Download - acute on CKD
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Definisi• Gagal ginjal akut: penurunan mendadak cepat (beberapa
jam-hari) LFG + gambaran klinik azotemia, oliguria, ↑ kreatinin serum.
• Penyakit ginjal kronis adalah proses patologis dengan etiologi yang beragam , mengakibatkan penurunan fungsi ginjal yang progresif (bulan-tahun), permanen dan biasanya berakhir pada end-stage renal disease (ESRD)
• Acute on chronic kidney: ↓ akut LFG akibat reversible factors atau correctable factors pada insufisiensi ginjal atau CKD stadium dini.
ACUTE ON CHRONIC KIDNEY DISEASE
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Kriteria Penyakit Ginjal Kronik1. Kerusakan ginjal > 3 bulan, berupa kelainan
struktural atau fungsional, + penurunan LFG, dengan manifestasi:– Kelainan struktur histopatologis– Tanda kerusakan ginjal, termasuk kelainan
komposisi darah dan urin, atau kelainan dalam tes pencitraan
2. Laju filtrasi glomerulus <60ml/menit/1,73m2 selama 3 bulan + kerusakan ginjal
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Acute on CKD Causes
Prerenal
• Extracellular fluid volume depletion
• Decreased effective circulating blood volume
• Drug-induced haemodynamic renal failure: NSAIDs, ACEi, ARB, radiocontrast agents
Intrarenal
• Acute tubular necrosis
• Acute interstitial nephritis
• Crystal-induced ARF• Severe hypertension• Relapse or
progession of underlying disease
Postrenal
• Obstruction of the upper and lower urinary tracts
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Gambaran Klinik
Derajat penurunan LFG
Underlying Renal Disease
Faktor pemburuk faal ginjal
Tergantung dari 3 faktor berikut:
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Tipe Kering Tipe BasahGambaran Klinik -oliguria, anuria
-Dehidrasi-Hipotensi-Febris atau suhu normal-Kesadaran (somnolen, koma)
-oliguria, anuria-Hipertensi berat-Bendungan paru akut-Kardiomegali-JVP ↑
Underlying renal disease
-Penyakit ginjal polikistik-Nefropati kronik asam urat-Nefropati obstruksi kronik intrarenal (nefrolitiasis)
Penyakit parenkim ginal+retensi Na:-Glomerulopati idiopati-Nefropati IgA-Nefropati diabetik
Faktor pemburuk LFG
-Natriuresis-Urosepsis-Septik shock-Kolik ginjal+obstruksi uropati unilateral atau bilateral-Iatrogenik
-ISK berulang-Hipertensi berat-HHD-CAD
-Hepatomegali-muka sembab, asites, oedem tungkai-Asidosis-Kesadaran
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Pemeriksaan Penunjang DiagnostikTipe Kering Tipe Basah
Gambaran Klinik - analisis urin-Hb, L-U, K, elektrolit serum-AGD
- analisis urin-U, K, elektrolit serum-Elektrolit & AGD
Underlying renal disease
-Analisis urin dan CFU/ ml-Asam urat serum-USG ginjal, UT, prostat-CT scan ginjal-Nefrotomogram
-Analisis urin-Proteinuria kuantitatif 24 jam-Profil imunoglobulin & komplemen-Imunodiagnosis-Gula darah
Faktor pemburuk LFG
-Elektrolit, Na&K serum, urin-CFU/ ml urin-Kultur darah-Hb, L-Pencitraan ginjal (BNO, USG, CT scan, renografi)
-analisis urin &CFU/ ml urin-echocardiografi-profil lipid
-Foto thoraks-EKG
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Diagnostic approach and management of acute-onchronic kidney disease
Is the renal failure acute or is it acute-on-
chronic?
• Identifying and managing potentially
reversible causes.
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Establishing whether renal failure isacute or acute-on-chronic
• preexisting renal disease or predisposing factors for CKD, the common risk factors being hypertension, diabetes mellitus, autoimmune disease, chronic analgesic use, etc.History
• proteinuria and/or haematuria on dipstix examination glomerular diseaseClues on
clinical examination
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• Kreatinin naik 25-50% indikasi acute on CKD
• USG ginjal menciut, kecuali pada diabetic nephropathy, amyloidosis, HIV associated nephropathy and autosomal dominant polycystic kidney disease
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TABEL DIAGNOSIS DAN MANAJEMEN ACUTE ON CKD
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TABEL DIAGNOSIS DAN MANAJEMEN ACUTE ON CKD
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TABEL DIAGNOSIS DAN MANAJEMEN ACUTE ON CKD
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Prognosis
• Tergantung tipe gambaran klinik dan faktor pemburuk LFG
• Pada umumnya, tipe kering lebih baik dari tipe basah. Selama rawat jalan harus mendapat terapi konservatif adekuat dan rasional cegah ↓ progesif LFG dan GGT
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ConclusionPrevention of ARF is crucial in CKD patients in
whom the ultimate goal is preserving renal function and delaying the onset of end-stage renal disease.
Once acute-on-chronic has developed it is mandatory to look for the cause and removal of the precipitating factor and/or appropriate treatment will often result in recovery or stabilisation of renal function.
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Daftar Pustaka
• Madala. 2007. Acute renal failure in patients with chronic kidney disease. Ajol, 25(8): 395-398. www.ajol.info/index.php/cme/article/view/43804/27324, 3 April 2011.
• Enday Sukandar. 2006. Nefrologi Klinik. Edisi III. Bandung: Pusat Informasi Ilmiah Bag. IPD Fak. Kedokteran Unpad/ RSHS.