Jurnal Reading: Sit Dolor Amet

JURNAL READING
PRESENTATOR :
WIRDANI FADHILA SIREGAR
TAUFIQ ASRI MUNANDAR
ASMAUL HABIBI
LIRY ANDIYANI
MERY MARLINA
Sit Dolor Amet
Introduction
◦ Chronic kidney disease (CKD) is a common condition that refers to a long-term loss of kidney function. It tends to be
diagnosed in the presence of other comorbidities (particularly hypertension, diabetes, and cardiovascular disease), isolated
CKD is the exception rather than the rule, and CKD is associated with socioeconomic deprivation.
◦ Effective identification and management are necessary in order to prevent CKD progression and cardiovascular events, reduce
the risks associated with acute kidney injury (AKI), and improve patient safety and medicines management.
Introduction
◦ CKD in primary care is commonly asymptomatic, and the exact pathology underlying its development is often unknown (as
no renal biopsy is usually performed) .
◦ It is identified and defined by the presence of an abnormality of kidney structure or function (or both) present for at least 3
months.
◦ It is classified by the degree of renal dysfunction, as measured by the estimated glomerular filtration rate ([eGFR] derived
from serum creatinine using standard estimating equations) and by the presence or absence of structural kidney abnormality or
by other evidence of chronic kidney damage, particularly albuminuria .
Staging of CKD
The Kidney Disease Improving
Global Outcomes (KDIGO)
organization has summarized
the stages of CKD using a
“trafic light” staging system
that incorporates both
creatinine-based eGFR and
albuminuria .
Location of Care
◦ The predominant location in which care for people with CKD takes place is determined by a number of factors including cause
and severity of disease and health system culture, which vary considerably across the world.
◦ For patients with more severe kidney disease requiring RRT (dialysis and transplant), the main location of care is usually
secondary care.
Diagnostic
criteria
According to the KDIGO CKD
guidelines (and the English
National Institute for Health
and Care Excellence (NICE)
CKD guidelines), a patient is
identified with CKD if
abnormalities of kidney
structure or function were
present for a minimum of 3
months. The abnormalities are
shown in Table 1.
Proteinuria
◦ There has been considerable debate about different methods of proteinuria identification, including the role of urine dipsticks
and protein-to-creatinine ratio. This has caused some confusion among primary care practitioners. While dipstick tests can
detect albumin, they may be less good at detecting other urinary proteins and are poor at protein quantification, and ACR has
been shown to have greater sensitivity than protein-to-creatinine ratio for lower levels of proteinuria.
◦ KDIGO now clearly recommends ACR as the investigation of choice and a single early morning urine sample adequate to
identify proteinuria.
Proteinuria
◦ In clinical practice, although these diagnostic criteria are clear, it can be challenging to apply them. For example, blood and
urine tests may need to be repeated in order to identify the chronicity of kidney dysfunction, and the timing of repeat testing
needs to be carefully considered.
◦ When an eGFR <60 mL/min/1.73 m2 is identified in an individual with previously normal renal function, the first step is to
confirm the result and to exclude the possibility that the patient is developing transient elevation of creatinine (and fall in
eGFR) associated with other factors, such as AKI, by repeat testing within a short period of time.
◦ This can be dificult for primary care organizations operating in a predominantly reactive framework.
◦ For diagnoses of conditions that do not require consideration of time (eg, making a diagnosis of anemia based on an isolated
hemoglobin result) such issues do not usually arise. There is evidence of key clinical actions, such as timely albuminuria
testing, being highly dependent on accurate recording of a CKD diagnosis.
Diagnostic decision
pathway of such an
event based on NICE
guidelines.
These include the targeted use

of cystatin C in people who are
considered “borderline” CKD
(ie, people with a creatinine-
based eGFR 45–59
mL/min/1.73 m2 but no
evidence of proteinuria).
Disclosing the diagnosis to patients
◦ Once the diagnosis of CKD is established, an important consideration is how to communicate this with the patient. However,
while discussions around CKD and the maintenance of kidney health may be a platform to address both vascular risk and
reduce the demands on urgent care through the prevention of AKI, patient and public understanding remains limited.
◦ As discussed, a shift to use CKD-EPI formula reduces the prevalence of CKD, particularly at the stages G2–G3 cutoff, and in
doing so, may address concerns about unnecessary disease labeling and patient monitoring.
Managing People with CKD
◦ Primary care plays an important role in the monitoring and management of CKD, particularly in efforts to reduce the risk of
cardiovascular disease and other complications.
◦ Only a small proportion of people with mild or moderate CKD will progress to end-stage disease. In a population based study
in Norway (the HUNT II study), for example, of 3,069 people with CKD followed for median 8 years, only 38 (1%)
progressed to end-stage disease.
Blood Pressure
Managing hypertension is a key
strength of primary care and
controlling BP arguably the
most important intervention in
reducing both progression and
cardiovascular risk in people
with CKD.
Their recommendations for BP
control among people with
nondialysis dependent CKD are
shown in Table 4.
Both KDIGO and NICE advise
against using combined
angiotensin-converting enzyme
and angiotensin receptor
blocker in people with CKD
due to insufficient evidence of
benefit.
Estimated glomerular filtration rate
◦ KDIGO guidelines recommend testing with a slightly greater frequency than NICE such as three tests per year for people with
CKD stage G4A2 rather than twice a year recommended by NICE.
◦ Progression of CKD is defined in the most recent NICE guidelines as a sustained decrease in eGFR of 25% or more and a
change in GFR category within 12 months or a sustained decrease in GFR of 15 mL/min/1.73 m2 per year.
Patient safety, reducing AKI risk, and optimizing medicines
management
◦ Key considerations include identifying those at risk (CKD, sepsis, dehydration, and hypovolemia), good medicines
management (avoiding nonsteroidal anti-inflammatory drugs and other nephrotoxic agents), administration of key
immunizations to reduce infection risk (including influenza and pneumococcal), and identifying those with deteriorating renal
function by serum creatinine testing.
◦ It is also important to monitor for evidence of CKD progression post-AKI, including regular review of medication.
Making decisions
about referral
NICE guidance sets out some
referral criteria for
consideration. These are shown
in Table 6 .
Conclusion
◦ CKD has important prognostic implications, and many health systems cannot afford to see increasing numbers of people
progress to end- stage renal disease and require dialysis or renal transplant.
◦ CKD is often asymptomatic in its early stages, and clinicians working in primary care have a vital role to play in its
identification, risk stratification, and monitoring.
◦ Primary care also has a pivotal role in the prevention of complications and progression in managing risk factors such as high
BP and the prevention in AKI.
◦ CKD often occurs in conjunction with other chronic disease comorbidities, and primary care clinicians are best placed to take
a holistic view of care in mild-to-moderate CKD and empower patients.

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These include the targeted use

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