GAGAL GINJAL KRONIS

DAN
INDIKASI DIALISIS

dr. Musrifah Budi Utami, SpPD

MKes

Definisi
Diagnosis gagal ginjal kronis (GGK) harus didasarkan
pada kerusakan ginjal dan gangguan fungsi ginjal,
serta berdasarkan laju filtrasi glomerulus (GFR) (NKF
KDOQI guidelines, 2002)

(NKF KDOQI guidelines,

2002)

Glomerular Filtration Rate (GFR)

(Levy, et.al; 2009)

Klasifikasi GGK

(NKF KDOQI guidelines,

2002)

Penyebab
Major causes of chronic renal failure.
Glomerulopathies
Tubulointerstitial nephritis
Drug hypersensitivity
> Primary glomerular diseases:

Heavy metals

1. Focal and segmental glomerulosclerosis

Analgesic nephropathy

2. Membranoproliferative glomerulonephritis

Reflux/chronic pyelonephritis

3. IgA nephropathy

Idiopathic

4. Membranous nephropathy

Hereditary diseases

Polycystic kidney disease

> Secondary glomerular diseases:

Medullary cystic disease

Alport's syndrome

1. Diabetic nephropathy

Obstructive nephropathies

2. Amyloidosis

Prostatic disease

3. Postinfectious glomerulonephritis

Nephrolithiasis

4. HIV-associated nephropathy

Retroperitoneal fibrosis/tumor

5. Collagen-vascular diseases

Congenital

6. Sickle cell nephropathy

Vascular diseases

7. HIV-associated membranoproliferative
glomerulonephritis

Hypertensive nephrosclerosis
Renal artery stenosis

(Tierney, et.al; 2006)

Symptoms and signs of uremia

Organ
System

Symptoms

General

Fatigue, weakness

Skin

Pruritus, easy bruisability

ENT

Metallic taste in mouth,

epistaxis

Signs
Sallow-appearing,
chronically ill
Pallor, ecchymoses,
excoriations, edema, xerosis
Urinous breath

Eye

Pale conjunctiva

Pulmonary
Shortness of breath
Cardiovascula Dyspnea on exertion,
r
retrosternal pain on
inspiration (pericarditis)
Gastrointestin Anorexia, nausea, vomiting,
al
hiccups
Genitourinary Nocturia, impotence
Neuromuscula Restless legs, numbness and
r
cramps in legs
Neurologic
Generalized irritability and
inability to concentrate,
decreased libido

Rales, pleural effusion

Hypertension, cardiomegaly,
friction rub

Isosthenuria

Stupor, asterixis,
myoclonus, peripheral
neuropathy(Tierney, et.al;

(Levy, et.al; 2009)

(Levy, et.al; 2009)

Management of renal failure:

blood pressure control

(Levy, et.al; 2009)

JNC 7
Goal BP for all CKD patients of

Management of renal failure:

slowing
the rate of decline
Blood glucose control in diabetics:
Lipid control.
Optimizing fluid balance
Low protein diet
Correcting acidosis (sodium bicarbonate

)
Use of EPO
(Levy, et.al; 2009)

Management of renal failure:

treatment of anaemia
GFR <30ml/min / <45ml/min in diabetics) and no other cause is

identified.
If Hb <12g/dl in men and postmenopausal women, or <11g/dl in
premenopausal women, check ferritin, transferrin saturation, B12,
and red cell folate.
Aim for serum ferritin 200g/l.
Iron replacement: should initially be with oral iron, but if ferritin
remains below target, or if more rapid response needed (Hb
<10g/dl) arrange for IV iron.
Serum ferritin 200g/l for at least a month, EPO, darbepoetin
alfa, or an erythropoietin-stimulating agent (ESA) should be
commenced if:
> Hb <10.5g/dl;
> Hb 10.5-11.5/dl and
symptomatic angina or claudication;
exertion significantly limited by shortness of breath;
(Levy, et.al;
2009)
patient does job dependent on manual labour
or exertion.

Management of renal failure:

calcium and phosphate
Hyperparathyroidism

The principles are the same as for patients on dialysis, to avoid

hypercalcaemia
Hyperphosphataemia
This is caused by phosphate retention and
hyperparathyroidism.
Management involves:
> dietary phosphate restriction;
> use of phosphate binders: calcium carbonate, calcium
acetate (less calcium absorbed so lower risk of
hypercalcaemia),
sevelamer and lanthanum carbonate
(Levy, et.al; 2009)

Management of renal failure:

prevention of symptoms
correction of anaemia
counselling and education
protein restriction
control fluid balance
starting dialysis early when

symptoms restrict the patients

lifestyle,
(Levy, et.al; 2009)

Management of renal failure:

metabolic complications
Hyperkalaemia

Monitoring of drug treatment, Low potassium diet, Oral

ion-exchange resins , Fludrocortisone (increasing colonic
potassium excretion), IV insulin and dextrose, Oral or IV
sodium bicarbonate if the patient is acidotic but not
fluid overloaded, B-Agonists such as salbutamol given
by inhaler or nebulizer, HD.
Acidosis
oral sodium bicarbonate (Start at dose of sodium
bicarbonate 500mg bd and titrate upwards until plasma
bicarbonate is in normal range, 1g sodium bicarbonate
provides 10mmol sodium)
Poor nutrition
(Levy, et.al; 2009)
low plasma albumin and malnutrition are poor

Initiation of Dialysis
Stages of chronic kidney disease: a clinical action plan. 1,2
Stage
Description
1
Kidney damage
with normal or
GFR

GFR3
(mL/min/1.73 m2)

90

6089

Kidney damage
with mildly GFR
Moderately GFR

Severely GFR

1529

Kidney failure

3059

< 15 (or
dialysis)

Action4
Diagnosis and treatment.
Treatment of comorbid
conditions.
Slowing of progression.
Cardiovascular disease risk
reduction.
Estimating progression.
Evaluating and treating
complications.
Preparation for kidney
replacement therapy.
Replacement (if uremia is
present).

From National Kidney Foundation, KDOQI, chronic kidney disease guidelines.

Chronic kidney disease is defined as either kidney damage or GFR < 60 mL/min/1.73 m 2 for 3 or more months.
Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or
urine tests or imaging studies.
1
2

(Tierney, et.al; 2006)

When to start dialysis in ESKD

The current K/DOQI (USA) and European
guidelines when the GFR is <15ml/min
(taking into account whether patients have any symptoms
from ESKD)

definitively before GFR = 6ml/min.

The UK Renal Association guidelines
when the GFR is <10ml/min.
(Levy, et.al; 2009)

Dialysis is started in some patients to

enable specific treatments or
interventions which would carry high risk
with severe renal failure.
Examples are:
> coronary interventions pretransplantation
> major surgery, e.g. abdominal surgery
for
malignancy
(Levy, et.al; 2009)
> parenteral nutrition because
of fl uid

Treatment modalities for ESKD

HD

- centre
- satellite
- home

PD
- continuous ambulatory PD (CAPD)
- automated PD (APD)

Transplantation
- cadaver
- living related donor
- living unrelated donor (emotionally related)
Conservative management
- best supportive care.
(Levy, et.al; 2009)

Indikasi Dialisis

A Inpatients with laboratory evidence of impaired renal

. function e.g. creatinine clearance <20-25 mL/min/1.73m 2

1. Symtoms known to be associated with uremic:

a. Nausea, vomiting, impaired nutrition because of poor appetite;
another gastrointestinal symptoms, including gastritis with hemorrhage,
ileus dan colitis with or without hemorrhage.
b. Altered mental status (e.g. lethargy, somnolence, malaise, stupor, coma, or
deliriumsor sign of uremic enchepalopathy, asterixis, tremor, multifocal
myoclonal, seizure)

c. Pericarditis, high risk of hemorrhage and/ or tmponade

d. Bleeding diarthosis associated with uremic platelet dysfunction
2. Refractory or progressive fluid overload
3. Uncontrolable hyperkalemia
4. Severe metabolic acidosis, especially in an oliguric patient

Worsening of renal function with blood urea nitrogen

B. exceeding 70-100 mg/dl or decreased creatinine
clearance <15-20 mL/min/1,73m2.
(Levy, et.al; 2009)

Indikasi Dialisis
Complications that may prompt initiation of kidney

replacement therapy
Intractable extracellular volume overload and/or
hypertension

Hyperkalemia refractory to dietary restriction and

pharmacologic treatment

Metabolic acidosis refractory to bicarbonate treatment

Hyperphosphatemia refractory to dietary counseling and to

treatment with
phosphorus binders

Anemia refractory to erythropoietin and iron treatment

Otherwise unexplained decline in functioning or well-being

Recent weight loss or deterioration of nutritional status,

especially if accompanied
by nausea, vomiting, or other evidence of gastroduodenitis

Urgent Indications

Neurologic dysfunction (e.g., neuropathy, encephalopathy,

psychiatric disturbance)
Pleuritis or pericarditis without other explanation
Bleeding diathesis manifested by prolonged(Daugirdas,
bleeding time
et.al;

Modified from the National Kidney Foundation's 2006 Kidney Disease Outcomes Quality Initiative (KDOQI)

Assessment of patients for dialysis:

when not to dialyse
dementia, unless there are family

members who are dedicated to helping

with treatment and care;
severe peripheral arterial disease;
hypotensive heart failure;
severe mental illness, so the patient has no
awareness of the treatment and is unable
to comply;
malignant disease with poor prognosis
(Levy, et.al; 2009)

TERIMA KASIH

Datar referensi :
Daugirdas, J.T; Blake, P.G; Todd, S; 2000 Handbook of Dialysis

3rd edition, Lippincott Williams & Wilkins Publishers

Levy, J; Brown, E; Daley, C; Lawrence, A; 2009,
Oxford
Handbook of Dialysis 3rd edition, Oxford University Press
Inc., New York
Tierney, L.M, McPhee, S.J; Papadakis , M.A; 2006, Current
Medical Diagnosis & Treatment, 45th Edition, McGraw-Hill
Davison, A.M; Cameron, J.S; Grunfeld, J.P; Ponticelli, C; Ritz, E;
Winearls, C.G; Ypersele, C, 2005. Oxford Textbook of Clinical
Nephrology, 3rd Edition, Oxford University Press.
NKF KDOQI Guidelines, 2002.
The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure, 2004, NIH Publication

Penyebab

(Oxford Handbook of Dialysis,

2009)

Gejala

anorexia

Raynauds phenomenon

nausea and vomiting

metabolic flap

fatigue and weakness

nocturia, polyuria

pruritus

headache

lethargy

pericarditis

peripheral oedema

fever

dyspnoea

cough

insomnia

diarrhoea

bleeding tendency

constipation

pulmonary oedema

seizures

apathy

hiccough

muscle cramps

restless legs

feeling cold

sexual dysfunction

growth retardation (children)

confusion

Neuropathy

coma

cognitive impairment

proximal myopathy

(Oxford Handbook of Dialysis,

C. Indications in the chronic setting

Dialysis is initiated when eGFR < 10 mL/min/1.73 m 2.
Problems with criteria that are limited to clearance
measures occur in patients with renal impairment
who have problems with fluid overload,
hyperkalemia, or failure to thrive that are out
of proportion to their eGFR. For example, patients
with advanced age and cognitive impairment may be
poorly compliant with taking high-dose diuretics or
potassium-lowering agents. Patients with advanced
cardiac disease and borderline eGFRs may have
trouble with refractory fluid retention.

 Patients without financial resources or insurance may have

trouble paying for high-dose diuretics and antihypertensives

to achieve good fluid and potassium control. Such patients
may present frequently to emergency facilities with
pulmonary edema, hyperkalemia, and worsening azotemia,
which improve after short hospitalization or even after
several hours in the emergency room and treatment with
appropriate medications. Once these patients are initiated on
dialysis, frequent dialysis therapy prevents fluid and
potassium problems, and the emergency room visits and
hospital admissions often decrease markedly or cease
altogether. Delay in initiation of dialysis for such patients
until their eGFRs fall into a specified range may have an
adverse effect on their long-term survival.

Management of renal failure:

lipids and fluid balance
Lipid control
healthy eating, drug therapy (statins, ezetimibe)
Optimizing fluid balance
Fluid overload
All patients should be assessed for fluid overload whenever seen. This can
be corrected by the use of diuretics, and salt and fluid restriction. Larger
doses of diuretics are needed as renal function worsens, but renal function
can deteriorate during diuresis because of the reduction in blood volume
and hence renal perfusion. Patients with advanced renal failure can be precipitated
on to dialysis when treated with diuretics. Patients with cardiac
failure can often only maintain adequate renal perfusion when oedematous,
with some degree of pulmonary oedema.
Fluid depletion
Worsens renal function because of reduced renal perfusion. Any patient
with renal impairment, normal BP (not on hypotensive drugs), and no
oedema is probably fluid depleted. If necessary this can be managed with
oral sodium supplements (slow sodium or sodium bicarbonate). IV saline
is indicated in the presence of postural hypotension.

Mitigating risk of progression of CKD

and of cardiovascular disease
A. Cessation of smoking
B. Control of blood pressure and proteinuria
C. Beta-blockers and aspirin: Cardioprotective effects
D. Strict glycemic control in diabetics with CKD
E. Lipid-lowering therapy
F. Correction of anemia
G. Control of serum phosphorus, vitamin D, and
parathyroid hormone
H. Protein restriction
I. Approach to obesity
J. Acidosis
K. Microcrystalline charcoal
L. Nephrology referral
(Levy, et.al; 2009)