a-comprehensive-approach-to-kidney-disease-and-hypertension by hazwan
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A Comprehensive Approach to Kidney Disease and Hypertension
PAWANG HAZWANUnit Ginjal dan Hipertensi
Ilmu Penyakit Dalam
Ginjal
Fungsi Ginjal• Regulasi volume cairan• Regulasi keseimbangan elektrolit• Regulasi keseimbangan asam dan basa• Regulasi tekanan darah (RAAS)• Regulasi eritropoesis• Ekskresi sampah metabolik• Metabolisme vitamin D• Sintesis prostaglandin
Apa penyebab Gagal Ginjal ?
Gagal Ginjal
Akut
Kronik
• Chronic– CKD: Chronic Kidney
Disease• Acute
– ARF: Acute Renal Failure– AKI: Acute Kidney Injury
• Acute Classification– Pre-renal– Renal– Post-renal
The CKD problem
• Clinically silent in the early stages• Cost of renal disease can be extreme to health
care service• Effects of renal disease can be extreme on
patient• Treatments now available to slow progression• Need an “early warning” system for CKD
Diseases of the Kidney
All global renal diseases affect glomerular
filtration rate (GFR)
• Diabetes• Hypertension• Atherosclerosis• Glomerular diseases• Toxins
– Gentamicin– NSAIDS– Compound analgesics
• Inherited diseases• Tubular disorders
Definition of CKD• Kidney damage for 3 months
– Defined by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR)
• Reduced GFR for 3 months• New staging for chronic kidney disease (CKD)
is primarily based on kidney function.
National Kidney Foundation (NKF). Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.
• Glomerular Filtration Rate is the volume of fluid passing through the glomerulus in a given period of time.
• Influenced by renal perfusion pressure, renal vascular resistance, glomerular damage, post-glomerular resistance.
• “Normal Range” approx 90 - 150 mL/min– Approx 170 L per day
• A larger healthy person has a higher GFR– Can be reported as 90 - 150 mL/min/1.73m2
• Values fall with increasing age
Other reasons for estimating the GFR
• Monitoring progression of CKD• GFR estimates are used for drug dosing
decisions– Dosing of renally excreted drugs– Avoiding nephrotoxic drugs
• Risk factor for cardiovascular disease mortality
• Renal involvement in systemic diseases, such as diabetes mellitus or SLE
J Winterbottom 2005
Sign n SymptomsUraemia symptoms;Bad breath (urinous,ammonia)
Oedema (eyes, face, arms,hands, feet)
HypertensionExtended neck veinsFatigue (anaemia,toxic substances)
Neurological disturbances (lethargy, confusion,sleep disorders)
J Winterbottom 2005
Sign n Symptoms
Nausea & vomitingHeadachesPruritus (phosphate, calcium, aluminium)
BreathlessnessBone & joint problems (calcium/phosphate
imbalances,VitD deficiency,demineralization)Bone pain
J Winterbottom 2005
Investigation
HbUrea n electrolyteCreatinineAlk phosphatasePTHUrineimaging
Bagaimana dengan Anemia Renal ?
Anemia Rates Increase as Levels of CKD Severity Progress
20
8
17
43
8
15
62
15
10
14
95
0
20
40
60
80
100
<2 2-2.9 3-3.9 ≥4
Creatinine (mg/dL)
Anemia Prevalence (%
)
Hgb Values
11-12 g/dL10-11 g/dL<10 g/dL
Hgb = hemoglobin.Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.
Chronic Kidney Disease (CKD) Progression
Gagal GinjalNormal
Chronic kidney disease (CKD) Anemia is an expected complication of CKD
Increased cardiovascular morbidity
Left Ventricular Hypertrophy (LVH)
Congestive Heart Failure (CHF)
Treatment
recombinant human erythropoietin (r-HuEPO)
Diambil : Jerome Rossert dkk, Nephrol Dial Transplant (2002) 17: 359–362
Why are CKD/ESRD Patients Predisposed to CV Disease?
INFLAMMATION plus CaP deposition
CV DISEASE AND DEATH
CKD/ESRD
ANEMIA LVH/CHFLIPIDS HTN
CAD and PVD
Why are CKD/ESRD Patients Predisposed to CV Disease?
• 30-50% of ESRD patients have INFLAMMATION (increased CRP, increased IL-6, decreased albumin)– Increased CRP is a primary marker for inflammation predicting
cardiovascular disease in normal adults– Increased CRP is the primary marker for increased cardiovascular
mortality on dialysis
• CKD/ESRD patients have metastatic calcification (coronary arteries) because of secondary hyperparathyroidism and elevated PO4 levels.
Bagaimana hubungan antara hipertensi dengan CKD ?
Distribution of hypertensives (65-89 years)
MEN
59.3%
30.3%
10.4%
WOMEN
63.6%
8.7%
27.7%
ISOLATED SYSTOLIC
ISOLATED DIASTOLIC
COMBINED
ISOLATED SYSTOLIC
ISOLATED DIASTOLIC
COMBINED
Framingham study
Factors Affecting Blood Pressure
Blood Pressure
Cardiac Output
Total Peripheral Resistance
= XAmount of blood
ejected per minute Blood flow through blood vessels
Prevalence of HTN in CKD
80% of patients with glomerulonephritis and 30% of patients with chronic interstitial disease are hypertensive.
Aggressive BP Control, Proteinuria and CKD Progression – what is the optimal BP
for CKD?
-12
-10
-8
-6
-4
-2
0<1 gm/D 1-2.9
gm/D>3 gm/D
Mean fall in GFR
(ml/min/yr)
<125/75<140/90
Klahr S et al, N Engl J Med 330:877, 1994
**
GOAL BP<125/75 if >1 gm proteinuria
GFRProteinuriaAldosterone releaseGlomerular sclerosis
A II
Atherosclerosis*VasoconstrictionVascular hypertrophyEndothelial dysfunction
LV hypertrophyFibrosisRemodelingApoptosis
Stroke
Death
*Preclinical data.LV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate.
Hypertension
Heart FailureMI
Renal Failure
Angiotensin II plays a central role in organ damage
Renin Angiotensin Aldosterone System
Angiotensinogen
Non-ACE pathways(eg, chymase)
Vasoconstriction Cell growth Na/H2O retention Sympathetic activation
Renin Angiotensin I
Angiotensin II
ACE
Cough,angioedema
Benefits? Bradykinin
Inactivefragments
Vasodilation Antiproliferation
(kinins)
Aldosterone AT2
AT1
Decreasedvasodilatoryprostaglandins
Increasedangiotensin II
Low GFR
How About Renal Osteodystrophy
Bone Disease in CKD
Metabolic abnormalities Hyperphosphatemia Hypocalcemia PTH elevation
Bone Disease in CKD Renal Osteodystrophy
Osteomalacia / osteitis fibrosis cystica / osteosclerosis
Metastatic calcification Vascular!
Bone Disease in CKD Renal Osteodystrophy
Matur nuwun