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Chronic Kidney Disease (CKD) Evaluation and Management

What should we do if we have patient with Chronic Kidney Disease? Today, Mbah Dukun Bagong, modern shaman from medical and health information explains how to treat and give therapy for patient with chronic Kidney Disease (CKD). If someone has been established, there is an increased risk for Chronic Kidney Disease (CKD), but not yet exposed to CKD, it needs to be evaluated as below:

Clinical evaluation for all patients:
 Measurement of blood pressure
 serum creatinine to measure GFR
 The ratio of protein - creatinine ratio or albumin - creatinine morning, or when urine specimens (untimed spot urine specimen)
 Examination of urine sediment or disptik for detection of red blood cells and white blood cells
Clinical evaluation for a particular patient (depending on risk factors):
 ultrasound (eg for patients with symptoms of urinary tract obstruction; infection or stones, family history of polycystic kidney disease)
 serum electrolytes (Na, K, Cl, bicarbonate)
 Concentration of urine (specific gravity or osmolality)
 urine acidity (pH)

             It has been mentioned above (the definition of CKD) that markers of kidney damage is the presence of abnormalities in the composition of the blood or urine, or radiological abnormalities. Although there is some indication, but the NKF K / DOQI stresses the importance of proteinuria as a marker of kidney damage. The term proteinuria showed an increased excretion of urine for albumin, other specific proteins, or total protein. While the term specifically albumin showed an increase in urinary albumin excretion. Microalbuminuria indicates that the excretion of albumin above the normal value, but below levels that can be detected by tests for total protein. In adults with an increased risk of CKD is advisable to check with spot urine albuminuria, both with special disptik ratio for albumin or albumin / creatinine

Patients with CKD should be evaluated to determine:
a. Diagnosis (type of kidney disease)
b. comorbid conditions
c. Severity, through the determination of the degree of renal function
d. Complications, related to the degree of renal function
e. The risk of loss of kidney function
f. Risk of cardiovascular disease

For all patients that have been defined as CKD, the evaluation lab to do are:
 serum creatinine to determine GFR
 The ratio of protein / creatinine ratio or albumin / creatinine morning or when the spot urine
 Examination of urine sediment or dipstick for red blood cells and white blood cells
 radiological examination of kidney, usually ultrasound
 serum electrolytes (Na, K, Cl, bicarbonate)
Guidelines for K / DOQI 2002 recommends that interventions that are considered effective in inhibiting the progression are:
1. controlling blood sugar levels
2. control of blood pressure
3. RAA system activity control

              The American Diabetes Association (ADA) recommends the use of ACE inhibitors in all patients with DM who proved existing kidney disorders (microalbuminuria or proteinuria), view or presence of hypertension, as long as the use of these drugs are contraindicated and not cause complications.
ACE inhibitors and angiotensin receptor antagonists (ARBs) have a special protective role in patients with diabetic kidney disease and non-diabetic, besides lowering systemic blood pressure also lowers blood pressure and capillary filtration glomeruler proteins thus slowing progression of kidney damage. In addition both drugs also reduced cell proliferation and fibrosis caused by angiotensin 2.
While interventions are still under evaluation and are not yet conclusive
1. Restriction of protein in the diet
2. Lipid-lowering drugs
3. correction of anemia

Some Practical Aspects Management of CKD Patients
In everyday practice management of CKD is as follows:
1. Basic treatment of the disease
2. Control of water and salt balance
3. Diets low in protein, high aklori
4. control of blood pressure
5. control of electrolyte imbalance and acid-base
6. prevention and treatment of renal osteodystrophy (ODR)
7. treatment of specific symptoms uremi
8. early detection and treatment of infections
9. adjustment of drug delivery
10. detection and treatment of complications
11. preparation for dialysis and transplantation.

1. Basic Medicine
Treatment that can still be corrected absolutely must be done. Including, control of blood pressure, blood sugar regulation in diabetic patients, correction if there is obstruction of the urinary tract, as well as the treatment of urinary tract infection (UTI).

2. Control of Water and Salt Balance
Fluid administration adjusted to the production of urine. Namely 24-hour urine output plus 500 ml. Salt intake depends efaluasi ekektrolit, generally in the limit 40-120 mEq (920-2760 mg). Normal diet contains an average of 150 mEq. High doses of furosemide can still be used in early CKD, but in the next phase is no longer useful and the obstruction is contraindicated. Weighing, monitoring urine output and fluid balance records will assist the management of fluid and salt balance.

3. And High Protein Diet Low Calorie
Restricted protein intake from 0.6 to 0.8 grams / kg / day. Average daily protein requirements in patients with Chronic Renal Failure is 20-40 grams. Caloric needs at least 35 kcal / kg / day. High protein low calorie diet will improve the complaints of nausea, lower BUN and will improve symptoms. Besides low-protein diet will inhibit progression of decline in renal physiology.

4. management of Hypertension
In contrast to the control of hypertension in general, the CKD problem of fluid restriction absolutely necessary. Target blood pressure 125/75 is required to inhibit the rate of progression of decline in renal physiology. -ACE inhibitors and ARBs are expected to inhibit the progression of CKD. Serial monitoring of renal physiology needs to be done in the early treatment of hypertension when used ACE-inhibitors and ARBs. If the suspected presence of renal artery stenosis, ACE inhibitors are contra-indications.

5. Control of Electrolyte Balance and Acid-Base
The main electrolyte balance disorders in CKD is hyperkalemia and asidosis.Hiperkalemia may remain asymptomatic despite life-threatening. EKG changes, sometimes only emerge after a life-threatening hyperkalemia. Prevention includes:
a) low-potassium diet
avoid fruit (bananas, oranges, tomatoes) and vegetables of excess
b) avoiding the use of K-sparring diuretics
Treatment of hyperkalemia depends on the degree of emergency:
Intensive - glukonase calcicus intravenous (10-20 ml of 10% Ca gluconate)
- Intravenous glucose (25-50 ml of glucose 50%)
- 10-20 units of insulin
- Intravenous sodium bicarbonate (25-100 ml 8.4% NaHCO3)
  can be used also fast-acting insulin 2 U are mixed into a 25 cc 40% dextrose, administered iv bolus.
Increases the expression of potassium
   • Furosemide
   • K-exchange resin
• Dialysis

Acidosis led to complaints of nausea, weakness, water-hunger and drowsiness. Intravenous treatment with NaHCO3 only given in severe acidosis, whereas if it is not life threatening can be administered either by mouth.

6. Prevention and Treatment of ROD
Included in this action is
a. control hiperphosphatemia
Serum P levels should be maintained less than 6 mg / dl.dengan way low phosphorus diet alone is not enough sometimes, so it should be given phosphate binder medication. 300-1800 mg of aluminum hydroxide is supplied with a meal. This method is now abandoned because of side effects of aluminum intoxication and constipation. As another option may be given 500-3000 mg of calcium carbonate with meals with a profit increase calcium intake and also for the correction of hypocalcemia. Foods that contain high phosphorus should be avoided such as milk, cheese, yogurt, ice cream, fish and nuts. Hiperphosphatemia control can also inhibit progression of decline in renal physiology.
b. Supplements of vitamin D3 active
1:25 dihydroxy vitamin D3 (calcitriol) is given only if the normal P levels. Limitation provision if the Ca × P <65. The dose given was 0:25 micrograms / day.
c. Paratiroidektomi
Done if the ODR process continues

7. Specific Treatment of Symptoms Uremi
Included here is the symptomatic treatment of pruritus, complaint handling gastrointestinaldan anemia. Diets low in protein, P-control as well as giving diphenhydramine may improve pruritus complaints. Low-protein diets also improve complaints of anorexia and nausea. Anemia that occurs in CKD mainly caused by a deficiency of the hormone erythropoietin. It also can be caused by defisisensi Fe, folic acid or B12. administration of recombinant erythropoietin in patients with CKD who underwent HD will improve the quality of life, can also be given to pre-HD patients with CKD. Before giving erythropoietin and iron supplementation is required evaluation undergraduate levels, TIBC, and ferritin. I.

8. Detection and Treatment of Infection
Patients with CKD is an patients with a low immune response, so the possibility of infection should always be considered. Febrile symptoms sometimes do not emerge because of this low immune response.

9. Dispensing Adjustment
Some drugs require dose adjustment due to excretion of metabolites through the kidneys. The use of nephrotoxic drugs such as aminoglycosides, co-trimoxazole, amphotericin should dihndari and diberika only on special circumstances. NSAIDs also decrease kidney function. Tetracycline also reduced protein catabolism. Nitrofurantoin should be avoided and the use of K-sparing diuretics should also be careful because it causes hyperkalemia.
10. Detection and Treatment of Complications
With more and continued PGK greater likelihood of complications arise. Some complications are indications for immediate commencement of hemodialysis (HD) even though the patient has not reached the stage of CKD stage 5.

Complications are an indication for HD action include:
a) uremic encephalopathy
b) Pericarditis or pleuritis
c) progressive peripheral neuropathy
d) progressive ODR
e) hyperkalemia that can not be controlled with medical treatment
f) overload syndrome
g) a life-threatening infections
h) Social conditions

11. Preparation of Dialysis and Transplantation
Patients with CKD and their families must be informed early on that at some point people will goes a HD or renal transplantation. Preparation of vascular access should've done before creatinine clearance below 15 ml / min. Vascular access creation is recommended if creatinine clearance was below 20 ml / min. Need to restrict blood vessel puncture area that will be used for limb-vascular access. Besides the preparation of medical terms is also important to non-medical preparation.

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