Download - Aki Ckd Ferry Final Ppt
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Moderator :dr. Ginova Nainggolan, SpPD-KGH
Ferry Valerian Harjito
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Dahulu : ARF → gagal ginjal akut Sindroma klinis yang ditandai penurunan fungsi ginjal
mendadak (jam, minggu) → kemampuan ekskresimetabolic waste ↓, pengaturan keseimbangan asambasa, elektrolit, cairan ↓
peningkatan kreatinin serum > 0,5 mg/dl dlm 48 jam
Lebih dari 35 definisi ARF berbeda ARF → AKI (Acute Kidney Injury)
Kriteria RIFLE ADQI : 2003 Modifikasi RIFLE oleh AKIN : 2005
Mehta RL dan Chertow GM. Acute Renal Failure, Definitions and Classification : Time for Change? J Am Soc Nephrol. 2003.14:2178-2187.
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Kriteria LFG Kriteria Urine Output (UO)
RiskKenaikan SCr 1,5 ×
atau penurunan LFG > 25%
UO < 0,5 ml/kg/jam
(selama 6 jam)
InjuryKenaikan SCr 2 ×
atau penurunan LFG > 50%
UO < 0,5 ml/kg/jam
(selama 12 jam)
Failure
Kenaikan SCr 3 ×
atau penurunan LFG > 75%
atau SCr ≥ 4 mg/dL
UO < 0,3 ml/kg/jam
(selama 24 jam)
atau anuria dalam 12 jam
LossGagal ginjal akut menetap
(Loss = hilangnya fungsi ginjal >4 minggu)
ESRD End Stage Renal Disease (Gagal Ginjal Terminal) >3 bulan
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Tidak ada perbedaan dalam umur dan jenis kelamin Dilakukan pemeriksaan kadar kreatinin serum paling
sedikit 2 x dalam 48 jam Dalam menentukan urine output, hidrasi pasien
harus dalam keadaan normal dan tidak ada obstruksi pada saluran kemih
Diagnosis AKI harus dilengkapi dengan tahapan penyakit sesuai kriteria RIFLE atau AKIN.
Perlu dibedakan antara diagnosis AKI, CKD, atau acute on CKD
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Pre Renal (55%)
Di rumah sakit : 40%
Di luar rumah sakit : 70%
Intra Renal (40%)
Sepsis (50%)
Nefrotoksisitas (35%)
Keadaan iskemia dan lainnya (15%)
Post Renal (5%)
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Hipovolemia
Hemoragik, luka bakar, dehidrasi
Kehilangan cairan lewat Gl; muntah, diare, drainase
Kehilangan cairan lewat ginjal: diuretik, DM, hipoadrenalisme.
Pankreatitis, peritonitis, trauma, luka bakar, hipoalbuminemia berat Penurunan cadiac output:
Penyakit otot jantung, katup dan perikardium; aritmia, tamponade
Lain-lain: HT pulmonal, emboli pulmonal masif, ventilasi mekanik Perubahan rasio resistensi sistem vaskular renal:
Vasodilatasi sistemik: sepsis, antihipertensi, anestesi, anafilaksis
Vasokonstriksi renal: hiperkalemia, norepinefrin, epinefrin, siklosporin, tacrolimus, amfoterisin
Sirosis dengan asites (sindrom hepatorenal) Hipoperfusi renal dgn kegagalan autoregulasi renal: COX-I, ACE-I Sindrom hiperviskositas: MM, makoglobulinemia, polisitemia
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Obstruksi vaskular renal (bilateral atau unilateral) Penyakit glomerulus atau mikrovaskular renal
Glomerulonefritis dan vaskulitis
HUS, TTP, DlC, kehamilan toksik, HT, nefritis radiasi, SLE, skleroderma Nekrosis tubular akut
lskemik akibat AKI pre renal (hipovolemik, CO ↓, vasokonstriksi renal, vasodilatasi sistemik, komplikasi obstetri
Toksin eksogen dan endogen Nefritis interstitial
Alergi AB (β laktam, cotrimoxazole, rifampisin), NSAID, diuretik, kaptopril
lnfeksi bakteri (misal pielonefritis akut, leptospirosis), CMV, kandida
lnfiltrasi: limfoma, leukemia, sarkoidosis Obstruksi tubulus: protein mieloma, as.urat, oksalat, asiklovir,MTX, sulfonamid Renal allograft rejection
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Ureter : Kalkuli, bekuan darah, sumbatan pada papilla, keganasan, kompresi ekstemal (misalnya fibrosis retroperitoneal)
Bladder neck : neurogenic bladder, hipertropi prostat, kalkuli, keganasan, bekuan darah
Uretra : striktur, katup kongenital, phimosis
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Azotemia prerenal :
Tanpa adanya kerusakan struktural
AKI Intrinsik :
Iskemia → deplesi ATP
loss of brush border microvilli → obstruksi
tubulus
Aktivasi protease dan fosfolipase
Pembentukan ROS : Haber Weiss Reaction
Kerusakan tubulus : Acute Tubular Necrosis (ATN)
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Abuelo JG. Normotensive Ischemic Acute Renal Failure. N Engl J Med 2007;357:797-805
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Sutton TA, Fischer CJ, Molitoris BA. Microvascular Endothelial Injury and Dysfunction during Ischemic Acute Renal Failure. Kidney Int 2002;62:1539-49.
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Sutton TA, Fischer CJ, Molitoris BA. Microvascular Endothelial Injury and Dysfunction during Ischemic Acute Renal Failure. Kidney Int 2002;62:1539-49.
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Abuelo JG. Normotensive Ischemic Acute Renal Failure. N Engl J Med 2007;357:797-805
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Thadhani R, Pascual M, BonventreJV. Acute Renal Failure. N Engl J
Med.1996;334:1448-60
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Pemeriksaan
Penunjang
Diagnostik
AKI Pre RenalAKI Intra
Renal (ATN)
AKI Post
Renal
Rasio
BUN/Kreatinin> 20:1 20:1
Fraksi Ekskresi
Natrium< 1% >3%
Berat Jenis Urine >1.020 1.010-1.020
Osmolalitas urine > 500 mOsm 250-300 mOsm
Natrium urine < 20 mmol/hari > 40 mmol/hari
Sedimen Hyaline cast Granular cast red cell cast
USG Normal Normalpielonefrosis
hidronefrosis
Fraksi Ekskresi Natrium = Na urine x Kreatinin serumNa serum x Kreatinin urine
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Prinsip terapi konservatif : Diet protein dan nutrisi yang proporsional Pengobatan yang sesuai terhadap etiologi AKI Hati-hati pemberian obat yang bersifat nefrotoksik Hindari keadaan penyebab deplesi ECFV /hipotensi Hindari ggn keseimbangan elektrolit dan asidosis metabolik Hindari instrumentasi tanpa indikasi medis yang kuat Hindari penggunaan media kontras tanpa indikasi medis kuat Kendalikan HT sistemik dan tekanan intraglomerular Kendalikan keadaan hiperglikemia dan lSK
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Komplikasi Terapi
Kelebihan cairan
Intravaskuler
Batasi garam (1-2 gram/hari) dan air (<1 liter/hari)
Diuretik (biasanya furosemide/thiazide)
HiponatremiaBatasi cairan (<1 liter/hari)
Hindari pemberian cairan hipotonis (termasuk dekstrosa 5%)
Hiperkalemia
Batasi asupan kalium (<40 mmol/hari)
Hindari suplemen kalium dan diuretik hemat kalium
Beri resin potassium-binding ion exchange (kayexalate)
Beri glukosa 50% sebanyak 50 cc + insulin 10 unit
Beri natrium bikarbonat (50-100 mmol)
Beri salbutamol 10-20 mg inhaler atau 0,5-l mg lV
Kalsium glukonat 10% (10 cc dalam 2-5 menit)
Asidosis metabolikBatasi asupan protein (0,8-1,0 g/kgBB/hari)
Beri NaHCO3 (usahakan kadar > 15 mmol/l, pH arteri > 7,2)
HiperfosfatemiaBatasi asupan fosfat (800 mg/hari)
Beri pengikat fosfat ( Ca asetat-karbonat, Al HCl, sevalamer)
Hipokalsemia Beri kalsium karbonat atau kalsium glukonat 10% (10-20 cc)
Hiperurisemia Tidak perlu terapi jika kadar asam urat < 15 mg/dl
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Diuretik Loop diuretics : dosis awal bolus 40 mg IV Bila tidak ada reaksi :
▪ dosis digandakan ▪ drip cepat 100-250 mg/kali dalam 1-6 jam ▪ drip lambat l0-20 mg/kgBB/hari, max. 1000 mg/hari.
Mannitol Dosis 12,5-25 gram bolus/infus sampai 250 gram/hari
Albumin Dopamin “Renal dose” < 2,5 µgr/kgBB/menit
Stem cell
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Oliguria (output urine < 200 cc/12 jam) Anuria/oliguria berat (output urine < 50 cc/ l2 jam) Hiperkalemia (K+ > 6,5 mmol/L) Asidosis berat (pH < 7,1) Azotemia (urea > 30 mmol/liter) Gejala klinik berat (terutama edema paru) Ensefalopati uremik Perikarditis uremik Neuropati/miopati uremik Disnatremia berat (Na > 160 atau < 115 mmol/L) Hipertermia/hipotermia Overdosis obat yang dapat terdialisis
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Tingkat mortalitas : Pada komunitas : < 10%
Di ruangan rawat inap : 30-50%
Di ICU : 70-80%
Tidak banyak berubah selama 4 dekade terakhir Penyebab kematian tersering : Infeksi dan sepsis
Komplikasi kardiopulmonal Efek jangka panjang : masih belum diketahui AKI ireversibel : 5-16%
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Kerusakan ginjal > 3 bulan, berupa kelainanstruktural /fungsional, dengan/tanpapenurunan LFG dengan manifestasi:
Kelainan patologi
Tanda kelainan ginjal, termasuk kelainan komposisidarah, urin, atau pencitraan
LFG < 60 ml/menit/1,73m2 selama 3bulan, dengan/tanpa kerusakan ginjal.
National Kidney Foundation: Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis. 2002:39:S1-S246.
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Derajat Penjelasan LFG
(ml/menit/1,73m2)
1 Kerusakan ginjal dengan LFG
normal atau ↑
≥ 90
2 Kerusakan ginjal dengan LFG ↓
ringan
60 – 89
3 Kerusakan ginjal dengan LFG ↓
sedang
30 – 59
4 Kerusakan ginjal dengan LFG ↓
berat
15 – 29
5 Gagal ginjal < 15 atau dialisis
National Kidney Foundation: Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis. 2002:39:S1-S246.
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National Kidney Foundation: Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis. 2002:39:S1-S246.
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♂ LFG (ml/menit/1,73m2) = (140 - umur) x berat badan
72 x kreatinin plasma (mg/dL)
♀ LFG (ml/menit/1,73m2) = 0,85 x (140 - umur) x berat badan
72 x kreatinin plasma (mg/dL)
LFG (mL/min per 1.73 m2) = 186 x (kreatinin plasma)–1.154 x (umur)–0.203
♀ dikali 0,742 ; keturunan Afrika Amerika dikali 1,21
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Amerika Serikat
No. Penyebab Insiden
1 Diabetes mellitusTipe 1Tipe 2
44,9 %3,9 %
41,0 %
2 Hipertensi dan penyakitpembuluh darah besar
27,2 %
3 Glomerulonefritis 8,2 %
4 Nefritis interstitial 3,6 %
5 Kista, penyakit bawaan 3,1 %
6 Penyakit sistemik (lupus, vaskulitis)
2,1 %
7 Neoplasma 2,1 %
8 Tidak diketahui 5,2 %
9 Penyakit lain 4,6 %
Sudoyo K, et al., ed. Buku Ajar Ilmu Penyakit Dalam. Edisi ke-4. Jakarta: Pusat Penerbitan IPD
FKUI; 2006.
Indonesia tahun 2000
No. Penyebab Insiden
1 Glomerulonefritis 46,39 %
2 Diabetes mellitus 18,65 %
3 Obstruksi dan infeksi 12,85 %
4 Hipertensi 8,46 %
5 Sebab lain 13,65 %
Abboud H, Henrich W. Stage IV Chronic Kidney Disease. NEJM. 2010;362:56-65.
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Abboud H, Henrich W. Stage IV Chronic Kidney Disease. N Engl J Med. 2010;362:56-65.
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Etiologi yang mendasarinya
Kompleks imun
Mediator peradangan (glomerulonefritis)
Paparan racun (penyakit tubulus ginjal & interstitium ) Mekanisme progresif : hiperfiltrasi dan hipertrofi nefron tersisa Proses maladaptasi : sklerosis surviving nephrons Uremia:
akumulasi racun, termasuk produk metabolisme protein
hilangnya fungsi ginjal lain : keseimbangan cairan dan elektrolit dan regulasi hormon
peradangan sistemik progresif, konsekuensi vaskuler dan gizi
Fauci A, Braunwald E, Kasper D. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
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Hipertensi
Diabetes mellitus
Dislipidemia
Penyakit autoimun
Usia yang lebih tua
Keturunan Afrika
Riwayat keluarga
penyakit ginjal
Albuminuria
Proteinuria
Abnormalitas sedimen
urine
Episode AKI sebelumnya
Kelainan struktur saluran
kemih
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National Kidney Foundation: Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis. 2002:39:S1-S246.
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National Kidney Foundation: Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis. 2002:39:S1-S246.
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National Kidney Foundation: Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Am J Kidney Dis. 2002:39:S1-S246.
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Gangguan Cairan, Elektrolit, dan GangguanKeseimbangan Asam-Basa Homeostasis Natrium Dan Air
Homeostasis Kalium
Asidosis Metabolik
Gangguan Metabolisme Kalsium dan Fosfat Kalsium dan Fosfat
Manifestasi Tulang Pada CKD
Kelainan Hematologik Anemia
Hemostasis abnormal
Fauci A, Braunwald E, Kasper D. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
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Terapi
restriksi asupan garam (1-2 gr/hari)
Diuretik
Gangguan konservasi natrium dan air Hiperkalemia – hipokalemia Asidosis metabolik
Retensi Na dan air
Kerusakannefron
EkspansiECFV
HT
Fauci A, Braunwald E, Kasper D. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
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Fauci A, Braunwald E, Kasper D. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
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Defisiensi eritropoietin
Hiperparatiroidismesekunder
Inflamasi / Infeksi
Masa hiduperitrosit pendek
Defisiensi besi
Hemoglobinopati
ANEMIA
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National Kidney Foundation: Kidney Disease Outcomes Quality Initiative. Clinical
Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification, and Stratification. Am J Kidney
Dis. 2002:39:S1-S246.
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Kelainan Kardiovaskular
Penyakit Vaskular Iskemik
Gagal Jantung
Hipertensi dan Hipertrofi Ventrikel Kiri
Penyakit Perikardial Kelainan Neuromuskular
Gangguan memori, gangguan tidur
Iritabilitas : cegukan, kram, fasikulasi
Asterixis, mioklonus, kejang, koma
Restless legs syndromeFauci A, Braunwald E, Kasper D. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
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Kelainan Gastrointestinal dan Gizi
Anoreksia, mual,muntah
Fetor uremikum, dysgeusia, gastritis
Gangguan Metabolik Endokrin
Kadar estrogen ↓ : infertilitas
Kelainan Dermatologik
Endapan metabolit pigmen urokrom
Pruritus uremikum
Nephrogenic fibrosing dermopathy
Fauci A, Braunwald E, Kasper D. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
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Fauci A, Braunwald E, Kasper D. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
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Pendekatan Awal
Anamnesis
Pemeriksaan Fisik
Pemeriksaan Laboratorium
Pemeriksaan Radiologis
Biopsi Ginjal
Menegakkan Diagnosis dan Etiologi dari CKD
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Restriksi Protein 0,6-0,75 g/kg/hari
Asupan energi 35 kkal/kgBB ↓ Hipertensi Intraglomerular dan Proteinuria Target 130/80 mmHg
1st line : ACE inhibitor dan/atau ARB ↓ Progresivitas Nefropati Diabetik Target HbA1C < 7%
Obat-obatan hipoglikemia
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Manajemen Komplikasi Lain CKD Anemia, hiperPTH, asidosis, dll.
Penyesuaian dosis obat Dialisis Adanya gejala uremia
Hiperkalemia, ECFV, asidosis refrakter
Diatesa hemoragika
GFR < 10 ml/min/1,73 m2
Transplantasi Ginjal Edukasi Pasien
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