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    Diagnosis Aki Dan CKD

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    Ely Kartika
    This document discusses definitions, classifications, diagnosis and management of acute kidney injury (AKI), chronic kidney disease (CKD) including CKD stage 5, and acute on chronic kidney disease (Acut on CKD). It defines AKI based on increases in serum creatinine and decreases in urine output. It describes the RIFLE and AKIN criteria for diagnosing AKI. It also stages CKD based on glomerular filtration rate and albuminuria levels. The document outlines diagnostic steps, etiologies, complications and treatments for AKI, CKD and Acut on CKD, including indications for renal replacement therapy like dialysis.

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    © All Rights Reserved
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    Diagnosis Aki Dan CKD

    Uploaded by

    Ely Kartika
    63 views39 pages
    This document discusses definitions, classifications, diagnosis and management of acute kidney injury (AKI), chronic kidney disease (CKD) including CKD stage 5, and acute on chronic kidney disease (Acut on CKD). It defines AKI based on increases in serum creatinine and decreases in urine output. It describes the RIFLE and AKIN criteria for diagnosing AKI. It also stages CKD based on glomerular filtration rate and albuminuria levels. The document outlines diagnostic steps, etiologies, complications and treatments for AKI, CKD and Acut on CKD, including indications for renal replacement therapy like dialysis.

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    This document discusses definitions, classifications, diagnosis and management of acute kidney injury (AKI), chronic kidney disease (CKD) including CKD stage 5, and acute on chronic kidney disease (Acut on CKD). It defines AKI based on increases in serum creatinine and decreases in urine output. It describes the RIFLE and AKIN criteria for diagnosing AKI. It also stages CKD based on glomerular filtration rate and albuminuria levels. The document outlines diagnostic steps, etiologies, complications and treatments for AKI, CKD and Acut on CKD, including indications for renal replacement therapy like dialysis.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    63 views39 pages

    Diagnosis Aki Dan CKD

    Uploaded by

    Ely Kartika
    This document discusses definitions, classifications, diagnosis and management of acute kidney injury (AKI), chronic kidney disease (CKD) including CKD stage 5, and acute on chronic kidney disease (Acut on CKD). It defines AKI based on increases in serum creatinine and decreases in urine output. It describes the RIFLE and AKIN criteria for diagnosing AKI. It also stages CKD based on glomerular filtration rate and albuminuria levels. The document outlines diagnostic steps, etiologies, complications and treatments for AKI, CKD and Acut on CKD, including indications for renal replacement therapy like dialysis.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 39

    Pendekatan Diagnosis dan

    Tatalaksana Acut Kidney Injury,


    Acut on CKD dan CKD Stage 5

    Acut Kidney Injury


    (Gangguan Ginjal Akut)

    CHAPTER 2.1: DEFINITION AND


    CLASSIFICATION OF AKI

    2.1.1: Acute kidney injury (AKI) is defined as


    any of the following (Not Graded):
    Increase in SCr by 0.3 mg/dl within 48
    hours; or
    Increase in SCr to 1.5 times baseline,
    which is known or presumed to have
    occurred within prior 7 days; or
    Urine volume <0.5 ml/kg/h for 6 hours.

    Definitions of AKI, CKD and AKD

    (KDIGO,

    RIFLe and AKIN criteria for diagnosis of AKI


    RIFLE criteria (within 7 days)
    Class
    R-Risk

    GFR criteria
    Creatinine increase 1.5 or GFR loss >
    25%
    I-Injury Creatinine increase 2 or GFR loss >
    50%
    FCreatinine increase 3 or GFR loss >
    Failure 75% or creatinine increase >4 mg/dL
    hours
    (acute increase >0.5 mg/dL)
    L-Loss Persistent loss of kidney function >4
    weeks
    E-ESKD ESKD > 3 months

    Urine output criteria


    0.5 < mL/kg/hour >6
    hours
    0.5 <mL/kg/hour >12
    hours
    0.3 < mL/kg/hour
    >24 hours or anuria
    >12 hours

    AKIN criteria (within 48 hours)


    Stage
    1

    Serum creatinine criteria


    Creatinine increase 1.5 or creatinine
    increase >0.3 mg/dL
    Creatinine increase 2

    Urine output criteria


    0.5 < mL/kg/hour >6
    hours
    2
    0.5 < mL/kg/hour
    >12 hours
    et al., Update
    diagnosis and 0.3
    management
    ofacute
    3(Ali Akcay
    Creatinine
    increaseon
    3the
    or creatinine
    < mL/kg/hour
    >4 mg/dL (acute
    increase
    >0.5 >24 hours
    or anuria
    kidney increase
    injury. International
    Journal
    of Nephrology
    and Renovascular
    mg/dL)
    >12 hours
    Disease
    2010:3 129140)

    Classified
    Non oliguric : urine output > 400 ml / day
    Oliguric : urine output < 400 ml / day
    Anuric : urine output < 100 ml / day

    Caused
    PreRenal (40-80%)
    Intrarenal / Intrinsic AKI (10-30%)
    PostRenal (5-15%)

    DIGNOSTIC STEP OF AKI


    Patient with :
    Oligouria /
    Anuria

    Prerenal
    Renal
    Post renal

    History of Disease

    Physical Examination

    Imaging Laboratory test


    BNO
    Routine
    USG Abdomen
    BUN/SC
    Electrolyte (K,Na

    Shock
    ballotment
    pain angulus
    costovertebtalis
    full of VU
    BPH

    Initial diagnostic tools in AKI

    History and Physical exam


    Detailed review of the chart, drugs administered,
    procedures done, hemodynamics during the
    procedures.
    Urinalysis
    Renal imaging
    USG
    Markers of CKD
    iPTH, size<9cm, anemia, high phosphate, low
    bicarb
    Renal biopsy

    Pendidikan Kedokteran Berkelanjutan 2012

    Tatalaksana AKI

    1
    2
    3

    Mengenal kondisi klinik yang


    dihadapi

    Pengelolaan berdasarkan
    tahapan AKI
    Memilih jenis pengobatan yang
    tepat
    Terapi konservatif (suportif)
    Terapi pengganti ginjal

    gelolaan AKI berdasarkan tahapann


    TAHAP A :
    Mencegah AKI berlanjut
    Memperhatikan etiologi dan penyakit penyerta :
    bila AKI akibat pre-renal/dehidrasi, pada tahap
    initial dilakukan rehidrasi
    bila AKI akibat sepsis, trauma,obat-obatan, dll,
    harus ditangani penyebab/penyakit penyerta
    bila ada bendungan post-renal harus dilakukan
    koreksi secepatnya

    TAHAP B :
    Mencegah penurunan fungsi ginjal berlanjut
    Usaha agar penurunan fungsi ginjal tidak
    berlanjut adalah dengan cara memperbaiki
    produksi urin.
    Pengelolaannya berbeda pada tiap tahap.
    Rehidrasi, bila kausanya pre-renal
    Terapi Pengganti Ginjal (TPG) bila ada indikasi

    TAHAP C :
    Mempertahankan homeostasis tubuh
    Koreksi thd gangguan keseimbangan elektrolit
    dan asam basa

    INDIKASI INISIASI TPG PADA AKI


    KELAINAN METABOLIK

    ASIDOSIS

    BUN > 76 mg/dl


    BUN > 76 mg/dl
    BUN > 100 mg/dl
    Hiperkalemia > 6mEq/L
    Hiperkalemia > 6mEq/l
    (dengan kelainan EKG)
    Disnatremia
    Hipermagnesemia > 8
    mEq/L
    Hipermagnesemia > 8
    mEq/l
    (dgn anuria atau hilang
    reflek
    tendon)
    pH > 7.15
    pH < 7.15

    ANURIA/OLIGOURIA
    RIFLE - R
    RIFLE - I
    RIFLE - F
    KELEBIHAN CAIRAN
    (volume overload)

    Sensitif diuretik
    Resistan diuretik

    Relatif
    Relatif
    Absolut
    Relatif
    Absolut
    Relatif
    Relatif
    Absolut

    Relatif
    Absolut
    Relatif
    Relatif
    Absolut
    Relatif
    Absolut

    Chronic Kidney Disease


    (Penyakit Ginjal Kronik)

    DEFINISI dan STAGING CKD


    DEFINISI CKD
    Abnormalitas struktur dan fungsi ginjal, yg berlangsung selama
    > 3 bulan, dg implikasi (mempengaruhi) terhadap kesehatan

    STAGING OF CKD

    CKD dikelompokkan berdasarkan atas causa, kategori GFR,


    kategori albuminuria

    Menentukan kategori GFR sebagai berikut :

    Menentukan kategori albuminuria

    Etiologi CKD

    DIGNOSTIC STEP OF CKD


    Patient with :
    Kelainan dispepsia

    History of Disease

    Physical Examination

    Imagin
    Laboratory test
    USG Abdomen
    Routine
    BUN/SC
    Electrolyte (K,Na

    hipertensi
    Anemia

    Penyakit Ginjal Kronik


    Penyakit Ginjal kronik bersifat progresif dan irreversibel.
    Progresi CKD (eGFR <60 ml/min) dipengaruhi oleh :
    1. Faktor risiko yang tidak bisa diubah :

    - Usia
    - Gender
    - Ras
    - Genetik
    - Berkurangnya massa ginjal

    2. Faktor risiko yang bisa diubah :


    - Hipertensi
    - Proteinuria

    Refferal to nefrologist
    Plasma creatinine >1.2 in women and 1.5 mg
    in men, or eGFR <60 mL/min per 1.73 m2.
    Lower costs and/or decreased morbidity and
    mortality may be associated with early
    referral and care by subspecialists

    PATHOGENESIS

    KOMPLIKASI
    CKD

    Tatalaksana Penyakit Ginjal


    Kronik

    Tatalaksana PGK sesuai


    derajatnya
    DERAJAT

    LFG

    RENCANA TATALAKSANA

    90

    60-89

    MENGHAMBAT PERBURUKAN
    FUNGSI GINJAL

    30-59

    EVALUASI DAN TERAPI


    KOMPLIKASI

    15-29

    PERSIAPAN TERAPI
    PENGGANTI GINJAL

    <15

    TERAPI PENYAKIT DASAR,


    EVALUASI PERBURUKAN
    FUNGSI GINJAL,
    MEMPERKECIL RISIKO
    KARDIOVASKULAR

    TERAPI PENGGANTI GINJAL

    Tatalaksana Penyakit Ginjal


    Kronik

    Penatalaksanaan medik pasien CKD fokus


    pada
    1. Menunda/memutus progresi CKD
    2. Mengobati manifestasi patologik CKD
    3. Perencanaan long-term renal
    replacement therapy

    1.

    Menunda atau Memutus Progresi CKD

    Terapi penyakit yg mendasari jika


    mungkin
    Kontrol TD secara agresif sesuai target
    guideline ( 130/80)
    Terapi hiperlipidemia sesuai target
    guideline
    Kontrol GD secara agresif rekomendasi
    ADA target A1c [HbA1C] < 7%
    Hindari nephrotoxin radiocontrast media,
    NSAIDs, aminoglikosida
    RAS blocker untuk diabetic kidney
    disease & proteinuria

    2. Mengobati Manifestasi Patologik CKD

    Anemia: Hb < 10 g/dL Tx/


    erythropoiesis-stimulating agents (ESAs)
    epoetin alfa / darbepoetin alfa
    Hiperfosfatemia: Tx/ phosphate binders
    dan restriksi P diet
    Hipocalsemia: Tx/ suplemen calcium dg /
    tanpa calcitriol
    Hiperparatiroidisme : Tx/calcitriol,
    vitamin D analogues, calcimimetics
    Volume overload: Tx/ loop diuretics /
    ultrafiltration
    Asidosis metabolik : Tx/ suplemen alkali
    oral

    KDIGO :
    - intake protein 0.8 g/kg/day pada dewasa
    dg atau tanpa DM dan GFR < 30 ml/min/
    1.73 m2 (GFR categories G4-G5)

    Terapi Anemia
    Target Hb 10-12 g/dL Hb normal pada CKD
    stages 4-5 peningkatan risiko terjadi
    kondisi yg sebaliknya
    Sebelum mulai Tx/ ESA periksa cadangan
    besi target : iron saturation 30-50%,
    ferritin 200-500 ng/mL

    Penyakit Ginjal Kronik Stage 5


    ( CKD Stage 5 )

    Stage lanjut dari CKD


    Gejala klinis jelas
    GFR < 15 ml/men/1,73 m2
    Ginjal sudah sangat mengecil
    Memerlukan terapi pengganti ginjal

    Terapi Pengganti Ginjal


    (Renal Replacement Therapy)

    Guideline Canadian Society of Nephrology,


    February 2014 :
    Menunda dialisis pasien CKD tanpa gejala
    sampai eGFR 6 mL/min/1.73 m2 atau sampai
    timbul indikasi klinik (gejala2 uremia,
    overload cairan, hiperkalemia refrakter
    atau asidemia)

    Indications to initiate dialysis in


    patients with CKD
    1.Pericarditis

    or pleuritis (urgent indication)


    2.Progressive uremic encephalopathy or neuropathy
    3.A clinically significant bleeding diathesis attributable to uremia
    (urgent indication)
    4.Fluid overload refractory to diuretics
    5.Hypertension poorly responsive to antihypertensive medications
    6.Persistent metabolic disturbances that are refractory to medical
    therapy. These include hyperkalemia, metabolic acidosis,
    hypercalcemia, hypocalcemia, and hyperphosphatemia.
    7.Persistent nausea and vomiting
    8.Weight loss or signs of malnutrition

    Acut on CKD
    Kenaikan kreatinin serum 50% nilai dasar
    atau kenaikan serum kreatinin > 0.3 mg/dl yang
    terjadi secara mendadak pada pasien yang
    diketahui CKD.
    Memerlukan penilaian dan tatalaksana yang
    cepat untuk mencegah progresifitas yang
    irreversibel.
    Insiden 10 30 %
    USA : 30 %
    Australia : 33 %
    Cina : 35,5 %

    Acut on CKD
    Pre renal : hipovolumi
    Renal : Sitostatik, zat kontras
    Post Renal : Keganasan (ca cervix), BPH,
    batu.
    Tatalaksana sesuai tahapan
    Terapi yang optimal dapat mencegah
    menjadi CKD Stage 5.
    Tidak memerlukan HD seumur hidup

    Terimakasih

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