ckd management rsua printout -...
TRANSCRIPT
8/7/2018
1
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%)
8/7/2018
2
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
8/7/2018
3
PAGE 13 | Present situation of Dialysis in Indonesia
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 |
Dialysis in Indonesia (IRR 2015)
Hypertension, 44%
Diabetes, 22%
Unknown, 3%
Other, 9%
Chronic Pyelonephritis,
7%
Secondary Nephropathy, 7%
Primary GN, 8% Etiology
PAGE 15 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 15 |
Dialysis in Indonesia (IRR 2015)
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
PAGE 16 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 16 |
Dialysis in Indonesia (IRR 2015)
< 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
PAGE 17 | Present situation of Dialysis in Indonesia
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)
PAGE 18 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 18 |
Jaminan Kesehatan Nasional (JKN)
8/7/2018
4
PAGE 19 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 19 |
Jaminan Kesehatan Nasional (JKN)
PAGE 20 | Present situation of Dialysis in Indonesia
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
PAGE 21 | Present situation of Dialysis in Indonesia
RUMAH SAKIT
PAGE 21 |
Dialysis in Indonesia (IRR 2015)
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
PAGE 22 | Present situation of Dialysis in Indonesia
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
PAGE 23 | Present situation of Dialysis in Indonesia
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
8/7/2018
5
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
The image part with relationship ID rId3 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
How the Proteinuria Induces Renal
Damage ?
8/7/2018
6
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
The image part with relationship ID rId7 was not found in the file.
Microalbuminuria
Injured Endothelium
The image part with relationship ID rId7 was not found in the file.
Interstitial Albumin Leak
RenalVasculature
SystemicVasculature
Cardiovascular Risk FactorsAge DiabetesHypertensionSmokingAbsent nocturnal BP dippingSalt sensitivityLeft ventricular hypertrophyDyslipidemiaCentral obesityInsulin resistanceElevated CRPSympathetic dysfunctionHyperuricemia
The image part with relationship ID rId7 was not found in the file.
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
8/7/2018
7
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
The image part with relationship ID rId3 was not found in the file.
• 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
8/7/2018
8
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
The image part with relationship ID rId3 was not found in the file.
Lifestyles, Fitnessand Rehabilitation
The image part with relationship ID rId3 was not found in the file.
Hipertenzija - samo dio višestrukogrizičnog sindroma sa teškim
posljedicama
Treat the BP to Target
The image part with relationship ID rId4 was not found in the file.
Intrauterineprogramming
Mosaic 2007
Environmental
Renal
Anatomical
Adaptive
NeuralEndocrine
Humoral
Haemodynamics
Genetic
BP
The image part with relationship ID rId3 was not found in the file.
The image part with relationship ID rId13 was not found in the file.
WHAT IS THE BLOOD PRESSURE TARGET
FROM TIME TO TIME?
48
IN CKD
8/7/2018
9
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%
The image part with relationship ID rId4 was not found in the file.
Treat the BP to Target
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.
Treat the BP to Target
130/80
140/90
130/80The image part with relationship ID rId4 was not found in the file.
Treat the BP to Target
130/80
The image part with relationship ID rId13 was not found in the file.
The image part with relationship ID rId13 was not found in the file.
The image part with relationship ID rId2 was not found in the file.
The image part with relationship ID rId2 was not found in the file.
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.
The image part with relationship ID rId13 was not found in the file.
The image part with relationship ID rId13 was not found in the file.
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
10
The image part with relationship ID rId13 was not found in the file.
The image part with relationship ID rId13 was not found in the file.
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.
The image part with relationship ID rId13 was not found in the file.
Interventions to Slow CKD Progression
Treat the BP to Target
130/80
Pgc SNGFR
NephronLoss
TGF-Cytokines
CAMs
MacrophagesFibroblasts
2° FSGSand TIF
Ang IIMechanical Stress
1°Renal Disease
Proteinuria
Systemic Hypertension
Interventions to Slow CKD Progression
Inhibit RAS
Proteinuria
NewAnti-inflammatory
Anti-fibroticStop
Smoking
TreatDyslipidaemia
Treat Hypertension
Weight loss Dietary Protein
Treat the BP to Target
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
Treat the BP to Target
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
Treat the BP to Target
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
INTERACTION OF HYPERTENSION, PROTEINURIA and GFR LOSS
Hebert, et al. KI 2001:59;121-1226Treat the BP to Target
8/7/2018
11
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
The image part with relationship ID rId3 was not found in the file.
Treat the BP to Target
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
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
The image part with relationship ID rId3 was not found in the file.
Treat the BP to Target
DILTIAZEM
8/7/2018
12
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
Treat the BP to Target
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
Treat the BP to Target
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
8/7/2018
13
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
TREAT the BP TO TARGET
1st & 2nd Prevention 3rd Prevention
I FEEL FINE HD
130/80
TREAT the BP TO TARGET
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
8/7/2018
14
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?
8/7/2018
15
Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies
CKDdeathCKDdeath
ComplicationsComplications
Screeningfor CKD
risk factors
CKD riskreduction;
Screening forCKD
Diagnosis& treatment;Rx. comorbidconditions;
↓ progression
Estimateprogression;
Rx. complications;Prepare for
replacement
Replacementby dialysis
& transplant
NormalNormalKidneyfailureKidneyfailureDamageDamage GFR GFR
Vascular Lesion & Remodelling
CitokynInflammation
Permiability↑Microalb & Macroalb
TrombosisVasoconstrictionHTN
CVD
Normoalbuminuria MacroalbuminuriaMicroalbuminuria
ATHEROSCLEROSIS
Increasedrisk
Increasedrisk
CVDCVDCVD
Treat the BP to Target
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
Treat the BP to Target
RENOPROTECTION EFFECT
• Renoprotection consist of :
• BP lowering (125/75 mmHg)
– Decrease proteinuria ( negative )
– Decrease risk of fibrosis
Low protein diet + Keto.A
Treat the BP to Target
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
INTERACTION OF HYPERTENSION, PROTEINURIA and GFR LOSS
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
Interventions to Slow CKD Progression
Inhibit RAS
Proteinuria
NewAnti-inflammatory
Anti-fibroticStop
Smoking
TreatDyslipidaemia
Treat Hypertension
Weight loss Dietary Protein
Treat the BP to Target
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%
The image part with relationship ID rId4 was not found in the file.
Treat the BP to Target
Hypertension Syndrome
Atherosclerosis Syndrome
OutcomeOutcome
Pathophysiology of progression
Area of Trial End Point
Risk Reduction
Risk Factors
Cardiovascular Risk FactorsAge DiabetesHypertensionSmokingAbsent nocturnal BP dippingSalt sensitivityLeft ventricular hypertrophyDyslipidemiaCentral obesityInsulin resistanceElevated CRPSympathetic dysfunctionHyperuricemia
HULU HILIR
Treat the BP to Target
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
Treat the BP to Target
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
Treat the BP to Target
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
8/7/2018
17
Treat the BP to Target
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
Protection, Prevention, and Regression the Progressivity of
Atherosclerotic Syndrome Dominited by :
HULU Treat the Organ DamageTreat the BP to Target
CONCLUSION
Protection, Prevention, and Regression the Progressivity of
Atherosclerotic Syndrome Dominited by :
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
8/7/2018
18
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
19
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
Risk factors for the development, progression, and complications of CKD
Risk factor Definition Examples
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
Risk factors for the development, progression, and complications of CKD
Risk factor Definition Examples
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