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CLINICAL SCIENCE
SESSIONACUTE KIDNEY INJURY
Disusun oleh :
Ammar Fauzan Islami
Gigih Perwira Mukti
Preseptor :
Apen Afgani, dr., Sp.PD, M.es
Program Pendidikan ProfesiDokter
SMF Ilmu Pen!akit DalamF "nis#a $ %S"D Al Ihsan
Pro&insi 'awa (arat)*+
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Defnisi
Merupakan kondisi dimana ter-adipenurunan seara
mendadak pada GF% /Glomerular FiltrationRate0 !ang
mengaki#atkan ter-adi retensi ti#a1ti#a darimeta#olit1
meta#olit #aik endogen maupun eksogen
/urea,potassium, fosfat, sulfat, kreatinin, dano#at1o#atan0 !ang
normaln!a akan dikeluarkan oleh gin-al.
Penurunan akut la-u 2ltrasi glomerulus
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Epidemiologi
Sekitar 4156 dari pasien !ang dirawat di
rumah sakit dan sekitar )14*6 dari pasien di
unit perawatan intensif.
Angka kematian di AS aki#at gagal gin-al
akut #erkisar antara )*13*6. ematian di
dalam %S 7*1*6 dan di I8" se#esar 5*1936
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ETIOLOGI
Prerenal Renal ARF/Prerenal Azotemia !!"#
Pen$a%it $ang men$e&a&%an ter'adin$a (ipoper)*si
gin'al tanpa ter'adin$a %er*sa%an integritas paren%im
gin'al
Intrinsi+ Renal ARF/Renal Azotemia ,-"#
Pen$a%it $ang se+ara langs*ng meli&at%an/mer*sa%
paren%im gin'al
Postrenal Renal ARF/Postrenal Azotemia !"#
Pen$a%it $ang &er%aitan dengan o&str*%si tra%t*s
*rinar$
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P%%;A< AI=A%F /P%%;A< A>?@MIA0
.en*n'*%%an adan$a inade%*at dari per)*si gin'aldi%arena%an ter'adi pen*r*nan ol*me intraas+*larata* pen*r*nan sir%*lasi e)e%ti) as+*lar0
.er*pa%an %eadaan $ang masi( reersi&le setela(per)*si gin'al %em&ali normal0
Pen$e&a& terseringn$a adala( de(idrasi danpengg*naan di*reti+ $ang &erle&i(an0
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Sign S!mptom
pasien merasa (a*s
ter'adi orthostatic dizziness pasien merasa p*singpada saat posisi t*&*( &erdiri#
terdapat ri1a$at (ilangn$a +airan
dari pemeri%saan fsi% 2 ter'adi pen*r*nan t*rgor %*lit3+ollapse ne+% ein3 mem&ran m*%osa %ering3orthostatic blood pressure
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La&oratori*m
4rine
&iasan$a ter'adi pen*r*nan ol*me
Spesif+ grait$ tinggi SG# 5 60-7!
Osmolalit$ tinggi 5 8--mOsm/%g
4rea 9 :lood C(emistr$
:4N 2 Creatinine ratio mening%at
Central ;eno*s Press*re
lo1 +entral eno*s press*re
Fl*id +(allenge
ter'adi pening%atan *rine o*tp*t setela( di&eri +airan
menanda%an prerenal ARF# +airan $ang di&eri%an &iasan$a adala(
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Et2 aso%ontri%si3 (ipotensi3 (ipoolemia3 perdara(an3 ata* tida% ade%*atn$a+*ra( 'ant*ng
:*r*%n$a per)*si %e gin'al
Pen*r*nan te%anan fltrasi
Pen*r*nan GFR3 defnisi ARF
Olig*ria
:ila per)*si %e gin'al tida% mem&ai% dan ter*s=mener*s mem&*r*%
%egagalan men$edia%an ol*me dara( ata* te%anan dara( $ang
.en+*%*pi
Ne%rosis t*&*lar a%*t ata* ne%rosis %orti%al a%*t
Intrarenal ARF
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INTRINSIC RENAL A?I/ARF RENAL [email protected]#
Di&agi men'adi 7 %ategori 2
60 Spesif+ Intrarenal Disease
Pen$e&a& 2
A+*te glomer*lonep(ritis
A+*te Interstitial Nep(ritis
Toi+ Nep(ropat($
Bemol$ti+ 4remi+ Disease
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S$mptom 9 Sign 2
terdapat ri1a$at in)e%si tra%t*s respiratori &agian atas
ata*p*n ri1a$at n$eri tenggoro%an
ri1a$at diare
n$eri &agian p*ngg*ng &ilateral
terdapat gross (emat*ria
terdapat &e&erapa pen$a%it sistemi% $ang &er%aitan 2
Beno+(=S+(nlein P*rp*ra SLE
S+leroderma
BI;
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4rine
terdapat sedimen le*%osit3 eritrosit '*ga +ell*lar dan gran*lar +ast
pada %eadaan allergi+ nep(ritis terdapat eosinop(il
sodi*m *rine 6-=,- mE/L
:lood Test
*m*mn$a terdapat imm*ne +omple
pada (emol$ti+ *remi+ s$ndrome terdapat t(rom&o+$topenia
Renal &iops$Ter'adi per*&a(an %ara%teristi% pada paren%im gin'al
=ra$
a%ni dengan mela%*%an intraeno*s *rograp($
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70 Nonspesif+ Intrarenal Disease
Pen$e&a& 2
A+*te T*&*lar Ne+rosis ATN#
A+*te Corti+al Ne+rosis S$mptom 9 Sign 2
de($drasi 9 s(o+%
pen*r*nan *rine o*tp*t
tanda *remia per*&a(an mentation dan GI s$mptom#
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La&oratori*m
4rine
Spesif+ Grait$ a1aln$a nai% lal* t*r*n (ingga 60--!=60--6!
4rine osmolalit$ ,!- mOsm/%g
Terdapat sel t*&*lar dan gran*lar +ast Harnan$a muddy bron
Central ;eno*s Press*re
*m*mn$a normal ata* ter'adi sedi%it pening%atan
Fl*id C(allenges
Pada %eadaan ini pem&erian +airan tida% a%an &erpengar*( ter(adappening%atan *rine o*tp*t3 &erg*na dalam mem&eda%an dengan ARF Prerenal
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Is+(emi+/ne)roto%si%3
Radi%al &e&as O7 to%si% dan pelepasan mediator inamasi
Pem&eng%a%an sel3 'e'as sel3 ne%rosis
?e(ilangan sel=sel sepan'ang epitel t*&*l*s
T*&*lar ne+% lea%
Pen*r*nan GFRdefnisi ARF#
olig*ria
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Is+(emi+ ata* ne)roto%si% pelepasan mediator inamasi
'e'as endotel as%*lar
;aso%ontri%si3 %ongesti as%*lar
Pen*r*nan GFRdefnisi ARF#
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POSTRENAL A?I/ARF
Postrenal a+*te renal )ail*re dise&a&%an ole(
operasi a&domen &a1a(3 *ret(ral ata* *reteral
o&str*%si $ang dapat men$e&a&%an A+*te Renal
Fail*re0 Pen$e&a& :ilateral 4reteral O&str*%si seperti2
Peritoneal ata* retroperitoneal neoplsti+3 dengan massaata* nodes
Retroperitoneal f&rosis Cal+*lo*s disease
Posts*rgi+al ata* tra*mati+ inter*ption
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.ani)estasi %linis
S!mptom and signs
Renal pain dan renal tenderness
edema
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C1%a! 2nding Radion*+lide renal s+an memperli(at%an *rine lea% ata*
+ases o) o&str*+tion
Retensi isotope pada renal pelis
4ltraso*nd eamination men*n'*%%an dilatasi *pper +olle+tings$stem %ara%teristi% de)ormitas pada ($dronep(rosis
Instrumental eamination
C$stos+op$ dan retrograde *reteral +at(eterizationmen*n'*%%an *reteral o&str*%si0
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O&str*%si tra%t*s *rinari*smengenai %ed*a gin'al se+ara&ilateral#
Pening%atan te%anan intral*minal
4p stream
Pen*r*nan GFR grad*al
Pen*r*nan GFRdefnisi ARF#
olig*ria
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Diagnosis &anding A?I/ARF/Gagalgin'al a%*t
60 Olig*ria
Dapat dise&a&%an &e&erapa pen$a%it gin'al ma*p*n dil*ar gin'al pre9post renal#0 Pen$a%it=pen$a%it paren%imgin'al a%*t tida% 'arang men$e&a&%an olig*ria $ang
lama3 le&i( dari , mingg*0
Pre=renal )ail*re ata* (ipoper)*si renalis
Fa%tor renal/gin'al
Glomer*lopati ata* as%*ler
Ne)ritis intersisial
Ne%rosis a%*t t*&*lar
Post=renal a+*te o&str*+tie nep(ropat($#
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70 A+*te on C(roni+ Renal Fail*re
Diagnosis ini perl* dipertim&ang%an3 &ila 2
Terdapat %om&inasi ge'ala GGA dan GG?
Ditem*%an ge'ala %lini% $ang memper&erat )aal gin'al3seperti gagal 'ant*ng %ongesti)3 in)e%si sal*ran %emi(dan gin'al3 pielone)ritis3 dan de(idrasi0
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Treatment A?I/ARF
Prerenal ARF
!rerenal AR"dapat +epat mem&ai% 'i%a gangg*an(emodinami% diper&ai%i0
#ypo$olemia replacement %uid&
'e$ere hypo$olemia%arena perdara(an trans)*si dara(pac(ed red cells#0
)ild*moderate hemorrha+e,plasma loss3 +onto(n$a l*%a&a%ar3 pan%reatitis isotonic saline0
!rerenal %arena mening%atn$a %e(ilangan +airan padasistem *rinari*s ata* sistem pen+ernaan3 ma%a di&eri%an2
Lar*tan (ipotoni%3 +onto(n$a -3,!" salineJ
Isotonic saline di&eri%an pada %as*s=%as*s $ang para(0
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Ki%a terdapat tanda=tanda %egagalan 'ant*ng &eri%anla(positi$e inotropes3 agen=agen pered*%sipreload dan a)terload3 o&at=o&at antiaritmia dan&ant*an alat=alat seperti intraaortic balloon pumps0
Ki%a terdapat gangg*an ion=ion ma%a di&eri%ans*plemen potasi*m dan &i%ar&onat0
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Intrinsic renal ARF
Ki%a ter'adi ischemicata* nephroto-icARF ANP atrial
natriuretic peptides#3 dopamin dosis renda(3 antagonisendot(elin3 loop*bloc(in+ diuretics.Ca channel bloc(er./*adrenoreceptor bloc(ers3 analog prostaglandin3antio%sidan3 antibodies a+ainst leucocyte adhesionmoleculesdan insulin*li(e +roth 0actor type I0
Ki%a ARF ter'adi %arena renal diseaseacute
+lomerulonephritisata* $asculitis#
gl*%o%orti%oid3al(ylatin+ a+ents3 and,orplasmapheresis&
Bipertensi dan ARF %arena s+leroderma ACE in(i&itor0
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Postrenal ARF
.em&*t*(%an %ola&orasi antara nephrolo+ist. urolo+istdan radiolo+ist0
Ki%a ter'adi o&str*%si di *retra ata* le(er %and*ng%emi( transurethral or suprapubic placement o0bladder catheter0
Ki%a ter'adi o&tr*%si di *reter percutaneouscatheterization o0 dilated renal pel$is,ureter&
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). Hemodialisa
adala( metode $ang dig*na%an *nt*% mengang%atprod*% sisa seperti potasi*m dan *rea dalam dara(%eti% gin'al mengalami renal )ail*re0
Bemodialisa dapat dila%*%an pada pasien ra1at 'alanata* ra1at inap0
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Indikasi:
*rea 5
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fek samping
Bipotensi
Fatig*e
C(est pain Leg=+ramps
Na*sea
(eada+(e
omplikasi am$loidosis
ne*ropat($
(eart disease
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Peritoneal dialisa
:ent*% lain dari dialisa adala( peritoneal dial$sis PD#0
Dalam PD3 +airan dialisa dimas*%%an %e dalam ronggaa&domen &ell$#3 $ang di lapisi mem&ran tipis3mengand*ng &an$a% pem&*l*( dara(0 .em&ran inidise&*t peritone*m0
Peritone*m ini $ang nantin$a &erperan se&agaimem&ran semipermea&el0
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?riteria *nt*% mem*lai terapi penggantigin'al pada pasien %ritis dengan A?I/ARF
Olig*ria2 prod*%si *rin7--- mL in 67 (
An*ria 2 prod*%si !- mL in 67 (
Biper%alemia2 %adar potasi*m583!mmol/L
Asidemia%era+*nan asam $ang &erat#2pBQ
Azotemia 2 %adar *rea5
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Pengo&atan s*porti) pada GGA
omplikasi Pengo#atan
?ele&i(an ol*me intraas%*lar
Biponatremi
Biper%alemi
:atasi garam 6=7g/(ari# dan air6L/(ari#3 )*rosemid3 *ltrafltrasi ata*dialisis
:atasi as*pan air 6L/(ari#3 (indari in)*s
lar*tan (ipotoni%
:atasi as*pan diet ? ,-mmol/(ari#3(indari di*reti% (emat ?Potassi*m=&inding ion e+(ange resinsNatri*m &i%ar&onat !-=6--mmol#Agonist :7 sal&*tamol3 6-=7-mgdiin(alasi ata* -3!=6mg I;#?alsi*m gl*%onat 6-ml lar*tan 6-" dalam
7=! menit#
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Cont
omplikasi Pengo#atan
Asidosis meta&oli%
Biper)os)atemia
Bipo%alsemia
N*trisi
natri*m &i%ar&onat *pa$a%an &i%ar&onatser*m 56!mmol/L3 pB 5Q37#
:atasi as*pan diet )os)at --mg/(ari#O&at pengi%at )os)at %alsi*m asetat3%alsi*m %ar&onat#
?alsi*m %ar&onat3 %alsi*m gl*%onat 6-=
7-ml lar*tan 6-"#
:atasi as*pan protein diet -3=6g/%g::/(ari# 'i%a tida% dalam %ondisi%ata&oli%?ar&o(idrat 6--g/(ari#N*trisi enternal ata* parenteral3 'i%aper'alanan %lini% lama ata* %ata&oli%
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Pen+ega(an
GGA dapat di+ega( pada &e&erapa %eadaanmisaln$a pengg*naan zat %ontras $ang dapatmen$e&a&%an ne)ropati %ontras0
Pada pen$a%it tropi% perl* di1aspadai%em*ng%inan GGA pada gastroenteritis a%*t3malaria3 dan demam &erdara(0
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DAFTAR P4STA?A
60 G*$ton3 Art(*r C 9 Ball3 'o(n E0 Te-tboo( o0 )edical !hysiolo+y 11 thed0 P(iladelp(ia2 Elseier Sa*nders0 7--80
70 Totora3 Gerard K 9 Derri+%son3 :r$an0 !rinciple o0 Anatomy and!hysiolo+y 11 th edition0 4SA0 HILE0 7--80