Chronic Kidney Disease

and Nutritional Intervention

Nur Samsu
Division of Nephrology and Hypertension
Department of Internal Medicine
FMUB Dr Saiful Anwar Hospital
2015

Objectives
Definition

and classification of CKD

Investigations

and Principles Management of

CKD
Interventions

for slowing progression of CKD

Nutrition/dietary

protein intervention
2

What Does The Kidney Do?

Remove

Waste Products from the body

Remove Drugs from body
Balance the bodys fluids
Release hormones that regulate blood
pressure
Produce an active form Vit D that
promotes strong healthy bones
Control production of red blood cells

Ginjal

Sistem
Filtrasi
Glomerulu
s

Glomerulus

Kapiler Glomerulus

Slit diaphragm

Barier Filtrasi/Penyaring

GBM

Fenestrated endothelium

Komponen komplek protein Slit-Diaphragm

Penampakan lapisan luar penyaring ginjal yang sehat dengan mikroskop elektron

Penampakan lapisan luar penyaring ginjal yang sakit (sindroma nefrotik)

Normal Kidney Function

MDRD

GFR >90 mL/min/1.73 m2 and all

of the following
No

hematuria
No proteinuria
No parenchymal or structural abnormality
(cyst, scar, hydronephrosis)

Kidney/Dialysis Outcomes Initiative. Am J Kidney Dis. 2002;39:S1S266.

Filtration, Reabsorption and Secretion

Normal GFR 120 ml/min/1.73m2

In a day 210 L of water is filtered

Only 20% nephrons work at a time

2 L /day of urine is excreted

Criteria for CKD

(either of the following present for > 3 months)
Markers of
kidney damage
(one or more)

Albuminuria (AER 30 mg/24 hours; ACR 30 mg/g

[ 3 mg/mmol]).
Urine sediment abnormalities.
Electrolyte and other abnormalities due to tubular
disorders.
Abnormalities detected by histology.
Structural abnormalities detected by imaging.
History of kidney transplantation.

Decreased GFR

GFR < 60 ml/min/1.73 m2 (GFR categories G3a G5)

KDIGO 2012, Kidney International Supplements (2013) 3, 5-14

Staging of CKD
GFR Category

GFR
(ml/min/1.73 m2)

Terms

G1

90

G2

60 89

Mildly decreased

G3a

45 59

Mildly to moderately decreased

G3b

30 44

Moderately to severely decreased

G4

15 29

Severely decreased

G5

< 15

Normal or High

KIDNEY FAILURE
KDIGO 2012, Kidney International Supplements (2013) 3, 5-14

Definition and Stages of CKD

GFR
(mL/min/1.73 m2)

With Kidney
Damage

Without Kidney
Damage

With
HBP

Without
HBP

With
HBP

Without
HBP

> 90

High BP

normal

60 89

High BP with
GFR

GFR #

30 59

15 29

< 15 or Dialysis

Shaded areas represent CKD; HBP is defined as > 140/90 mmHg

# May be normal for age

AJKD 2002: 39(2)

Age-Related Decline in GFR

Age-related
Should
GFR

declines in GFR occur

not be considered disease

6089 mL/min/1.73 m2

Kidney/Dialysis Outcomes Initiative. Am J Kidney Dis. 2002;39:S1S266.

Normal GFR in Adults

Predictors of Progression
Cause

of CKD
Level of GFR
Level of albuminuria
Age
Sex
Race/ethnicity
Elevated Blood
Pressure

Hyperglycemia
Dyslipidemia
Smoking
Obesity
History

of CVD
Ongoing exposure
to nephrotoxic
agents

Investigation and Principles

Management of CKD

16

Stages in Progression of CKD and Therapeutic

Strategies
COMPLICATIONS

Normal

Increased Risk

Screening for
CKD risk
factors

CKD risk
reduction,
Screening for
CKD

DM/HT

Damage

3
Diagnosis &
treatment,
Treat comorbid
conditions,
Slow
progression
PROTEINURIA

GFR

Kidney
failure

Estimate
progression, Treat
complications,
Prepare for
replacement
Creatinine

CKD
death

Replacement
by dialysis &
transplant

17

(K/DOQI Guidelines 2002)

Proteinuria
Care plan

STAGE 1 & 2
Proteinuria plus
eGFR 60+
(to determine eGFR
over 60, hand
calculate GFR using
Cockcroft-Gault
formula)

CKD
Care plan

STAGE 3
eGFR 3059
ml/min

ESKD
Care plan

STAGE 4
eGFR 15-29
ml/min

MODERATE

SEVERE

KIDNEY

KIDNEY

DAMAGE

DAMAGE

STAGE 5

PALLIATIVE CARE

eGFR <15
ml/min
FAILURE

DIALYSIS
HAEMODIALYSIS
PERITONEAL DIALYSIS
TRANSPLANTATION

GFR = (140 - Age) x wt (kg)

72 x se creat (mg/dL)

Chronic
Kidney
Disease
Diagnosis

End Stage
Kidney
Disease
Diagnosis

Kidney
Failure

SUPPORTIVE CARE APPROACH

Investigating CKD

Why eGFR ? Why not Creatinine ?

s.Creatinine Concentration
High s.Creatinine
with Normal GFR

Spurious elevation:

Cephalosporin

Alcohol intoxication

Blocking tubular secretion:

Cimetidine or trimethoprim

Increased creatinine
production:

Exogenous: ingestion of
large quantities of meat

Endogenous: Muscular
disorders, or increases in
muscular mass

Normal s.Creatinine
with CKD

Poor production of
creatinine:
Severely

malnourished

patients
Elderly
Small

children

Ladies

of small size

21

Principles Management
Early

recognition of CKD

Estimate

the severity of CKD

The cause of CKD
Detection and correction of any reversible
cause.
Avoidance of additional renal injury
Institution of interventions to delay progression
Treatment of complications
Planning for renal replacement therapy

22

Clinical Features
Mild

to Moderate CKD:

Usually

Severe

NO SYMPTOMS

renal failure: NON SPECIFIC

Pale,

fatigue & shortness of breath

Hypertension, headaches
Polyuria/nocturia
Body itch
Poor appetite, nausea, vomiting
Hyperventilation
Swelling of the face and legs

23

Complications of CKD
Stage of CKD

Complications

Stage 1

Stage 2

BP

Stage 3

Stage 4

Malnutrition
Metabolic acidosis
Kalium

Stage 5

Azotemia
Volume overload

iPTH

Ca2+/PO4 disturbances
Dyslipidemia
LVH
Anemia

24

http://www.health.gov.bc.ca/gpac/pdf/ckd.pdf

Interventions

25

DOMAINS OF CKD CARE

CV RISK
FACTOR
MODIFICATION

PROTEINURIA
REDUCTION

EVALUATE
CKD
PROGRESSION

VAX

NUTRITIONAL
ASSESSMENT

ANEMIA
MGMT

CKD-MBD
MGMT

GLYCEMIC
CONTROL
LIPID
CONTROL

HTN

27

NKF K/DOQI Guidelines, 2002

Interventions to delay progression

Strict

glucose control in
diabetes
Strict blood pressure
control
RAA system blockade
Treat anemia of CKD

Optimize

nutrition

Treat

associated CVD
and dyslipidemia

Prevent

renal
osteodystrophy (ROD)

ME Rosenberg. Chronic Kidney Disease: Progression

in NephSAP. Ed. RJ Glassock. 2003;2(3):85111.

Prevent

AKI and avoid

nephrotoxins
28

Early CKD Treatment Preserves Kidney

Function
100

75

GFR

50

25
10
4

Time (yr.)
29

TH Hostetter, National Kidney Disease Education Program, 2003.

11

Glycemic Control in Diabetics

Tight

control of blood glucose HbA1C

<7%
Delay

the onset of microalbuminuria

Decrease or stabilize protein excretion
in patients who already had
microalbuminuria
Zabetakis PM, Nissenson AR. Am J Kid Dis. 2000;36(suppl):S31-S38.
The Diabetes Control and Complications Trial, long-term Sweden study, Japanese study
30

Hyperlipidemia
In

CKD:

Mainly

hypertriglyceridemia

Increases glomerulosclerosis by:

Increasing

mesangial proliferation and matrix

production
Altering glomerular hemodynamics
Increasing local inflammation

K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease.
Am J Kidney Dis 2003:41(Suppl 3):S1S91.

31

Dyslipidemia Treatment
Smoking

cessation

Aspirin

use

Weight

loss

Aerobic

Exercise

Statins
Fibric Acid

Derivatives

LDL Goal

< 100mg/dL, HDL > 40mg/dL, TG

< 150mg/dL, Non-HDL-C < 130mg/dL

K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease.
Am J Kidney Dis 2003:41(Suppl 3):S1S91.

32

Anemia
Present

when GFR < 30-35 mL/min

Causes:
Reduced

EPO production
Others: iron deficiency, rapid destruction of RBC,..
Anemia

CHF

is an independent risk factor for death in

Studies
1%

of LV Dysfunction (SOLVD) 7000 patients

lower Hct was associated with 1% higher risk of mortality

Al Ahmad. et al. J Am Coll Cardiol. 2001;38:955-962.

33

Anemia: A Risk Multiplier

8.0

7.3

7.0

6.0

6.3

6.0
4.6

5.0
3.6

4.0
3.0
2.0

1.0

1.5

2.0

2.0

2.4

2.4

3.7

3.7

4.7

4.0

2.9

1.0

N
on
e
D
An M o
em nl
ia y
on
ly
C
K
D
D
M
on
/C
D
ly
M
K
D
/A
o
ne
m nly
ia
D
M
on
/C
ly
C
K
H
D
F
/A
on
ne
ly
m
ia
D
on
M
C
/
ly
C
K
H
D
F
/A
on
ne
C
ly
H
m
F/
ia
D
An
M
o
/C
em nly
H
F/
i
An a o
em nly
C
ia
C
H
H
F/
F/ on
C
ly
C
K
K
D
D
/A
ne on
D
l
M
/C mia y
D
H
M
on
F/
/C
ly
C
H
K
F/
D
C
on
K
D
ly
/A
ne
m
ia

0.0

Source: Medicare sample (5%), followup from 1996 to 1997 of enrollees aged >65 y.o.,
adjusted for age, gender and race.

34

Cardio - Renal - Anemia

Syndrome
Vicious Circle of Destruction

CKD
To save the HEART and the KIDNEY,
treat the ANEMIA

CHF

Anemia
35

Hypertension
Role of the Kidney in Hypertension
Renal-Body

Fluid Feedback System for

Long-Term BP Regulation
Mechanisms of Impaired Renal-Pressure
Natriuresis in Hypertension
Salt-Sensitive and Salt-Insensitive
Hypertension
The Renin-Angiotensin System
Aldosterone
36

CKD and Hypertension

Core Concepts of Treatment
Hypertension and proteinuria
independent variables that predict
long-term decline in renal function

Renal disease a CAUSE and CONSEQUENCE of HT

Reduction of BP reduces CV & renal risk

Reduction of proteinuria lower CV & renal risk

37

www.hypertensiononline.org

Interchangeable,

CAPD

depends on residual renal function

Transplant

HD

Hemodialysis

39

Hemodialysate

Artificial
kidney

Hollow fiber Dialyzer

44

A HD patient in the USA

Principles of peritoneal dialysis

47

Transplantasi Ginjal

Donor

Resipien

Nutrition/Dietary Protein
Intervention

Alternatives to Avoid

status nutrisi pasien pada

awal dialisis adalah faktor
risiko penting terhadap
mortalitas dan morbiditas
American Journal of Kidney Diseases, K/DOQI Clinical Practice Guidelines Vol 35 No 6, supp2 (June) 2000

Nutritional Intervention
Rationale
AA loads

:
induce glomerular hyperfiltration

Protein

restriction in small studies retards

CKD progression

Obesity

(BMI >38 kg/m2) associated with

glomerular hyperfiltration

Protein Intake Associated with Kidney Function

55
S Klahr, et al. N Engl J Med 1994;330:877884.
EL Knight, et al. Ann Intern Med 2003;138:460467.

CKD: Nutrition Protein Intake

Associated with Kidney Function
Nurses

Health Study (n=1135 females);

11-year followup
Median

protein intake, 92.3 g/d

Each 10-g in protein intake CCr by 1.21
mL/min
Highest quintile CCr by 4.77 mL/min

S Klahr, et al. for th MDRD Study Group. N 56

Engl J Med. 1994;330:877884
EL Knight, et al. Ann Intern Med 2003;138:460467.

Nutrition Therapy
Consult

Renal Dietitian at CKD Stage 3

Protein restrict @ GFR <25 mL/min/1.73 m
2

High

biologic protein: 0.60.75 g/kg BW

Initiate dialysis if
GFR

<1520 with energy malnutrition from low protein

intake
6% weight loss or <90% of IBW in < 6 months

57
K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias
in CKD. AJKD 2003:41(Suppl 3):S1S91.

Progression of CKD :
Proteinuria
PROTEINURIA is the major determinant in the rate of CKD
progression!
Protein, which is excessively filtered by the glomerular
membranes:

Disturbs the membrane permselectivity

Changes the glomerular hemodynamics

Contributes to interstitial injury by causing inflammatory reactions

renal scarring and correlate with declining renal function
Keane WF. AJKD. 2000;35(4suppl1):S97-S105.
Yusuf S, et al. NEJM. 2000;342(3):145-153.

Dual Significance of Proteinuria

Proteinuria results from injury to
glomerular circulation
Increased proteinuria is associated with
progressive CKD
In diabetes and hypertension, proteinuria
signifies injury to the systemic circulation
Proteinuria is associated with increased
CV risk

Agarwal R. Cardiol Rev. 2001;9(1):36-44.

Bakris GL, et al. AJKD. 2000;36(3):646-661.
Bianchi S, et al. AJKD. 1999;34(6):973-995.

Protein-restricted diets
Effect on progression in non-diabetic CKD patients

PEDRINI et al. (1996): Ann Intern Med, 124, 627-632

Protein-restricted diets
Efficacy in delaying the need of dialysis
Study

Year

Treatment

(non-diabetics)

Control

OR

renal death/n renal death/n

IHLE et al
JUNGERS et al
KLAHR et al
LOCATELLI et al
MALVY et al
ROSMAN et al.
WILLIAMS et al
Total (95%CI)

1989
1987
1994
1991
1999
1989
1991

4 / 34
5 / 10
18 / 291
21 / 230
11 / 25
30 / 130
12 / 33

13 / 38
7/9
27 / 294
32 / 226
17 / 25
34 / 117
11 / 32

101 / 753

141 / 741

(95 % CI)

0,1

0,2

Reducing protein intake in patients with CKD reduces the occurence of

renal death by 40% compared with higher/unrestricted protein intake
FOUQUE et al. (2003): The Cochrance Library, Volume 1

10

Guidelines :
Protein in pre-dialysis patients

The CARI Guidelines

For patients with progressive CKD, who receive a

protein-restricted diet, the protein content should
not be lower than 0.75 g/kg IBW/day.

The protein should be of at least 50% high biological

value.

Energy intake of at least 35 kCal/kg IBW/day to

minimized PEM (level II evidence)

Kidney Disease Outcomes Quality

Initiative:
For

individuals with CKD who are not undergoing

MD, the institution of a planned low-protein diet
providing 0.6 g protein/kg/d should be considered.

For

individuals who will not accept such a diet, an

intake of up to 0.75 g protein/kg/d may be
prescribed.

British Renal Association

High

biological value protein diet restricted to a

total protein intake of 0.81.0g/kg/24 hours, with
adequate energy intake (at least 35 kCal/kg
IBW /24 hours),

VLPDs

(less than 0.5 g/kg/24 hours) are not

recommended, for the risk of protein malnutrition
from negative nitrogen balance.

European Dialysis & Transplant Nurses

Association/European Renal Care Association:

The dietician advisor will advise the pre-dialysis patient on

a dietary protein intake of 0.61.0g/kg IBW/day for active,
non-catabolic patients.

Very restricted protein diets (< 0.5 g/kg/24hrs) require

supplements.

To avoid protein malnutrition or other subtle nutritional

problems, a higher protein minimum of 0.75 g/kg per day
is recommended when GFR < 30 mL/min.

Apakah ginjal anda sehat ?

Organ yang luar biasa:
Setiap

hari ginjal kita menyaring 200 liter darah

menghasilkan 2 liter sampah dan kelebihan air.
Pabrik penghasil 3 hormon penting, EPO, Renin,
kalsitriol

Thank you
for your attention

68

Konsensus Nutrisi Pada PGK,

PERNEFRI
2012

PANDUAN 1
Tujuan Penatalaksanaan Nutrisi
Pada Penyakit Ginjal Kronik

Tujuan Umum
1.

Mengendalikan gejala-gejala uremia

2.

Mencegah progresivitas penyakit ginjal

3.

Mempertahankan status nutrisi yang optimal

4.

Mengendalikan kondisi-kondisi terkait PGK

seperti anemia, hipertensi, dislipidemia,
penyakit tulang dan kardiovaskular.

Tujuan Khusus
PGK Predialisis

Mengurangi akumulasi
produk-produk sisa nitrogen.
Mengurangi gangguan
metabolik terkait uremia.
Memperlambat laju
progresivitas penyakit ginjal.
Mengatur keseimbangan air
dan elektrolit.
Mengendalikan kondisikondisi terkait PGK seperti
anemia, penyakit tulang dan
penyakit kardiovaskular

PGK HD

Memperbaiki dan mempertahankan

status gizi optimal.

Mencegah penimbunan sisa

metabolisme berlebih.

Mengatur keseimbangan air dan

elektrolit.

Mengendalikan kondisi-kondisi
terkait PGK seperti anemia,
penyakit tulang dan penyakit
kardiovaskular

Tujuan Khusus
PGK PD

Transplantasi Ginjal

Jangka Pendek (<6 minggu pasca transplan)

Membantu penyembuhan luka
Memperbaiki dan mempertahankan
Meningkatkan anabolisme
status gizi optimal.
Mencegah infeksi
Mengantisipasi dan mengatasi efek
Mencegah penimbunan sisa
metabolisme obat imunosupresan

metabolisme berlebih.

Jangka Panjang (>6 minggu pasca transplan)

Mencapai atau mempertahankan berat
badan ideal
Mempertahankan kadar gula
Mengendalikan kondisi-kondisi
Mempertahakan kadar kolesterol >200mg/dL
terkait PGK seperti anemia,
Mempertahankan tekanan darah normal
penyakit tulang dan penyakit
Mempertahankan densitas tulang normal
Mengantisipasi dan mengatasi efek
kardiovaskular.
metabolisme obat imunosupresan
Mempertahankan fungsi ginjal sisa.
Mempertahankan gaya hidup sehat

Mengatur keseimbangan air dan

elektrolit.

PANDUAN 2
Penilaian Status Nutrisi

Parameter Penilaian Status Nutrisi

Antropometri :
TB, BB, IMT, LLA, TLK
Biokimia :
Albumin serum, Kolesterol total, Kreatinin serum, Transferin serum,
Prealbumin serum, Bikarbonat serum, status inflamasi (CRP)
Klinis atau Fisik :
Interdialytic Weight Gain (IWG)
Bioelectrical Impedance Analysis (BIA)
Subjective Global Assesment (SGA)
Riwayat Makan :
Food recall and food record
Malnutrition Inflammation Score (MIS)

Indikator Malnutrisi
1. SGA (B) dan (C)
2. Albumin serum < 3,8 g/dl
3. Kreatinin serum < 10 mg/dl
4. Indeks massa tubuh (IMT) < 20 kg/m2
5. Kolesterol < 147 mg/dL
6. Prealbumin serum < 30 mg/dL

PANDUAN 3
Rekomendasi Asupan Energi,
Protein dan Lemak

Rekomendasi Asupan Energi

1.

PGK pre-dialisis: 35 kkal/kgBB ideal/hari (30-35

kkal/kgBB ideal/hari pada sedentary life style atau
aktivitas minimal atau usia lanjut)

2.

PGK-HD: 30-35 kkal/kgBB ideal/hari.

3.

PGK-PD: 30-35 kkal/kgBB ideal/hari, dengan

memperhitungkan asupan kalori (dekstrosa) dari
cairan dialisat.

4.

Transplantasi ginjal: 30-35 kkal/kgBB ideal/hari.

Kalori Dialisat
Dekstrosa

1,5% = 86,08
Dekstrosa 2,5% = 144,68
Dekstrosa 4,25% = 243,91

Rekomendasi Asupan Protein

1. PGK pre-dialisis: 0,6-0,75 g/kgBB ideal/hari.
2. PGK-HD: 1,2 g/kgBB ideal/hari.
3. PGK-PD: 1,2-1,3 g/kgBB ideal/hari
4. Transplantasi ginjal: 1,3 g/kgBB ideal/hari pada 6

minggu pertama pasca transplantasi. Selanjutnya

0,8-1 g/kgBB ideal/hari.
5. Protein yang diberikan minimal 50% dengan

kandungan biologis tinggi (protein hewani).

Rekomendasi Asupan Lemak

1. PGK pre-dialisis, PGK-HD: 25-30% dari
total kalori
2. Pembatasan lemak jenuh <10%
3. Bila didapatkan disiplidemia dianjurkan
kadar kolesterol dalam makanan <300
mg/hari.

PANDUAN 4
Rekomendasi Vitamin, Air, Mineral
dan Trace Elements

PANDUAN 5
Monitoring dan Evaluasi

SKENARIO
Ny. F, 58 tahun, MRS pada tanggal 11 Januari 2015 di RS Pertiwi
karena mengalami sesak nafas dan hipertensi. Sejak Desember 2014,
Ny. F dinyatakan menderita GGK dan harus menjalani hemodialisa 2
kali seminggu. Gejala yang sering dialami Ny. F antara lain badan
terasa lemas, mual, muntah, nafsu makan menurun, volume BAK
berkurang, dan gatal-gatal. Terapi diet yang diberikan sekarang adalah
diet Rendah Protein RG. Ny. F sudah pernah berkonsultasi dengan ahli
gizi terkait diet yang harus dijalankan. Namun, yang menjadi kendala
utama dalam pengaturan diet Ny. F adalah Ny. F seringkali menolak
pembatasan garam dalam makanan dan masih suka mengkonsumsi
crekers, dan makanan kalengan. Asuhan gizi yang optimal dan
kolaborasi antar tim kesehatan sangat diperlukan untuk membantu
mempertahankan kualitas hidup pasien.

Problem
PGK

stadium V on Reguler HD
Hipertensi stadium 2
Anemia on PGK
Dispepsia
Hipoalbuminemia
Hiponatremia
Hiperkalemia

Pre-dialysis bicarbonate for 277 patients

120

Normal range

Number of patients

100

80

60

40

20

0
16

18

20

22

24

26

Bicarbonate (mmol/l)

28

30

32

Pre-dialysis potassium levels for 7500 sessions

2000

Normal range
1800

Number of patients

1600
1400
1200
1000
800
600
400
200
0
2

2.5

3.5

4.5

5.5

6.5

Potassium (mmol/l)

7.5

8.5

9.5

10

Pre-dialysis sodium levels for 7300 sessions

2000

Normal range
1800

Number of patients

1600
1400
1200
1000
800
600
400
200
0
124

126

128 130

132

134 136

138 140

Sodium (mmol/l)

142

144 146

148

150