Proteinuria CKD ESKD

Care plan Care plan Care plan

STAGE 1 & 2 STAGE 3 STAGE 4 STAGE 5 PALLIATIVE CARE

Proteinuria plus
eGFR 60+ eGFR 30-59 eGFR 15-29 eGFR <15
ml/min ml/min ml/min
(to determine eGFR
over 60, hand MODERATE SEVERE
calculate GFR using KIDNEY KIDNEY FAILURE
Cockcroft-Gault
DAMAGE DIALYSIS
formula) DAMAGE

HAEMODIALYSIS

PERITONEAL DIALYSIS

TRANSPLANTATION

GFR = (140 - Age) x wt (kg) Chronic End Stage Kidney

se creat (mmol/Lt) Kidney Kidney
Males = GFR x 1.23 Disease Failure
Disease
Diagnosis Diagnosis

SUPPORTIVE CARE APPROACH

 Chronic Kidney Disease in the US
• Over 20 Million Americans have some degree of renal
insufficiency….1 in 8 people.

• 20 million others are at risk

• Hypertension & Diabetes are the leading causes of

kidney failure
– 23% of all Americans have hypertension
– 16 million Americans have diabetes

• Both are independent risk factors for cardiovascular

disease
CKD is a major public health problem

1 in 7 Australian adults has CKD

1 in 3 Australian adults are at an increased risk of CKD developing
80-90% of CKD is unrecognised / untreated

Major risk factor for cardiovascular disease

Preventable and treatable
Over one million Australians have CKD (stages 3 - 5)
 Incident Counts and Rates of ESRD
by Primary Diagnosis

illi
illi
lla
lla

USRDS 2006
 IRR 2012 Penyakit Dasar PGT

12%
Hipertensi
12% 35%
DM
15% pielonefritis
26% glomerulonefrotis
lain-lain
IRR,2013

19% Hipertensi
31%
10% DM
Glomerulopati
14%
26% Pielonefritis
INDONESIAN lain-lain
RENAL REGISTRY
INDONESIAN
RENAL REGISTRY
 What Kidneys Do

 Kidneys control the amount of water and other

chemicals in blood.
 Kidneys remove harmful substances
 Kidneys control blood pressure
 Kidneys help make red blood cells
 Kidneys promote strong bones
What is Chronic Kidney Disease (CKD)?

Chronic kidney disease is defined

as:
• GFR < 60 mL/min/1.73m2 for a periodoror 3+
months with evidence of kidney damage
without

OR

• Evidence of kidney damage (with or without

decreased GFR) for 3+ months:
– microalbuminuria
– proteinuria
– glomerular haematuria
– pathological abnormalities
– anatomical abnormalities
 Chronic Kidney Disease
 Chronic kidney disease (CKD) is the permanent
loss of kidney function in both kidneys as a result of
 Physical injury or
 A disease that damages both kidneys, such as
DIABETES

 Damaged kidneys
 do not remove wastes
 do not remove extra water
from the blood as well as they should.
 What Else About CKD?
 CKD is a silent condition.
 In the early stages, there are no symptoms.
 CKD develops so slowly that people don't
realize they're sick until the disease is
advanced and they are rushed to the hospital
for life-saving dialysis.
Stages 1 & 2
 Normal eGFR ≥ 60 ml/m
 Kidney damage for more than 3 months as
manifested by
 Abnormalities in the tissue of the kidney (biopsy) or
 Markers of kidney damage including
 Abnormalities in the composition of urine or
 Changes seen by radiological images (x-ray, CT scan, ultrasound etc.)
 Risks associated
 Progression
 Heart disease
 Stages 3, 4 & 5
 Kidney damage getting worse
 eGFR getting progressively lower
 Risks associated
 Progressive kidney disease (dialysis)
 Increased cardiovascular risk
 Myocardial infarction (heart attack)
 Stroke
 Sudden death
The strategic framework for preventing CKD

• Primary prevention
• Secondary prevention
• Tertiary prevention
 CKD Prevention

CKD

RRT
Risk 1 2 3
Normal 4 5 Dialysis
factors
Transplant

Primary Secondary Tertiary

Prevention Prevention Prevention
Prevent CKD Early detection & prevention Treat advanced
development of progression/complications CKD

Levey et al. Am J Kidney Dis 53:522-35, 2009

Primary prevention
 To reduce the incidence and prevalence of risk
factors such as diabetes and high blood
pressure, in order to reduce the number of
people at risk of developing CKD
Several factors are involved in the
reduction in risk of CKD in the community

 Improving information and awareness of the disease

 Reducing prevalence of behavioural risk factors
 Stop smoking, insufficient physical acivity, non healthy diet
 Reducing prevalence and improving control of
biomedical risk factors
 High blood pressure (hypertension), diabetes mellitus
 Reducing exposure to external factors which
increase risk
 NSAIDs, antibiotics
 Identification of high-risk patients

 Hypertension
 Diabetes
 Obesity
 Cardiovascular disease
 Tobaccco smokers
 Aged over 50 years
 A family history of kidney disease
Secondary prevention
 Early detection and effective intervention in
the early stages of kidney damage are
essential to prevent or delay the deveopment
of ckd

 Screening is justified for selected high-risk

groups
How do we screen for CKD?

• Blood test for kidney function

• Testing for proteinuria (dipstick or spot urine), urine
albumin/creatinine ratio or urine protein/creatinine ratio
• Testing for hypertension
• Testing for diabetes

• Kidney check : Blood test (eGFR), urine test, BP check

CKD screening should be undertaken as a part of

general chronic disease management and also
opportunistically for those at high risk
The Kidney Check

1. Blood pressure test If all 3 tests are normal then

2. Biochemistry for Serum creatinine the kidneys are in good shape
(calculate eGFR) and need only be checked
again if the patient is in a high
3. Dipstick urine protein
risk group.
Kidney Int 2011; 80: 17-28
What is eGFR?

• eGFR is estimated glomerular filtration rate

• GFR can be estimated from serum creatinine using prediction

equations

• The current formula (MDRD) uses creatinine, age, gender. There is

no requirement for additional measurements of body surface area

• eGFR (using MDRD) is now automatically reported with every

request for serum creatinine in adults

• Superior to other equations and to 24-hour urine collection (when

GFR <60 mL/min/1.73m2)

Access the calculator at: www.kidney.org.au

* MDRD = Modification of Diet in Renal Disease, after the study that generated the
formula
** and race if Afro-American
 GFR Estimating Equations
Cockcroft-Gault formula
Ccr (ml/min) = (140-age) x weight *0.85 if female
72 Scr

MDRD Study equation

GFR (ml/min/1.73 m2) = 186 x (Scr)-1.154 x (age)-
.203 x (0.742 if female) x (1.210 if African

American)
Comparing eGFR and Creatinine

By the end of this workshop, participants will:

• Explain CKD as a public health problem in Australia

 Albumin Urine Kuantitatif

• Penanda kerusakan ginjal

Feature

• Pemeriksaan berdasarkan pengumpulan sampel urin

• Urin 24 jam
• Urin sewaktu = rasio albumin urin/kreatinin urin
• Sinonim : uACR= ACR =AER =UAE
• Membantu dalam menentukan pengelompokkan albuminuria :
Advantage

• Normoalbuminuria
• Mikroalbuminuria
• Makroalbuminuria
• Bermanfaat untuk skrining pasien diabetes, Hipertensi
Benefit

• Bila ditemukan mengalami albuminuria, pengobatan dapat segera

dilakukan.
• Memantau keberhasilan pengobatan
Tertiary prevention

 Focus on management CKD

 to prevent or delay further kidney damage
and loss of kidney function,
 reduce the incidence and prevalence of
ESKD and other complications
How to Slow CKD
 Educate patients on how they can control many of the things
that can make CKD worse and may lead to kidney failure.

 Gain tight control of blood glucose to delay or prevent kidney

failure, where appropriate.

 Keep blood pressure below 130/80 mm Hg. A combination of

two or more drugs may be necessary

 ACE (angiotensin-converting enzyme) inhibitors and ARBs

(angiotensin receptor blockers) protect the kidneys better than
other blood pressure medicines.

 Dietary therapy when practicable, low protein, low sodium, and

later low potassium and low phosphorus.
Behavioral Changes that Affect CKD Outcomes

 Ask to get tested for kidney disease

 Ask questions about kidney disease
 Take medicines regularly
 Stop smoking
 Stop using illicit drugs
 Abstain from alcohol
 Lose weight if overweight or obese
 Exercise if sedentary
 Adjust diet
 Keep appointments with health care system
Management of pre-dialysis
 appropriate selection of the preferred mode
of therapy, and adequate preparation
 timely initiation of treatment
 availability of counselling, education, and
rehabilitation throughout the process
 appropriate management of comorbid
conditions (such as anaemia, high blood
pressure and bone disease) and risk factors
(such as blood lipids and nutrition
When do we refer to Nephrologists
CKD 4 & 5
Resistant HT
Persistent proteinuria / haematuria
Difficulty achieving Bld sugar control
Established CKD
Uraemia
Heart failure
Anaemia
Too few people receive counseling
prior to dialysis

Reference: Adapted from USRDS Annual Data Report (NIDDK, 2010)

What is the role of the practice nurse in CKD?

Detection
To assist in early detection of CKD by recognising people
who are at increased risk
Kidney Health Check:
• blood pressure
• urine dipstick for proteinuria
• estimated glomerular filtration rate (eGFR)
What is the role of the practice nurse in CKD?

Management
To assist in the management of CKD by
•Treatment to slow or prevent progression of kidney failure
•Assess and manage symptoms (e.g. anaemia, nausea/vomiting)
•Monitor for nephrotoxic medications (e.g. NSAIDs)
•Promote self-management strategies (lifestyle modification)
•Screen and manage diabetes and hypertension