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I Wayan Sudhana
Manifestasi Klinis Penyakit
Ginjal Kronis (PGK)
• Hipertensi
• Gangguan elektrolit
• Anemia
• LVH
• PJK
• Hiperfosfatemia
• Nyeri Otot dan sendi
• Hiperparatiroidisme sekunder
• Odem
Anemia
Direct factors
Indirect factors
Med.CN/Nov/2016
Benefits of Increasing Hb
in CKD Patients
4
Hazard-rasio untuk
semua penyebab
3
mortalitas
0
<11.0 >11.0–12.0 >12.0–13.0 >13.0
Data dari 853 pasien pria dengan tingkat CKD 3-5 yang belum menjalani dialisis pada suatu pusat kesehatan selama
1990-2004 (rerata waktu follow-up 2.1 tahun)
Adjusted data from 853 male patients with CKD stages 3-5 not yet on dialysis at a single centre during
MED/RYN/May/2015 1990-2004 (mean follow-up 2.1 years). Reference was Hb >13.0g/dl
Kovesdy CP et al. Kidney Int 2006; 69: 560-564
LVH PREVALENCE AND RENAL FUNCTION
Patients (%)
80
70
60 n=246
50
40
30
20
10
0
50–75 25–50 <25 HD start
CrCl (ml/min)
The most important consequences of anemia is LVH development
Levin et al AJKD 1999
Anemia dapat meningkatkan dan
mempercepat level keparahan CKD
100
N = 1658
10 Hgb Values
Anemia Prevalence (%)
80
15 11-12 g/dL
60 15
10-11 g/dL
<10 g/dL
8
40 17
62
9 8 43
20 5
20
14
0
<2 2-2.9 3-3.9 ≥4 Creatinine (mg/dL)
Chronic Kidney Disease (CKD) Progression
Hgb = hemoglobin.
Kausz et al. Dis Manage Health Outcomes. 2002;10:505-513.
Mengenal Erythropoiesis
• Erythropoiesis proses pembentukan sel darah merah
(erythrocytes) pada mamalia termasuk manusia.
Berkisar 3 sd 4 hari
BESI / Fe
Berkisar
10 sd 13
hari
Berkisar 21 hari
Berkisar 1 sd 2 hari
Cukup Defisiensi
reaksi : (-)
Lanjutkan
(dalam 30 menit)
Iron Therapy
• Correction phase:
Iron sucrose 100 mg, diluted in 100 mls NaCL 0.9%, infusion
drips in 15-30 min
2x/week during HD. Estimated total dose 1 gram (10x)
May re-check after half dose (after 5x) administration
After 1 week re-check Iron status.
• Maintenance phase:
Iron sucrose 100 mg/2 week.
22
Lampiran 1
Algoritme
Terapi Besi
*Keterangan:
Iron sucrose atau iron
dextran: bila dapat
ditoleransi, dosis 100 mg
diencerkan dengan 100
ml NaCl 0.9%, drip IV 15-
30 menit pada saat HD.
Bila ST <20% dan FS
501-800 ng/ml lanjutkan
terapi ESA dan tunda
terapi besi, observasi
dalam satu bulan. Bila Hb
tidak naik, dapat
diberikan iron sucrose
atau iron dextran 100 mg
satu kali dalam 4 minggu,
observasi 3 bulan.
Bila ST <20% dan FS
>800 ng/ml terapi besi
ditunda. Dicari penyebab
kemungkinan adanya
keadaan infeksi-
23
inflamasi.
E S A Therapy
ESA Therapy: When to
initiate?
• For adult CKD 5D patients, we suggest that ESA
therapy be used to avoid having the Hb
concentration fall below 9.0 g/dl by starting ESA
therapy when the hemoglobin is between 9.0–10.0
g/dl.
• Individualization of therapy is reasonable as some
patients may have improvements in quality of life
at higher Hb concentration and ESA therapy may be
started above 10.0 g/dl.
KDIGO 2012
Terapi ESA
Kontraindikasi : Hipersensitivitas
status besi
KDIGO 2012:
• In general, we suggest that ESAs not be used to maintain Hb
concentration above 11.5 g/dl.
• Recommended target: 10-11.5 g/dL.
• In all adult patients, we recommend that ESAs not be used to
intentionally increase the Hb concentration above 13 g/dl.
• Reevaluate ESA dose if:
- The patient suffers an ESA related
adverse event.
- The patient has an acute or progressive illness
that may cause ESA hyporesponsiveness.
KDIGO 2012
ESA Therapy
30
SC – Meningkatkan Efisiensi
100
90
80
Mean dose (IU/kg/week)
70 32%
reduction in
60 dose
50
40
SC: Waktu
IV Paruh lebih panjang
SC
30
20
10
0
Pre - Dialysis
Patients
Subcutaneous administration
Peritoneal
Dialysis
Patients
Intravenous administration
Hemodialysis patients convenience
Patients Subcutaneous administration is better
Tsubaki Y et al. 2008 Japanese Society for Dialysis Therapy: Guidelines for Renal Anemia in Chronic Kidney Disease. Ther Apher Dial, Vol. 14, No. 3, 2010
Wish JB, Coyne DW. Use of Erhytropoiesis-Stimulating Agents in Patients with Anemia of Chronic Kidney Disease. Mayo Clinic Proc. 2007;82(11):1371-1380
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TERIMA KASIH
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EPORON
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