Post on 06-Feb-2018
MasalahPenatalaksanaanPenyakit Ginjal Kronis
Pranawa
Division of Nephrology and Hypertension Department of Internal Medicine
Faculty of Medicine, Airlangga University Dr. Sutomo Hospital
Surabaya
Tahapan Penyakit Ginjal Kronik
Tahap DeskripsiGFR
(ml/men/1.73 m2)
1 Kerusakan ginjal dengan LFG normal
atau turun
>/= 90
2 Kerusakan ginjal dengan penurunan
ringan LFG
60-89
3 Penurunan LFG sedang 30-59
4 Penurunan LFG berat 15-29
5 Gagal Ginjal < 15 atau dialisis
PenatalaksanaanPenyakit Ginjal Kronis
Konservatif (pra dialisis)
Aktif(ESRD)
Dialisis
Transplantasi
Hemodialisis
PD
Masalah
Sosio Epidemiologik
Medik
Masalah Sosial EpidemiologiK
Meningkatnya jumlah pasien
Ketersediaan sarana prasarana dan ketenagaan
Sistem pembeayaan
Pengertian pasien dan masyarakat
Results
9.412 Subject (64,1% Female)
Mean age 43,3+12,9 years.
Hypertension 19,4%
Proteinuria 2,8 %
Current Smooking 19,8% and Obesity 32,5%.
In subjects with either hypertension, proteinuria and/or diabetes, CKD was found in 12,5% (CG), 8,6% (MDRD) or 7,5% (Chinese MDRD).
Incidence of CKD in Indonesia
o based on the 2007 National Health Survey by the Ministry of Health Indonesia
okidney dysfunction : 3.8% (CKD-EPI eGFR
Prevalence of CKD in Selected Asian Countries
9Tsukamoto et al. Clin Exp Nephrol. 2009. Published online. doi 10.1007/s10157-009-0156-8; Ong-ajyooth L et al. BMC Nephrol.
2009;10:35; Wen et al. Lancet. 2008;371:2173-2182; Chen W et al. Nephrol Dial Transplant. 2009;24:1205-1212.
Area CKD Prevalence (stages) N
China
Beijing 9.3% (I-V), 1.7% (III-V) 13,925
Guangzhou/Zhuhai 12.1% (I-V), 3.2% (III-IV) 6311
Korea 1.39% (I), 3.64% (II), 2.67% (III-V) 329,581
Japan 9.2% (III-V) 574,023
Singapore 4.45% (III-V) 2112
Vietnam 3.9% (III-V) 8509
Indonesia 5.8% (I), 7.0% (II), 5.2% (III-V) 6040
Taiwan 11.9% (I-V) 462,293
Thailand 8.1% (III), 0.2% (IV), 0.15% (V) 3117
CKD, chronic kidney disease.
Indonesia almost 2 million square
kilometers 18,307 islands population : 255,339,621
Indonesia almost 2 million square
kilometers 18,307 islands population : 255,339,621
255.000 pasien ESRD
CAUSES OF ESRD in HD pts in SURABAYA
CAUSES 1994dr. Soetomo Hosp
1996-1998private Hosp
2000dr. Soetomo Hosp
Renal Stones 32% 16.8% 8.8%
Glomerulonephritis 27% 36.4% 34.3%
Hypertension 22% 15.9% 22.8%
Diabetic Nephropathy 14% 23.4% 32.0%
Others 2% 7.5% 2.1%
Causes of CKD at the start of HD
Hypertension 31%
Diabetes 26%Glomerulopathy 14%
Pyelonephritis 10%
Obstruction 7%
Obstruction 7% Uric Acid 2%Lupus 1% Polycystic 1%Unknown 2%
Others 6%
Indonesian Renal Registry 2013
INDONESIANRENAL REGISTRY
Jumlah Unit HD Per propinsi Yang Mengirimkan Data tahun 2016
Propinsi Sign UP Kirim Data
Aceh 10 4
Sumut 35 20
Sumbar 6 4
Riau 3 2
Kepri 6 2
Jambi 4 2
Bangka 4 3
Sumsel 7 3
Lampung 15 3
Bengkulu 2 1
Jabar 109 100
Banten 11 7
DKI 59 37
Jateng 57 18
DIY 15 6
Jatim 65 32
Bali 24 14
NTT 1 1
Kaltim 10 6
Kalsel 6 3
Sulut 3 3
Sulteng 1 1
Sulsel 7 6
Jumlah 460 278
INDONESIANRENAL REGISTRY
Jumlah Unit HD Per propinsi Yang Mengirimkan Data tahun 2016
Propinsi Sign UP Kirim Data
Aceh 10 4
Sumut 35 20
Sumbar 6 4
Riau 3 2
Kepri 6 2
Jambi 4 2
Bangka 4 3
Sumsel 7 3
Lampung 15 3
Bengkulu 2 1
Jabar 109 100
Banten 11 7
DKI 59 37
Jateng 57 18
DIY 15 6
Jatim 65 32
Bali 24 14
NTT 1 1
Kaltim 10 6
Kalsel 6 3
Sulut 3 3
Sulteng 1 1
Sulsel 7 6
Jumlah 460 278
Diperkirakan baru 50%
INDONESIANRENAL REGISTRY Jumlah pasien Baru dan Pasien Aktif
2007- 2016
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Pasien Baru 4977 5392 8193 9649 15353 19621 15128 17193 21050 25446
Pasien Aktif 1885 6543 8603 11484 17259 22140 21759 21165 30554 52835
0
10000
20000
30000
40000
50000
60000Pasien aktif 52.835
INDONESIANRENAL REGISTRY Jumlah pasien Baru dan Pasien Aktif
2007- 2016
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Pasien Baru 4977 5392 8193 9649 15353 19621 15128 17193 21050 25446
Pasien Aktif 1885 6543 8603 11484 17259 22140 21759 21165 30554 52835
0
10000
20000
30000
40000
50000
60000Pasien aktif 52.835
Diperkirakan 105.000 pasien
INDONESIANRENAL REGISTRY INSIDENSI DAN PREVALENSI PASIEN
HEMODIALISIS
9th Report Of Indonesian Renal Registry
2016
7
Data dari propinsi Jawa Barat dapat dilihat pada diagram di bawah ini
Data ini didapatkan dari 90 % unit HD yang ada maka data ini dirasa cukup lengkap dan dapat menilai insidensi dan prevalensi di wilayah tersebut. 90 % dibiayai oleh JKN baik PBI maupun non PBI. Penduduk Jawa Barat peserta JKN sebanyak 29 juta
Untuk data tahun 2016 dapat dihitung sbb :
Jumlah Total
Penduduk Jawa Barat 46,5 juta
Jumlah Pasien JKN (90%)
Peserta JKN Jawa Barat 29 Juta
Pasien Baru 6288 135 per juta penduduk
5659 195 per juta penduduk
Pasien Aktif 14869 319 per juta penduduk
13382 512 per juta penduduk
Distribusi Usia pasien HD Dalam Persen Tahun 2016:
Proporsi pasien terbanyak masih pada kategori 45 sd 64 tahun. Bila dilihat pada tabel di atas pasien yang berusia kurang dari 25 tahun memberi kontribusi sebesar 2,79 % hal ini menunjukkan sudah saatnya memberi perhatian pada kelompok usia muda untuk mulai memperhatikan kesehatan ginjal.
5029
74656288
7381
9382
14869
0
2000
4000
6000
8000
10000
12000
14000
16000
2014 2015 2016
Pasien Baru Pasien Aktif
BILA PESERTA JKN SELURUH INDONESIA SEBANYAK 130 JUTA ORANG MAKA JUMLAH PASIEN BARU PER TAHUN : 130 X 195 = 25.350
DAN PASIEN AKTIF PER TAHUN : 130 X 512 = 66.600Dan bila seluruh Indonesia menjadi peserta JKN maka pasien aktif HD
sebanyak :250 x 512 =
128.000 orang
INDONESIAN
RENAL REGISTRY
2016
Grafik Jumlah Pasien Penyakit Ginjal Kronik Tahap 5 (N18) berdasarkan Diagnosa Etiologi Di Indonesia
E1 (Glumerulopati Primer) (GNC)
6%
E2 (Nefropati Diabetika)52%
E3 (Nefropati Lupus) (SLE)1%
E4 (Penyakit ginjal Hipertensi)
24%
E5 (Ginjal Polikistik)1%
E6 (Nefropati Asam
Urat)1%
E7 (Nefropati Obstruksi)
4%
E8 (Pielonefritis Chronic0 (PNC)
3%
E9 (Lain-Lain)6%
E10 (Tidak Diketahui)2%
Global: 2,522,000 dialysis patients
Fresenius Medical Care : ESRD Patients in 2013 A Global Perspective
Comparison of HD and PD patient numbers in the 15 largest countries ranked by total dialysis patient population
Fresenius Medical Care : ESRD Patients in 2013 A Global Perspective
Kebutuhan mesin HD dan perawat255.000 pasien ESRD
90 % hemodialisis : 225. 000 pasien
10% CAPD : 25. 000 pasien
Dengan 3 shift 2 kali/mnggu
Diperlukan 2 x 225.000 = 450.000 tindakan/mnggu
Diperlukan 450.000 : 6 = 75.000 : 3 = 25.000 mesin
Diperlukan 25.000 perawat
Kebutuhan mesin HD dan perawat
Keadaan sekarang
105.000 - 128.000 pasien
Untuk 3 shift 2x/minggu
Diperlukan 12.500 mesin HD dan 12.500 perawat
INDONESIANRENAL REGISTRY Jumlah Perawat HD & Jumlah Mesin
Tahun 2016
Jumlah
Jumlah Perawat 4728
Jumlah Perawat Bersertifikat 3350
Jumlah Mesin 6604
0
1000
2000
3000
4000
5000
6000
7000
INDONESIANRENAL REGISTRY Jumlah Perawat Tahun 2016
Bersertifikat, 3350
Belum bersertifikat,
1378,
Perawat
Bersertifikat
Belum bersertifikat
Beaya BPJS untuk hemodialysis di Jawa Timur tahun 2016Rp 456.757.511.500
Beaya BPJS untuk hemodialysis di Jawa Timur tahun 2016Rp 456.757.511.500
Indonesia 3 T
CKD oleh Karena DM meningkat
Prevalensi DM meningkat
Harapan hidup pasien DM lebih baik
Tersedianya sarana terapi pengganti ginjal
Nephrology 19 (2014) 450458
Number of Dialysis Patient Will Increase Significantly, Particularly Due to National Insurance (JKN)
Number of Dialysis Patient Will Increase Significantly, Particularly Due to National Insurance (JKN)
Masalah Medik Perjalanan PGK dan Prognosis
Kesempurnaan instalasi dan kelengkapan saranaprasarana
Ketramplilan Tenaga Pelaksana
Kedisiplinan Pasien
Stages in Progression of
Chronic Kidney Disease and Therapeutic Strategies
Complications
Normal Increased
RiskDamage GFR
Kidney
failure
CKD
death
Screening
for CKD risk
factors
CKD risk
reduction,
Screening
for CKD
Diagnosis &
treatment,
Treat
comorbid
conditions,
Slow
progression
Estimate
progression,
Treat
complications,
Prepare for
replacement
Replacement
by dialysis &
transplant
Deteksi dini
Prevensi primer dan sekunder
Diabetic kidney disease markers.
Current markers
1. Creatinine, Cystatin C (estimated GFR).
2. Microalbuminuria
3. Macroalbuminuria or Proteinuria
Candidate markers in future
1. Urinary podocytes
2. NGAL
3. KIM-1
4. Smad 1
5. CTGF
6. TGF-
7. TNF-NGAL = Neutrophil Gelatinase-Associated Lipocalin; KIM-1 = Kidney Injury Molecule 1; CTGF = Connective tissue growth factor; TGF- = Transforming growth factor beta; TNF- = Tumor necrosis factor alpha.
Open J Nephrol. 2012; 2(2): 518.
Masalah Medik Perjalanan PGK dan Prognosis
Kesempurnaan instalasi dan kelengkapan saranaprasarana
Ketramplilan Tenaga Pelaksana
Kedisiplinan Pasien
KenyataanUkuran ruangan
Ratio mesin dan perawat
Kualitas air
Masih tinggi prevalensi hepatitis C
Kualitas hidup pasien ( termasuk nutrisi )
INDONESIANRENAL REGISTRY
LAMA HIDUP DENGAN HD DI INDONESIA TAHUN 20169th Report Of Indonesian Renal Registry
2016
17
Proporsi berdasarkan lama hidup dengan Hemodialisis
Lama Hidup dari mulai HD, n=1683 n (%)
36 Bulan 165 (9,8)
Tiga puluh sembilan persen pasien meninggal pada 3 bulan pertama menjalani hemodialisis dan hanya 9,8% saja yang menjalaninya lebih dari 36 bulan
n
Lama HD
Mean SD Median (IQR) Min Maks
Jenis Kelamin
Laki-laki 696 20 24 8 (3 30) 1 140
Perempuan 539 18 24 7 (2 28) 1 116
Usia
65 Tahun 222 21 26 8 (3 32) 1 139
Etiologi
Glomerulopati 7
10 13
3 (1 18)
1 30
Nefropati Diabetik 61 14 20 5 (2 24) 1 92
Penyakit Ginjal Hipertensi 59
9 16 3 (1 8) 1 96
Lain-lain 29 11 16 3 (2 11) 1 72
P.Penyerta 1, n (%)
Hipertensi
45
14 19
4 (2 29)
1 92
Diabetes melitus 50 6 8 3 (1 8) 1 36
Kelainan Kardiovaskular 6 8 10 4 (1 8) 1 28
INDONESIANRENAL REGISTRY Jumlah tindakan HD berdasarkan
Durasi HD (Td) 2016
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
< 3 Jam 2294 6368 3295 4207 3714 4817 5393 12608 5802 7613
3 - 4 Jam 76736 111647 120028 164541 226993 360753 359495 375557 374751 483129
> 4 Jam 36011 62973 91719 105546 239981 236193 314138 315102 339107 457402
0
100000
200000
300000
400000
500000
600000
INDONESIANRENAL REGISTRY
Grafik Jumlah tindakan HD berdasarkan Durasi Se Indonesia tahun 2016
Durasi HD > 31%
DurasiHD 3 - 4 Jam51%
DurasiHD > 4 Jam48%
Upaya perbaikan
Terus menyempurnakan SKN dan JKN dan pelaksanannya
Menyempurnakan regulasi
Mengikuti regulasi yang berlaku
Mengikuti pedoman pelaksanaan HD
Meningkatkan upaya prevensi PGK (penyempurnaan terapihipertensi dan DM)
Ringkasan
47
48
Ringkasan
Outlines
Terminology
Epidemiology
Pathology and Pathophysiology
Management
Summary
http://www.unckidneycenter.org/kidneyhealthlibrary/diabetes.html
Typical pattern of kidney damage in T2D patients Expansion of mesangial matrix with diffuse and nodular glomerulosclerosis (Kimmelstiel-Wilson nodules)
Thickening of glomerular and tubular basement membrane
Arteriosclerosis and hyalinosis of afferent and efferent arterioles
Tubulointerstitial fibrosis
Glomerular classification of DNRenal Pathology Society
Class Description
I Mild or nonspecific LM changes andEM-proven GBM thickening
II a Mild mesangial expansion
II b Severe mesangial expansion
III Nodular sclerosis (KimmelstielWilson lesion)
IV Advanced diabetic glomerulosclerosis
J Am Soc Nephrol , 2010. doi: 10.1681/ASN.2010010010
54
1. Photomicrograph adapted from Netter FH. The Ciba Collection of Medical Illustrations. Vol 6. Kidneys, Ureters, and Bladder. West Caldwell, NJ: CIBA Medical Education Division 1973:7. 2. Mauer MS, et al. Diabetic nephropathy. In: SchrierRW, Gottschalk CW, eds. Diseases of the Kidney. 5th ed. Vol 3. Boston: Little, Brown and Company; 1993:363. 3. Photomicrographs adapted from Fogo A, Weedman B. Diabetic nephropathy. In: AJKD Atlas of Renal Pathology. Available at: http://www2.us.elsevierhealth.com/ajkd/atlas/34/5/atlas34_5.htm (accessed May 2012).
Structural changes in the progression of diabetic nephropathy to end-stage renal disease (ESRD)
ESRD2,3
Kidney failure or ESRDGFR
PATHOPHYSIOLOGY
Hyperglycemia
AGE
Cytokine
Autoimmune
Adaptive ImmunityOdegaard, 2012
56
Traditional Epidemiology
DiseaseExposure
Molecular Epidemiology
Markers of Exposure Markers of Disease
Exposure Internal
Dose
Biologically
Effective
Dose
Early
Biological
Effect
Clinical
Disease
Prognostic
Significance
Altered
Structure/
Function
Markers of Susceptibility
Figure 13-1 Aspects of continuum between an exposure and a disease that can be studied by
molecular epidemiology. (Figure 1.2, p.6, from Schulte and Perera, 1993. Reproduced with permission
from the author and Elsevier Science)
57
CV, cardiovascular; LIFE, Losartan Intervention for Endpoint Reduction in Hypertension.
Ibsen H, et al. Diabetes Care. 2006;29:595600.
LIFE: Albuminuria predicts risk of CV events in people with Diabetes and Hypertension
Incidence of primary composite endpoint* stratifiedby time-varying albumin to creatinine ratio
0 20 30 40 50 70
End
po
int
rate
0.00
0.36
0.24
0.12
0.06
10
13 mg/mmol
(n=255, 238, 250)
1 mg/mmol
(n=274, 406, 311)
0.30
0.18
Month*Primary composite endpoint included cardiovascular death, myocardial infarction and stroke
Numbers in parentheses refer to the numbers of at-risk patients in each range at baseline and at years 2 and 4
60
312 mg/mmol
(n=267, 239, 213)
12 mg/mmol
(n=267, 174, 175)
ADA Executive Summary: Standards of Medical Care in Diabetes 2014
...............microalbuminuria (30299 mg/24 h) and macroalbuminuria(>300 mg/24 h) will no longer be used,
Persistent albuminuria at levels 30299 mg/24 h
and levels >300 mg/24 h.
Normal albumin excretion is currently defined as
Patients with diabetes are at high risk of kidney disease
59
Up to 40% of those with T2D will eventually
suffer from kidney failure2,3,6
1040%
Mortality is more frequent in T2D patients with kidney disease than in those without
60
Percentages indicate absolute excess mortality above the reference group (individuals with no diabetes or kidney disease)*No diabetes and no kidney disease; GFR, glomerular filtration rate; T2D, type 2 diabetesAfkarian M et al. J Am Soc Nephrol 2013;24:302
Stan
dar
dis
ed 1
0-y
ear
cu
mu
lati
ve
inci
de
nce
of
mo
rtal
ity
(95
% C
I)
4.1%
17.8%
23.9%
47.0%
7.7%
0
10
20
30
40
50
60
70
No kidney disease Albuminuria Impaired GFR Albuminuria &impaired GFR
No diabetes, nokidney disease
Excess mortality
Increased mortality
DM
Diabetic Kidney Disease
(Microalbuminuria / Proteinuria)
ESRD
Cardiovascular Disease
CVD as cause of death in CKD
CKD is a health burden, estimates of nearly 20 million affected in US
Causes of death in CKD
Infection15%
Other heart disease2%
Cerebrovascular
6%Unknown
7%
Other26%
Cancer4%
CHD41%
(NKF-K/DOQI 2003)
Uri
nar
ypro
tein
excr
etio
n(m
g/d
)
Glo
mer
ula
rfi
ltra
tion
rate
(GFR
)(m
L/m
in)
Functional
Structural
GFR -
(90-95%)
Renal
hypertrophy
Microalbuminuria,hypertension
Mesangial expansion,
glomerular basement
membrane thickening,arteriolar hyalinosis
Proteinuria, nephroticsyndrome, GFR
Mesangial nodules
(Kimmelstiel-Wilsonlesions)
Tubular-interstitial fibrosis
Natural history of diabetic nephropathyUrinary protein excretionGFR
Years
0
150
100
50
5 10 15 20 25
1000
200
20
5000
Incipient diabeticnephropathy
Pre Overt diabeticnephropathy
End-stage
renal disease
1 2 3 4 5
Natural History
Future DKD prevalence will be determined primarily by:
(i) ongoing trends with respect to diabetes prevalence;
(ii) the impact of improved diabetes management and primary prevention of DKD; and
(iii) the impact of early detection and secondary prevention of the progression of DKD.
Nephrology 19 (2014) 450458
Outlines
Terminology
Epidemiology
Pathology and Pathophysiology
Management
Summary
ADA Executive Summary: Standards of Medical Care in Diabetesd 2014NEPHROPATHY
General Recommendations
Optimize glucose control to reduce the risk or slow the progression of nephropathy.
Optimize blood pressure control to reduce the risk or slow the progression of nephropathy.
Diabetes Care Volume 37, Supplement 1, January 2014 S1
Comparison of tight BP vs tight glucose
control in UKPDS
-50
-40
-30
-20
-10
0
Tight glucose control
Tight BP control
Microvascular
endpoints
*
Stroke
Any diabetes-
related endpoint
Diabetes-related
deaths
*
*
*
* p
Kim, 2017
DRUG ADJUSTMENT
IN DKD
Tuttle, 2014
DRUG ADJUSTMENT
IN DKD
Tuttle, 2014
DPP-4 INHIBITOR KIDNEY PROFILE
Kim, 2017
74
Weight Gain and Hypoglycemia in Patients With Type 2 Diabetes and Moderate-to-Severe
Chronic Renal Insufficiency1
LS
Mea
n B
od
y W
eig
ht
Ch
ang
e F
rom
B
asel
ine
at W
eek
54, k
g
Sitagliptin(n=143)
Glipizide(n=148)
6,2
17.0
0
2
4
6
8
10
12
14
16
18
Symptomatic Hypoglycemia
Sitagliptin(n=210)
Glipizide(n=212)
a25 mg once daily or 50 mg once daily.bMean dose of glipizide was 7.7 mg per day. Glipizide was initiated at 2.5 mg/day and titrated to a maximum of 20 mg/day.
APaT = All Patients as Treated; LS = least squares.
1. Arjona Ferreira JC et al. Diabetes Care. 2013;36:10671073.
Pat
ien
ts W
ith
1
Hyp
og
lyce
mic
Eve
nt
Ove
r 54
Wee
ks, %
P=0.001
Baseline weight; sitagliptin = 68.0 kg; glipizide = 70.2 kg
a
0.6
1.2
b
1.5
1.0
1.5
0
0.5
0.5
1.0
LS mean difference at week 54 1.8; P
75
APaT, Excluding Data After Initiation of Glycemic Rescue Therapy
Weight Gain and Hypoglycemia in Patients With Type 2 Diabetes and End-
Stage Renal Disease on Dialysis1
6,3
10,8
0
2
4
6
8
10
12
Symptomatic HypoglycemiaP
atie
nts
Wit
h
1 E
pis
od
e o
f H
ypo
gly
cem
ia ,
%
Sitagliptin(n=64)
Glipizide(n=65)
0.2 (1.4, 1.1)
0.8 (0.5, 2.1)
-1,5
-1
-0,5
0
0,5
1
1,5L
S M
ean
Bo
dy
Wei
gh
t C
han
ge
Fro
m
Bas
elin
e at
Wee
k 54
, kg
Sitagliptin(n=45)
Glipizide(n=41)
APaT = All Patients as Treated; LS = least squares; CI = confidence interval.a25 mg once daily.bMean dose of glipizide was 5.3 mg per day. Glipizide was initiated at 2.5 mg/day and titrated to a maximum of 20 mg/day.
1. Arjona Ferreira JC et al. Am J Kidney Dis. 2013;61:579587.
Baseline, kg 68.2
a
b
LS Mean Between-Group Difference (95% CI)
1.0 (2.8, 0.9)
a
b
LS Mean Between-Group Difference (95% CI):
4.5% (15.3, 5.6); P=0.3
69.8
ADA Executive Summary: Standards of Medical Care in Diabetes 2014
HYPERTENSION/BLOOD PRESSURE CONTROL
Pharmacological therapy for patients with diabetes and hypertension should comprise a regimen that
includes either an ACE inhibitor or an angiotensin receptor blocker (ARB).
Diabetes Care Volume 37, Supplement 1, January 2014 S1
Blood pressure management inCKD ND patients with diabetes mellitus
We suggest that an ARB or ACE-I be used in adults with diabetes and CKD ND with urine albumin excretion of 30 to 300 mg per 24 hours (or equivalent*).
We recommend that an ARB or ACE-I be used in adults with diabetes and CKD ND with urine albumin excretion >300 mg per 24 hours (or equivalent*).
KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney DiseaseKidney International Supplements (2012) 2, 347356
XII. Treatment of Hypertension in association with Diabetic
Nephropathy
If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5
ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control
of volume is desired
THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg
DIABETES
with
Nephropathy
ACE Inhibitor
or ARB
IF ACEI and ARB are contraindicated or not tolerated,
SUBSTITUTE
Long-acting CCB or
Thiazide diuretic
Addition of one or more ofLong-acting CCB or Thiazide diuretic
3 - 4 drugs combination may
be needed
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Pharmacological therapy for patients with diabetes and hypertension
Guidelines Anti hypertesion
KDOQI ACE-I or ARB
KDIGO ARB or ACE-I
ESH ACE-I or ARB
ADA ACE-I or ARB
JNC 8 All
CHEP ACE-I or ARB
BP Targets in Diabetes Mellitus
GUIDELINES TARGET
KDOQI(2007) 130/80
KDIGO (2012) 140/90 (130/80)
ESH(2013) 140/85
JNC 8 (2014) 140/90
ADA (2014) 140/80
CHEP (2015) 130/80
Kim, 2017
EMERGING TREATMENT
EMERGING TREATMENT
A multifactorial intervention strategy is recommended in DKD
ACEi, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; DKD, diabetic kidney disease; HbA1c, glycated haemoglobin1. National Kidney Foundation. Am J Kidney Dis 2012;60:850; 2. NICE. Clinical guideline: Type 2 diabetes (CG87), May 2009 85
Glucose
BP
Lipids
ACEi/ARB
HbA1c target individualised, but generally ~7%1
Target of
We recommend that metformin be continued in people with GFR 45 ml/min/1.73 m2 (GFR categories G1-G3a); its use should be reviewed in those with GFR 3044 ml/min/1.73 m2 (GFR category G3b); and it should bediscontinued in people with GFR
ADA Executive Summary: Standards of Medical Care in Diabetes 2014
Medical Nutrition Therapy
Supplements for Diabetes Management (1)
There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies.
Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety.
. Diabetes Care Volume 37, Supplement 1, January 2014 S1
ADA Executive Summary: Standards of Medical Care in Diabetes 2014
Medical Nutrition Therapy
Supplements for Diabetes Management
Evidence does not support recommending n-3 (EPA and DHA) supplements for people with diabetes for theprevention or treatment of cardiovascular events.
There is insufficient evidence to support the routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes.
Diabetes Care Volume 37, Supplement 1, January 2014 S1
ADA Executive Summary: Standards of Medical Care in Diabetes 2014
Medical Nutrition Therapy
Supplements for Diabetes Management
There is insufficient evidence to support the use of cinnamon or other herbs/supplements for the treatment of diabetes.
It is reasonable for individualized meal planning to include optimization of food choices to meetrecommended daily allowance/dietary reference intake for allmicronutrients.
Diabetes Care Volume 37, Supplement 1, January 2014 S1
We recommend that adults with CKD seek medical orpharmacist advice before using over-the-counter medicines or nutritional protein supplements.
We recommend not using herbal remedies in people with CKD.
Kidney International Supplements (2013) 3, 1962
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
MEDICATION MANAGEMENT AND PATIENT SAFETY IN CKD
Outlines
Terminology
Epidemiology
Pathology and Pathophysiology
Management
Summary
SUMMARY
There is a linear growth in the incidence of Diabetic Kidney Disease(DKD)
DKD is a health problem with difficult management.
Problems in the handling of DKD, among others, in terms ofdiagnostics, monitoring and therapy that can be caused by variousfactors.
Some things to consider in the management of DKD is the controlof blood sugar and blood pressure .
There are some emerging and future treatments for DKD
Indonesia almost 2 million square
kilometers 18,307 islands population : 255,339,621
Indonesia almost 2 million square
kilometers 18,307 islands population : 255,339,621
255.000 pasien ESRD
MasalahEpidemioogi
Ketersediaan sarana prasarana
Tenaga
Tehnik pelaksanaan tindakan hemodialysis
Upaya pencegahan
Perjalanan klinis PGK
Sistem pembeayaan
Causes of CKD at the start of HD
Hypertension 31%
Diabetes 26%Glomerulopathy 14%
Pyelonephritis 10%
Obstruction 7%
Obstruction 7% Uric Acid 2%Lupus 1% Polycystic 1%Unknown 2%
Others 6%
Indonesian Renal Registry 2013
INDONESIANRENAL REGISTRY
Jumlah Unit HD Per propinsi Yang Mengirimkan Data tahun 2016
Propinsi Sign UP Kirim Data
Aceh 10 4
Sumut 35 20
Sumbar 6 4
Riau 3 2
Kepri 6 2
Jambi 4 2
Bangka 4 3
Sumsel 7 3
Lampung 15 3
Bengkulu 2 1
Jabar 109 100
Banten 11 7
DKI 59 37
Jateng 57 18
DIY 15 6
Jatim 65 32
Bali 24 14
NTT 1 1
Kaltim 10 6
Kalsel 6 3
Sulut 3 3
Sulteng 1 1
Sulsel 7 6
Jumlah 460 278
INDONESIANRENAL REGISTRY
Jumlah Unit HD Per propinsi Yang Mengirimkan Data tahun 2016
Propinsi Sign UP Kirim Data
Aceh 10 4
Sumut 35 20
Sumbar 6 4
Riau 3 2
Kepri 6 2
Jambi 4 2
Bangka 4 3
Sumsel 7 3
Lampung 15 3
Bengkulu 2 1
Jabar 109 100
Banten 11 7
DKI 59 37
Jateng 57 18
DIY 15 6
Jatim 65 32
Bali 24 14
NTT 1 1
Kaltim 10 6
Kalsel 6 3
Sulut 3 3
Sulteng 1 1
Sulsel 7 6
Jumlah 460 278
INDONESIAN
RENAL REGISTRY
2016
Grafik Jumlah Pasien Penyakit Ginjal Kronik Tahap 5 (N18) berdasarkan Diagnosa Etiologi Di Indonesia
E1 (Glumerulopati Primer) (GNC)
6%
E2 (Nefropati Diabetika)52%
E3 (Nefropati Lupus) (SLE)1%
E4 (Penyakit ginjal Hipertensi)
24%
E5 (Ginjal Polikistik)
1%
E6 (Nefropati Asam Urat)
1%
E7 (Nefropati Obstruksi)
4%
E8 (Pielonefritis Chronic0 (PNC)
3%
E9 (Lain-Lain)6%
E10 (Tidak Diketahui)2%
INDONESIANRENAL REGISTRY INSIDENSI DAN PREVALENSI PASIEN
HEMODIALISIS
9th Report Of Indonesian Renal Registry
2016
7
Data dari propinsi Jawa Barat dapat dilihat pada diagram di bawah ini
Data ini didapatkan dari 90 % unit HD yang ada maka data ini dirasa cukup lengkap dan dapat menilai insidensi dan prevalensi di wilayah tersebut. 90 % dibiayai oleh JKN baik PBI maupun non PBI. Penduduk Jawa Barat peserta JKN sebanyak 29 juta
Untuk data tahun 2016 dapat dihitung sbb :
Jumlah Total
Penduduk Jawa Barat 46,5 juta
Jumlah Pasien JKN (90%)
Peserta JKN Jawa Barat 29 Juta
Pasien Baru 6288 135 per juta penduduk
5659 195 per juta penduduk
Pasien Aktif 14869 319 per juta penduduk
13382 512 per juta penduduk
Distribusi Usia pasien HD Dalam Persen Tahun 2016:
Proporsi pasien terbanyak masih pada kategori 45 sd 64 tahun. Bila dilihat pada tabel di atas pasien yang berusia kurang dari 25 tahun memberi kontribusi sebesar 2,79 % hal ini menunjukkan sudah saatnya memberi perhatian pada kelompok usia muda untuk mulai memperhatikan kesehatan ginjal.
5029
74656288
7381
9382
14869
0
2000
4000
6000
8000
10000
12000
14000
16000
2014 2015 2016
Pasien Baru Pasien Aktif
BILA PESERTA JKN SELURUH INDONESIA SEBANYAK 130 JUTA ORANG MAKA JUMLAH PASIEN BARU PER TAHUN : 130 X 195 = 25.350
DAN PASIEN AKTIF PER TAHUN : 130 X 512 = 66.600Dan bila seluruh Indonesia menjadi peserta JKN maka pasien aktif HD
sebanyak :250 x 512 =
128.000 orang
Global: 2,522,000 dialysis patients
Fresenius Medical Care : ESRD Patients in 2013 A Global Perspective
Comparison of HD and PD patient numbers in the 15 largest countries ranked by total dialysis patient population
Fresenius Medical Care : ESRD Patients in 2013 A Global Perspective
Hong Kong Renal Registry Report 2012Trends in point prevalent distribution of renal replacement therapy patients as of December 31 of each year from 1996 to 2011.
Hong Kong Journal of Nephrology (2013) 15, 28e43
Kebutuhan mesin HD dan perawat255.000 pasien ESRD
90 % hemodialisis : 225. 000 pasien
10% CAPD : 25. 000 pasien
Dengan 3 shift 2 kali/mnggu
Diperlukan 2 x 225.000 = 450.000 tindakan/mnggu
Diperlukan 450.000 : 6 = 75.000 : 3 = 25.000 mesin
Diperlukan 25.000 perawat
Kebutuhan mesin HD dan perawatKeadaan sekarang
128.000 132.000 pasien
Untuk 3 shift 2x/minggu
Diperlukan 12.500 mesin HD dan 12.500 perawat
INDONESIANRENAL REGISTRY Jumlah Perawat Tahun 2016
Bersertifikat; 3350; 71%
Belum bersertifikat;
1378; 29%
Perawat
Bersertifikat
Belum bersertifikat
INDONESIANRENAL REGISTRY Jumlah Perawat Tahun 2016
Bersertifikat; 3350; 71%
Belum bersertifikat;
1378; 29%
Perawat
Bersertifikat
Belum bersertifikat
INDONESIANRENAL REGISTRY Jumlah Perawat HD & Jumlah Mesin
Tahun 2016
Jumlah
Jumlah Perawat 4728
Jumlah Perawat Bersertifikat 3350
Jumlah Mesin 6604
0
1000
2000
3000
4000
5000
6000
7000
INDONESIANRENAL REGISTRY Jumlah Perawat HD & Jumlah Mesin
Tahun 2016
Jumlah
Jumlah Perawat 4728
Jumlah Perawat Bersertifikat 3350
Jumlah Mesin 6604
0
1000
2000
3000
4000
5000
6000
7000
Bermain angka untuk pasien CKD di Indonesia
Jumlah pasien ESRD 0,1% dari 250.000.000 diperkirakan 250.000
Jumlah yang dilayani hemodialisis 5700 X 3 x3 = 51.300 (diperkirakan kemkes50.000)
Biaya tahun 2014 Rp 2.165.507.578.258,-
Jika terlayani semua pasien ESRD terlayani HD akan perlu beaya 5 X Rp2.165.507.578.258,- = Rp 10.827.537.891.290,-