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Gagal Ginjal Kronik dengan Hemodialysis reguler
“Peranan pasien dan keluarga”
R Tunggul Sukendar
Divisi Ginjal dan HipertensiBagian Ilmu Penyakit Dalam FK USU/
RSUP H. Adam Malik Medan
Mengenali Kelainan Ginjal
Ginjal ada 2 : kiri dan kananBerat masing-masing : 1/3 kgRenal blood flow : 1-1,5 L/menit
Unit fungsional Ginjal : NefronJumlah : masing-masing : 1 juta
GlomerulusTubulus proximalLengkung HenleTubulus distalTubulus pengumpul
CalyxPyelumUreterKandung kemihUrethra
RENAL CYSTIC DISEASE
CHRONIC PYELONEPHRITIS
Fungsi Ginjal
1. Fungsi EkskresiMeneluarkan zat toksis / racun
2. Fungsi Regulasi
Mengatur keseimbangan : air, garam/elektrolit Asam / Basa
3. Fungsi hormonalHormon renin, prostaglandinEritropoetin, Kalsitriol dll
Gangguan Ginjal :
Akut : :
Tiba-tiba, dalam beberapa hari / minggu anuria / Oligouria ataupun tidakBila anuria / Oligouria terjadi Oedema, Hipertensi, sesak nafas, sindroma uremik : mual, muntah
Kronik : Terjadi penurunan fungsi ginjal perlahan selama berbulan ataupun bertahun. Awalnya tanpa gejala sampai fungsi ginjal < 25%.
Seluruh organ dan sistem tubuh dikenai
46-year-old kidney patient, was diagnosed With polycystic kidney disease 17 years ago andhas been on hemodialysis ever since.
“Dialysis does not mean stop living,”
says Melvin Bradford.” It means find a new to live.It means develop skills that are going to help you to live longer.”
Melvin
Tujuan Pengobatan GGT:
Menurunkan mortalitas meningkatkan /memperpanjang lama hidup ( survival)
Memperbaiki kualitas hidup (QoL) Mengobati gejala/komplikasi kronik uremia Tindakan rehabilitasi
Dialisis Peritoneal
Kidney undergoing perfusion(in ice) after harvesting
Cooled kidney inSurgical gloves, ready For transplantation
Transplanted kidney afterremoval on clamps showing“pinking up” and urine formation
How Often Is Enough ?
• Once Weekly ?
Can’t control K or volume
• Twice Weekly ?
Only if residual function
• Thrice weekly ?
Appears adequate
• Daily ?
Yet to be proven
30
20
10
0
30
20
10
00 1 2 3 4 5 60 1 2 3 4 5 6
Time (days)Time (days)
Ure
a co
ncen
tratio
n(m
mol
/L)
Ure
a co
ncen
tratio
n(m
mol
/L)
HD1HD1 HD2HD2 HD3HD3
The discontinuous time course of serum urea concentration over one week with a thrice-
weekly dialysis schedule
The discontinuous time course of serum urea concentration over one week with a thrice-
weekly dialysis schedule
Volume responses and enhanced frequency dialysis
Mon
TuesW
ed
Thurs FriSat
SunM
on
Vo
lum
e
Slow Nocturnal Home hemodialysis :
6 x 8 jam (overnight) Dialysate flow : 300 ml/min Blood flow rate : 300 ml/min Hi flux membrane 2 x needles
No diet restrictionNo fluid restrictionNo BP tabletNo Phosphate binder
Kadang perlu penambahan PhosphateAtau Ca pada dialysat
Slow Nocturnal Home Hemodialysis Slow Nocturnal Home Hemodialysis
PPengaturan Nutrisi :
Target : Minimal uremik toksisiti Minimalisasi gangguan metabolisme (ca & P) ,
cairan dan elektrolit (K)
Mempertahankan status nutrisi yg baik gn makanan yg cukup menyenangkan (protein, kalori, vitamin dll)Protein
Garam dan airKalimCalsium dan Phosphat
Protein :
Sumber protein :
Daging ayam, kalkun, ikan, daging segar yang tak berlemak. Merupakan protein lengkap
Dairy product : susu, keju, yogurt dan telur juga merupakan protein lengkap tetapi :
tinggi kolesterol, lemak dan Phosphat
Kacang-kacangan, jagung dan biji-bijian (padi, gandum) protein yg tdk lengkap
Terlalu banyak protein :
Mual, muntah Lelah Bingung Kalium darah meningkat Lama HD akan meningkat
Terlalu sedikit protein :
Hilangnya massa otot Lelah BB berkurang Luka sulit sembuh
Garam dan air
Target : Capai Berat badan Kering (Dry weight) Pertahankan BB antar dialyisis : 1.5 kg Batasi garam : 2-3 g/hari
Jangan tambahkan garam saat memasak Jangan letakkan garam di atas meja Waspadai garam yg tersembunyi di makanan :
Asinan (somboy, ikan asin, telur asin dll) makanan kaleng (corned, sardinnes) kecap, saus tomat dll
Jangan gunakan garam palsu (high K) Untuk memberi kenikmatan gunakan bahan pedas
dari tumbuhan alami
Interdialytic Weight GainInterdialytic Weight Gain
1.5-2 kgUF rate rata-rata 2.0-2.5 kg0.5 kg : Cairan yg diminum + priming+flushing dll
Kerjasama yg baik dgn Dietitian
1953
Northern Territories
80/40
1997
Northern Territories
170/100
Why did they Migrate ?
Pressure is simple
V
MC Volume through the Pipes
Size of the Pipes
Salt restriction and SR + enhanced UF
64.1 62.20
1020304050607080
Before Salt restriction only
(n=20)
After
Bo
dy
we
igh
t k
g
020406080100120140160180
BP
mm
Hg
BW SBP DBP
65.5 61.70
102030405060708090
Before Salt restriction plus UF
(n=17)
After
Bo
dy
we
igh
t k
g
020406080100120140160180200
BP
mm
Hg
BW SBP DBP
Salt restriction alone:20/47 = 43% success
Salt restriction + UF+:37/47 = 79% success
Improved hypertension control
0
0.5
1
1.5
2
2.5
0 8 24
AN
tih
yp
erte
ns
ive
d
rug
s/d
ay
40
60
80
100
120
140
160
180
Blo
od
pre
ssu
re m
mH
g
AHTN SBP DBP
Kooistra MP et al Nephrol Dial Transplant 1998; 13: 2853-2860
Udema paru
Kalium
Kalium tinggi : denyut jantung tak teratur dapat berhenti tiba-tiba
Makanan tinggi Kalium :kentang, labu, coklat, pisang, alpokat, jamur, jeruk,Pasta tomat, sayuran, buah kering, high fibre breakfastCereal dll
Bila sayuran tinggi KPotong kecil-kecil, masak dan tiriskan
This fruits should be avoided
This fruits are recommended
Ca dan Posphat
Batasi : Susu Keju Yougurt
Ice cream Coklat Beer Firm Tofu
Hindarkan : Minuman Cola Daging asap Kacang-kacangan Whole grain cereal
Makan pengikat Phosphat saat/bersamaan makanEfek samping : Sulit buang air besar
(makan makanan serat tinggi)
Tumoral CalcinosisTumoral Calcinosis
• 1-2 months decrease in size• 8-9 months reabsorbed
Koreksi anemia