 - now

Kepesertaan

1 Dec 2017: ~ 186 Juta (± 74%)

Pengeluaran Penyakit Kronis -> Tinggi 2016 : 21% Budget (~ USD 1.05 Billion)


RUMAH SAKIT

PAGE 18 |


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RUMAH SAKIT

PAGE 19 |



RUMAH SAKIT

PAGE 20 |

Pembiayaan Pasien HD (IRR 2015)

National Health Insurance

86%

Private/Company3%

Out of Pocket10%

Other1%

Dialysis Cost Source

National Health Insurance Private/Company Out of Pocket Other


RUMAH SAKIT

PAGE 21 |


2011 2012 2013 2014 2015

Active Patients 6951 9161 9396 11689 30554New Patients 15353 19621 15128 17193 21050

0

5000

10000

15000

20000

25000

30000

35000

Active vs New Patients

Active Patients New Patients

National Health

Insurance

Peningkatan Pasien Aktif HD Sejak BPJS Dimulai


RUMAH SAKIT

CKD : ~ 0,3%

Dialysis : ~78.000 (28 HD Unit)

Total 58 HD Unit

PAGE 22 |

Dialysis (Jawa Timur)

Populasi (2015) : 42 Juta Jiwa


RUMAH SAKIT

PAGE 23 |

Dialysis (Jawa Timur)

Peningkatan pasien Meningkat 25 – 30% Sejak JKN Akses Fakses Naik -> Deteksi lebih awal

Keterbatasan Unit Mesin HD : ~ 540 Units ( ~ 11% Nasional) SDM Khusus Mayoritas pada rumah sakit

Demand vs. Supply Discrepancy

• CKD growing rapidly, progression to ESRD

• 13 nephrology centers (questionnaire)

• Previous data prevalence ESRD increased

• CAPD as alternative RRT

• High cost

• Covered by government health insurance

• Management approach should shifted from treatment to prevention

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The image part with relationship ID rId16 was not found in the file.

The image part with relationship ID rId16 was not found in the file.Early treatment can make a

difference

100

10

0

No Treatment

Current Treatment

Early Treatment

4 7 9 11

Time (years)

Kidney Failure

GFR

(m

L/m

in/1

.732

)

130/80 mmHg


Treat the BP to Target Division of Nephrology and Hypertension - Departement of Internal MedicineSchool of Medicine Airlangga University - Dr. Soetomo Teaching Hospital

NEPHROLOGY AT A GLANCE

Filtration, Reabsorption and Secretion

Normal GFR 120 ml/min/1.73m2

Only 20% nephrons work at a time

In a day 210 L of water is filtered

2 L /day of urine is excreted


How the Proteinuria Induces Renal

Damage ?

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Urinary ExcretionProteinLipidsComplements

Glomerular Disease

DILTIAZEM

Microalb/Proteinuriais early marker of kidney damage

Systemicbloodpressure Urinary space

of Bowman’scapsule

Tubulus

Albumin excretion increased by :* Systemic or glomerular hypertension* Reduced negative charge repulsion

on basement membrane* Enlarge filtration pores

Fenestrated capillaryendotheliumBasement membraneEphitelial cellfoot process

Filtration of Albumin into urinary spaceDILTIAZEM

DILTIAZEM

Microalbuminuria: A Manifestation of Diffuse Endothelial Cell Injury


Microalbuminuria

Injured Endothelium


Interstitial Albumin Leak

RenalVasculature

SystemicVasculature

Cardiovascular Risk FactorsAge DiabetesHypertensionSmokingAbsent nocturnal BP dippingSalt sensitivityLeft ventricular hypertrophyDyslipidemiaCentral obesityInsulin resistanceElevated CRPSympathetic dysfunctionHyperuricemia


Retinopati

Progression of Renal Injury in Hypertension and CV Disease

Renal injury

HyperfiltrationProteinuria

Hypertension

Fibrosis

DILTIAZEM

RENOPROTECTION EFFECT

• Renoprotection consist of :

• BP lowering (125/75 mmHg)

– Decrease proteinuria ( negative )

– Decrease risk of fibrosis

Low protein diet + Keto.A

DILTIAZEM The image part with relationship ID rId4 was not found in the file.

Hillege et al.: Circulation 106:1777-1782, 2002

PREVEND Study(Prevention of Renal and Vascular End Stage Disease)

Cardiovascular Death

40,548 Individuals in the General Population

25-50 100 > 100

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Proteinuria Is Also a Risk Factorfor Progression of CKD

*P-values are for comparison across the subgroups.Jafar et al. Kidney Int. 2001;60:1131-1140.

Urine Protein (g/d)

% W

ith

Do

ub

ling

o

f S

Cr

or

ES

RD P<.001*

0

10

20

30

40

50

<0.5 0.5-3.0 3.0-6.0 >6.0

DILTIAZEM


• Modifiable risks– Blood sugar control (?)– Lipid profile (OR 2.32)– Hypertension (OR 3.2)– Obesity (?OR 4 - 7)– Smoking (OR 6.52)– Microalbuminuria (OR 10.02)

Strength of MAU as a Cardiovascular Risk

Risk Ratio +/- Risk Factor for CVD

0

0.5

1

1.5

2

2.5

3

DILTIAZEM DILTIAZEM

Why detect CKD early?

When Your Kidneys Failed….

Dialisis

Transplant

Diabetes Hypertension

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Data presented only for those countries from which relevant information was available; “.” signifies data not reported. All rates are unadjusted. Israel, Japan, and Taiwan are dialysis only. Percent change from 2004-2005 is not reported for countries whose reporting methods changed during this period.

USRDS Annual Report 2008 and 2009

CKD is Growing Globally at 8% Annually and Dialysis Patient Population Doubled Since 2000

CKD Growth Drivers

• Aging population

• No. 1 cause of CKD is diabetes (40%–50%)

• No. 2 cause of CKD is hypertension (20%–30%)

Stage 5 Country Data

Asia Pacific

Cardiovascular Risk Factors are the Top 6 Leading Causes of Death

Hypertension

• How can I tell if I have High Blood Pressure?– Usually NO SYMPTOMS!

– “The Silent Killer”

– May have: • Headache

• Blurry vision

• Chest Pain

• Frequent urination at night


Lifestyles, Fitnessand Rehabilitation


Hipertenzija - samo dio višestrukogrizičnog sindroma sa teškim

posljedicama

Treat the BP to Target


Intrauterineprogramming

Mosaic 2007

Environmental

Renal

Anatomical

Adaptive

NeuralEndocrine

Humoral

Haemodynamics

Genetic

BP



WHAT IS THE BLOOD PRESSURE TARGET

FROM TIME TO TIME?

48

IN CKD

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Parving et al., Br Med J, 1989Viberti et al., JAMA, 1993Hebert et al., Kidney Int, 1994Lebovitz et al., Kidney Int, 1994Bakris et al., Kidney Int, 1996Bakris et al., Hypertension, 1997

Klahr et al., N Engl J Med, 1993Maschio et al., N Engl J Med, 1996GISEN Group, Lancet, 1997

Bakris et al., Am J Kidney Dis, 2000

Diabetes Non-diabetes

0

-2

-4

-6

-8

-10

-12

-14

GF

R (

ml/m

in/y

ea

r)

95 98 113110107104101 119116

130/80 140/90 Untreated HTN

r = 0.69; p < 0.05

MAP (mmHg)

What is the Optimal Blood Pressure in CKD?

MAP = [(2 x diastolic)+systolic] / 3

Mrs. Smith 160/95

Adequate BP management delays the progression of CKD

Bakris et al., Am J Kid Disease, 2000

If Rita’s blood pressure was consistently below target, the GFR loss per year would be

reduced by 80%



5.3

Blood Pressure and ESRD in Men16 Years Follow-Up Study of Subjects (MRFIT)

0

50

150

100

200/100,000/year

6.6 11.1 21.043.6

96.1

187.1

Klag MJ et al. N Engl J Med 1996;334, 13-18

SBP <120 <129 <139 <159 <179 <209 >210 mmHgDBP <80 <84 <90 <100 <110 <120 >120 mmHg

1. High blood pressure are a strong

independent risk factor for ESRD.

2. Interventions to prevent the disease need to

emphasize the prevention and control of

both high-normal and high blood pressure.


130/80

140/90

130/80The image part with relationship ID rId4 was not found in the file.


130/80





2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood

Pressure in Adults

© American College of Cardiology Foundation and American Heart Association, Inc.



Management of Hypertension in Patients With CKD

•Colors correspond to Class of Recommendation in Table 1.

•*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g creatinine.

•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP blood pressure; and CKD, chronic kidney disease.

.

130/80 130/80

8/7/2018

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BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions

Clinical Condition(s)BP

Threshold, mm Hg

BP Goal, mm Hg

GeneralClinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80Older persons (≥65 years of age; noninstitutionalized, ambulatory, community-living adults)

≥130 (SBP) <130 (SBP)

Specific comorbiditiesDiabetes mellitus ≥130/80 <130/80Chronic kidney disease ≥130/80 <130/80Chronic kidney disease after renal transplantation ≥130/80 <130/80Heart failure ≥130/80 <130/80Stable ischemic heart disease ≥130/80 <130/80Secondary stroke prevention ≥140/90 <130/80Secondary stroke prevention (lacunar) ≥130/80 <130/80Peripheral arterial disease ≥130/80 <130/80

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular

disease; and SBP, systolic blood pressure.


Interventions to Slow CKD Progression


130/80

Pgc SNGFR

NephronLoss

TGF-Cytokines

CAMs

MacrophagesFibroblasts

2° FSGSand TIF

Ang IIMechanical Stress

1°Renal Disease

Proteinuria

Systemic Hypertension


Inhibit RAS

Proteinuria

NewAnti-inflammatory

Anti-fibroticStop

Smoking

TreatDyslipidaemia

Treat Hypertension

Weight loss Dietary Protein


130/80

CKDdeathCKDdeath

Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies

ComplicationsComplications

Screeningfor CKD

risk factors

CKD riskreduction;

Screening forCKD

Diagnosis& treatment;Rx. comorbidconditions;

↓ progression

Microalb

Estimateprogression;

Rx. complications;Prepare for

replacement

Replacementby dialysis

& transplant

NormalNormalIncreased

riskIncreased

riskKidneyfailureKidneyfailure

DamageDamage GFR GFR

R/ Protein Diet + Ketoanalogue


Progressive Kidney Damage: Risk Factors and Pathophysiology

1. Huether SE, Pathophysiology,4th Edition, 2002, Chapter 35, 1191-12162. Pisoni R, Primer on Kidney Disease,3rd edition, 2001, Chapter 58, 385-396

Kidney Injury2

Reduction in nephron mass

Glomerular capillary hypertension

Glomerular permeabilityto macromolecules

Filtration of plasma

Proteins

Excessive tubular protein reabsorption

Tubulointerstitial inflammation

Kidney Scarring

Proteinuria

Systemicblood pressure

Risk Factors1

Proteinuria > 1.5 g/24 hr

Protein to Creatinine ratio > 1 g/g

Hypertension

Type of underlying kidney disease

African American race

Male gender

Obesity

Diabetes mellitus (DM) or family history of DM

Hyperlipidemia

Smoking

High protein diet

Hyperphosphatemia

Metabolic acidosis


HypertensionHypertension

GFR lossGFR loss

Glomerular injury

Glomerular injury

Tubular injury

Tubular injury

ProteinuriaProteinuria

5

1

2

3 6 4

7

8

9

INTERACTION OF HYPERTENSION, PROTEINURIA and GFR LOSS


Hebert, et al. KI 2001:59;121-1226Treat the BP to Target

8/7/2018

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difference

100

10

0

No Treatment

Current Treatment

Early Treatment

4 7 9 11

Time (years)

Kidney Failure

GFR

(m

L/m

in/1

.732

)

130/80 mmHg



DILTIAZEM

Differential Effects of CCB TherapyType 2 Diabetics With Nephropathy

Differential Effects of CCB TherapyType 2 Diabetics With Nephropathy

Nifedipine (n = 10)

Diltiazem (n = 11)

*p<0.05

SBP10

-50

-40

-30

-20

-10

0

DBP D 24 h proteinuira100

-500

-400

-300

-200

-100

0

BP

red

uctio

n vs

bas

elin

e (m

mH

g)

Pro

tein

uria

red

uctio

n vs

bas

elin

e (m

g/d

ay)

**

* *

*

Smith et al. Kidney Int. 1998;54:889-896.

Diltiazem & ACE-I CombinationType 2 Diabetics –MicroalbuminuriaDiltiazem & ACE-I CombinationType 2 Diabetics –Microalbuminuria

Pèrez-Maraver M, et al. (EASD) Meeting 2001; Abstract: 1056.

0

50

100

150

200

250

300

Captopril (n=17) Captopril + Diltiazem (n=11)

UA

E (

mg

/24

hrs)

Initial

2 Year Follow-Up

p < 0.05



difference

100

10

0

No Treatment

Current Treatment

Early Treatment

4 7 9 11

Time (years)

Kidney Failure

GFR

(m

L/m

in/1

.732

)

130/80 mmHg



DILTIAZEM

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THE ATHEROSCLEROTIC SYNDROME

M

o h

a

m

ma

d

Y

o

g

ia

n

t o

r

o Clinical manifestations of insulin resistance

Type 2 diabetes and glycemic disorders

Dyslipidemia– Low HDL– Small, dense LDL– Hypertriglyceridemia

Hypertension

Endothelial dysfunction/inflammation (hsCRP)

Impaired thrombolysis PAI-1

VisceralObesity

Insulinresistance

Glucotoxicity

Lipotoxicity

Adiponectin

Ath

erosclero

sis

Courtesy of Selwyn AP, Weissman PN.

R/ Metformin


Time (yrs) 0 5 20 30

DM Atherosclerotic Hypertension

2nd Prevention3rd Prevention

Micro Angiopathy Macro AngiopathyMicro Alb. Prot. Uria BP increase

Creatinin increaseCVD CKD HD

Risk Factors1st Prevention

Natural History of Type 2 Diabetes


I FEEL FINEQS 4:29 “Janganlah kamu membunuh dirimu,

sesungguhnya Allah Maha Penyayang terhadapmu”

Adipose Tissue is the Largest Endocrine Organ

AJP-Heart Circ Physiol, 2005.-

visfatin

It Promotes Endothel Disfunction (CVD)Cardiovascular Risk

FactorsAge DiabetesHypertensionSmokingAbsent nocturnal BP

dippingSalt sensitivityLeft ventricular

hypertrophyDyslipidemiaCentral obesityInsulin resistanceElevated CRPSympathetic

dysfunctionHyperuricemia

TREAT the BP TO TARGET

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Atherosclerosis

Ischemicstroke/TIA

MI

Diabetic nephropathy

Unstable angina

ACS

Thrombosis

130/80

I FEEL FINE

TREAT the BP TO TARGET1st & 2nd Prevention

3rd Prevention

ICU

130/80


1st & 2nd Prevention 3rd Prevention

I FEEL FINE HD

130/80


How to halt the progressivity of the atherosclerosis syndrome?

1st & 2nd Prevention

1st & 2nd Prevention 3rd Prevention

I Feel Fine

130/80TREAT the BP TO TARGET

Atherosclerosis

Ischemicstroke/TIA

MI

Diabetic nephropathy

Cardiovascular death

Unstable angina

ACS

Thrombosis

130/80

I FEEL FINE Let this not happen please!

Normal ESRD

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Kidney damage Benign Nephrosclerosis:

Leathery Granularity due to minute scarring

Polycystic Kidneys

KERUSAKAN GINJAL

PEMBENGKAKAN( HIDRONEFROSIS )

PENGKERUTAN( FIBROSIS )

Batu / Obstruksi Contracted Kidneys

Contracted smooth kidney

Scarred kidney –cut section

End Stage Renal Disease

Chronic Contracted Kidney

PCKD with ESRD

WHAT IS RENOPRECTION?

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CKDdeathCKDdeath


Screeningfor CKD

risk factors

CKD riskreduction;

Screening forCKD


↓ progression



replacement


& transplant

NormalNormalKidneyfailureKidneyfailureDamageDamage GFR GFR

Vascular Lesion & Remodelling

CitokynInflammation

Permiability↑Microalb & Macroalb

TrombosisVasoconstrictionHTN

CVD

Normoalbuminuria MacroalbuminuriaMicroalbuminuria

ATHEROSCLEROSIS

Increasedrisk

Increasedrisk

CVDCVDCVD


Microalbuminuria: A Manifestation of Diffuse Endothelial Cell Injury

Microalbuminuria

Injured Endothelium

Interstitial Albumin Leak

RenalVasculature

SystemicVasculature


Retinopati

Progression of Renal Injury in Hypertension and CV Disease

Renal injury

HyperfiltrationProteinuria

Hypertension

Fibrosis


RENOPROTECTION EFFECT

• Renoprotection consist of :

• BP lowering (125/75 mmHg)

– Decrease proteinuria ( negative )

– Decrease risk of fibrosis

Low protein diet + Keto.A


HypertensionHypertension

GFR lossGFR loss

Glomerular injury

Glomerular injury

Tubular injury

Tubular injury

ProteinuriaProteinuria

5

1

2

3 6 4

7

8

9



Hebert, et al. KI 2001:59;121-1226Treat the BP to Target

Pgc SNGFR

NephronLoss

TGF-Cytokines

CAMs

MacrophagesFibroblasts

2° FSGSand TIF

Ang IIMechanical Stress

1°Renal Disease

Proteinuria

Systemic Hypertension


Inhibit RAS

Proteinuria

NewAnti-inflammatory

Anti-fibroticStop

Smoking

TreatDyslipidaemia

Treat Hypertension

Weight loss Dietary Protein


8/7/2018

16

160/95

Adequate BP management delays the progression of CKD

Bakris et al., Am J Kid Disease, 2000

If Rita’s blood pressure was consistently below target, the GFR loss per year would be

reduced by 80%



Hypertension Syndrome

Atherosclerosis Syndrome

OutcomeOutcome

Pathophysiology of progression

Area of Trial End Point

Risk Reduction

Risk Factors


HULU HILIR


CKDdeathCKDdeath



Screeningfor CKD

risk factors

CKD riskreduction;

Screening forCKD


↓ progression

Microalb



replacement


& transplant

NormalNormalIncreased

riskIncreased

riskKidneyfailureKidneyfailure

DamageDamage GFR GFR

R/ Protein Diet + Ketoanalogue


HULU

HILIR

Time (yrs) 0 5 20 30

DM Atherosclerotic Hypertension

2nd Prevention 3rd Prevention

Micro Angiopathy Macro AngiopathyMicro Alb. Prot. Uria BP increase

Creatinin increaseCVD CKD HD

Risk Factors1st Prevention

Natural History of Type 2 Diabetes

HULU HILIRTreat the BP to Target

Search for target organ damageCerebrovascular disease

- transient ischemic attacks- ischemic or hemorrhagic stroke- vascular dementia

Hypertensive retinopathyLeft ventricular dysfunctionLeft ventricular hypertrophyCoronary artery disease

- myocardial infarction- angina pectoris- congestive heart failure

Chronic kidney disease- hypertensive nephropathy (GFR < 60

ml/min/1.73 m2)- albuminuria

Peripheral artery disease- intermittent claudication- ankle brachial index < 0.9

III. Assessment of the overall cardiovascular risk

BP 130/80 mmHg


HULU

HILIR

1. Tekanan Darah >60 thn 150/90 mmHg2. Tekanan Darah <60 thn

• Tidak ada komplikasi 140/90 mmHg• DM positif 130/80 mmHg• CKD positif 130/80 mmHg• Mikroalbuminuria positif 130/80 mmHg

3. DM A1C 6,5 – 7,04. LDL Kolesterol <705. Asam Urat <7,06. Mikroalbuminuria Negatif7. EGFR (kreatinin 0,9‐1,2) >60%8. Lingkar Perut wanita < 80 cm, Laki‐laki <90 cm9. Hb antara 10‐11 gr%

TARGET HIDUP SEHAT

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CONCLUSION

Protection, Prevention, and Regression the Progressivity of

Atherosclerotic Syndrome Dominited by :

130/80

140/90HILIR

AKIBAThulu

Treat the Risk FactorsTreat the BP to Target

CONCLUSION



HULU Treat the Organ DamageTreat the BP to Target

CONCLUSION



HILIR

What’s new in CKD?

What Old New

Blood Pressure Targets

People with >1g proteinuria/ day –BP target 125/75 mmHg

People with CKD (or other conditions) – BP target 130/80 mmHg

All other conditions – BP target 140/90 mmHg

People with CKD - should maintain a BP consistently below 140/90 mmHg

People with diabetes or microalbuminuria should maintain a BP consistently below 130/80 mmHg

Blood Pressure Targets

Stages of Chronic Kidney Disease(K/DOQI Guidelines 2002)

Stages of Chronic Kidney Disease(K/DOQI Guidelines 2002)

Chronic 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 tests or imaging studies

Chronic 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 tests or imaging studies

< 15 or dialysis< 15 or dialysisKidney failureKidney failure55

15 – 2915 – 29Severe GFRSevere GFR44

30 – 5930 – 59Moderate GFRModerate GFR33

60 – 8960 – 89Kidney damage with mild GFRKidney damage with mild GFR22

> 90> 90Kidney damage with normal or GFRKidney damage with normal or GFR

11

GFR(mL/min/1.73 m2)

GFR(mL/min/1.73 m2)DescriptionDescriptionStageStage

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Staging of Chronic Kidney Disease

What’s new in CKD?

Old New Rationale

CKD staging system

Determined by eGFR

Determined by kidney function (eGFR) and the level of albuminuria in all stages of CKD

Recommended by all Australian and international guidelines and is a better indicator of overall risk

Stage 3 CKD

Stage 3 CKD(eGFR 30-59 mL/min/1.73m2

)

Divided intoStage 3a (eGFR 45-59 mL/min/1.73m2)Stage 3b (eGFR 30-44 mL/min/1.73m2)

More accurately reflects risk stratification

staging schema

Albuminuria Stage

GFR Stage

GFR (mL/min/1.73m2)

Normal

(urine ACR mg/mmol)

Male: < 2.5

Female: < 3.5

Microalbuminuria

(urine ACR mg/mmol)

Male: 2.5-25

Female: 3.5-35

Macroalbuminuria

(urine ACR mg/mmol)

Male: > 25

Female: > 35

1 ≥90 Not CKD unless haematuria, structural

or pathological abnormalities present2 60-89

3a 45-59

3b 30-44

4 15-29

5 <15 or on dialysis

Using the new CKD staging schema

‘CKD Management in General Practice’ booklet has colour‐coded action plans for overall risk of

• Progression of CKD

• Cardiovascular events

Normal

Low

Moderate

High

MORE SEVERE

Stage 1 Stage 2 Stage 4 Stage 5Stage 3

GFRmL/min/1.73m2

Description

“PreCKD”

≥90 with risk factors

≥90 60-89 30-59 16-29 <15

At increased risk for Kidney damage

Kidney damage with normal or increased GFR

Mild ↓ Moderate ↓ Severe ↓ Kidney Failiure

Screening

CKD risk reduction

Diagnosis and treatment

Slow progression

Treat Comorbidities

CV risk reduction

Estimate Progression

Evaluate and treat complications

Prepare for RRT

Replacement therapy for indicationsAction

Plan*

CKD Staging system and Action plan

* Includes actions from preceding stages KDOQI

Stage 1 Stage 2 Stage 4 Stage 5Stage 3

GFRmL/min/1.73m2

Description

“PreCKD”

≥90 with risk factors

≥90 60-89 30-59 16-29 <15

At increased risk for Kidney damage

Kidney damage with normal or increased GFR

Mild ↓ Moderate ↓ Severe ↓ Kidney Failiure

Screening

CKD risk reduction

Diagnosis and treatment

Slow progression

Treat Comorbidities

CV risk reduction

Estimate Progression

Evaluate and treat complications

Prepare for RRT

Replacement therapy for indicationsAction

Plan*

CKD Staging system and Action plan

* Includes actions from preceding stages KDOQI

STAGES OF CHRONIC KIDNEY DISEASE : CLINICAL PRESENTATIONS

STAGE DESCRIPTION GFR RANGE Clinical Presentations *(mL/min/1,73m2)

At increased risk ≥ 60 CKD Risk Factors(without markers of damage)

1 Kidney damage ≥ 90 Markers of damage with normal or ↑ GFR (Nephrotic syndrome,

Nephritic syndromeTubular syndromes

Urinary tract sympatomsAsympmtomatic urinalysis abnormalities

Asymtomatic radiologic abnormalitiesHypertension due to kidney disease

2 Kidney damage 60 – 89 Mild complications with mild ↓ GFR

3 Moderate ↓ GFR 30 – 59 Moderate complications

4 Severe ↓ GFR 15 – 29 Severe complications

5 Kidney Failure < 15 Uremia(or dialysis) Cardiovascular disease

* Includes presentations from preceding stage. Chronic kidney disease is dfined 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 adnormalities in blood or urine or tests or imaging studies

8/7/2018

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Risk factors for the development, progression, and complications of CKD

Risk factor Definition Examples

Development Increases susceptibility to kidney damage

Older age, family history of CKD, US racial or ethnic minority status, low income, reduced kidney mass, hyperfiltration states

Directly initiates kidney damage

Diabetes, high blood pressure, obesity, dyslipidaemia, autoimmune diseases, infections, stones, obstruction, neoplasia, recovery from acute injury



Progression Worsens kidney damage or accelerates GFR decline

Higher level of proteinuria

Increases the risk of complications of decreased GFR

Factors related to hypertension, anaemia, malnutrition, bone and mineral disorders, neuropathy, drugs and procedure with kidney or systemic toxicity



Complications Accelerate the onset or recurrence of CVD

Traditional CVD risk factors, non-traditional ‘CKD-related’ risk factors

Increase morbidity and mortality in kidney failure

Late referral, dialysis factors, comorbid conditions

Stage 1-2 Stage 3 Stage 4 Stage 5

GFR >60 30-59 15-29 <15

BP<130/80 mm Hg, ACEI/ARB

Glycemic control

CVD risk reduction: Dyslipidemia management, Tobacco cessation

Avoid NSAIDS/Contrast

Anemia

Nutrition

Renal bone disease

Vascular access & Transplantation

CKD Intervention: Clinical Action Plan

ACEI = Angiotensin Converting Enzyme Inhibitor ARB = Angiotensin Receptor Blocker

The Adherence Continuum

Non-compliant pill irregularly pill regularly pill + behavior change

ckd management rsua printout -...

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