nefro
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nefroTRANSCRIPT
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1. ANAMNESE 2. PEMERIKSAAN FISIK 3. LABORATORIUM: RUTIN KHUSUS 4. PENCITRAAN 5. BIOPSI/ HISTOPATOLOGI 6. LAIN LAIN
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ANAMNESE: Keluhan Utama: Telaah (sampai detail) Anamnese pribadi Anamnese organ: Jantung&pemb.darah, pernafasan, gastro-intestinal, saraf dll. saluran kemih: poliuria, oliguria, anuria, nycturia hematuria, pyuria, chyluria pollakisuria, dysuria, stranguria dll
Anamnese keluarga, sosial dll Anamnese penyakit terdahulu Anamnese pemakaian obat
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PEMERIKSAAN FISIK:
1.SATUS PRAESENS: KESADARAN, TD, RR dll. 2.KEPALA: ANEMIS, MATA SEMBAB DLL 3. LEHER: TVJ 4. THORAX: COR, PULMO DLL. 5. ABDOMEN: HATI, LIMPA, BALLOTTEMENT ASCITES DLL 6. EXTREMITAS: OEDEMA DLL
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LABORATORIUM RUTIN: DARAH RUTIN: Hb, Hct. Lekosit DLL URINE RUTIN: PROTEIN, REDUKSI, SEDIMENT: ERITROSIT(mikro-hematuria), LEKOSIT (piuria) SILINDER KRISTAL dll
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Laboratorium khusus Fungsi ginjal: ureum, kreatinin, as-urat dll Elektrolit : Na, K, Cl, Ca, PO4 dll : Fungsi hati : SGOT, SGPT, Alk. Phosphatase, SPE dll
Lipid : Cholesterol, TG dll Immunologis: IgA, IgG, IgM dll. _
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Pencitraan/ Imaging: Radiologis: BNO, IVU/IVP , APG, RPG dll. Ultraosnografi/ Doppler USG Computed Tomographical Scanning (C-T Scan) Magnetic Resonance Imaging (MRI)
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Histopatologi:
Biopsi: Ginjal, tulang, tumor, excisi bedah dll
Mikroskop: Cahaya Immunofluoresence Elektron
Lain-lain: funduskopi
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FUNGSI GINJAL: EXKRESI REGULASI ENDOKRIN FUNGSI EXKRESI: METABOLIK GLOMERULAR CREATININ CLEARANCE UV Ccr = ----- ml/mnt P
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Ccr vs Glomerular Filtration Rate (GFR).
Inulin Clearance EDTA - isotop 99Tc - isotop Iohexol - Hi-Performance Liquid Chromatography
RUMUS COCKROFT-GAULT
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RUMUS COCKROFT-GAULT Pria 1,23 x (140- Usia) xBB (kg) Ccr = ------------------------------------- ml/mnt Scr ( umol/ltr) 140 - usia x BB (kg) atau = --------------------------------------- ml/mnt 72 x Scr (mg/dl) Wanita (140 – Usia) x BB (kg) Ccr = ------------------------------------ ml/mnt 7o x Scr (mg/dl)
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UREUM ----- PETUNJUK KEADAAN METABOLIK KREATININ -------Petunjuk fungsi ginjal/GFR Banyak dipengaruhi oleh: : Obat-obatan: Cimetidin, Trimetoprin, Probenecid dll Kimiawi: Protein, Glukose, Keton, Bilirubin dll.
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10 SINDROMA KLINIK PENYAKIT GINJAL
Kriteria berlandaskan: Klinik Laboratorium Pencitraan Histopatologi dll
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1. SINDROMA NEFRITIK AKUT (SNA): HEMATURIA (GROSS @ MIKRO @ SILINDER ERI) + OLIGURIA dan/atau CREATININ CLEARANCE dan/atau HIPERTENSI dan/atau OEDEMA.
2. SINDROMA NEFROTIK (SN) Proteinuria > 3 gram/24jam dengan/tanpa Oedema Hipoalbuminemia Hiperlipidemia
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3. KELAINAN URINE ASIPTOMATIK
HEMATURIA dan/atau PROTEINURIA dan/atau PIURIA dan/atau SILINDRRURIA tanpa diikuti sindroma lain
SNA, SN, GGA, GGK ISK, OSK, KTG BSK dan BSK.
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4. GAGAL GINJAL AKUT (GGA) Penurunan fungsi ginjal, tiba-tiba, (dalam beberapa hari/minggu), dengan/tanpa oliguria/anuria.
Oligurik --- Produksi urine <400 ml/24jam Non-oligurik --- Ccr<5 ml/mnt 5. GAGAL GINJAL KRONIK (GGK). Penurunan fungsi ginjal secara perlahan s/d bertahun Dengan tanda tanda kronisitas seperti Anemia, Kalsifikasi jar. Lunak dll.,
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6. INFEKSI SALURAN KEMIH (ISK). Bakteriuria bermakna pada pembiakan Urine: UPT/MSU: >/= 100,000 cfu/ml Aspirasi Supra Pubik (ASP) --- +ve Hati-hati kontaminasi. 7. OBSTRUKI SALURAN KEMIH (OSK) Penyumbatan aliran urine di sal.kemih oleh berbagai penyebab dipastikan dengan pencitraan
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8. KELAINAN TUBULI GINJAL (KTG) Perobahan sturuktural ginjal, terutama medulla, dengan manifestasi gangguan fungsi regulasi spt: gangguan elektrolit keseimbangan asam-basa. Sindroma Fanconi, Renal tubular acidosis (RTA) 9. BATU SALURAN KEMIH (BSK). Batu didaerah ginjal dan saluran kemih, ditunjukkan dengan keluarnya batu dan/atau pencitraan. : Batu Kandung Kemih (BKK): Masuk kawasan urologi.
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SINDROMA NEFRITIK AKUT
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HEMATURIA + oliguria dan proteinuria
dan/atau
kreatinin/ureum
dan/atau hipertensi
dan/atau oedema.
GLOMRULONEFRITIS VS GLOMERULOPATI
ETIOLOGI: GLOMERULO NEFRITIS AKUT,
SYSTEMIC LUPUS ERYTHEMATOSUS,
HENOCH-SCHONLEIN SYNDROMA,
NEFRITIS RADIASI,
INTOXIKASI DLL.
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PROTOTYPE SNA: POST-STREPTOCOCCUS GN
Mikrobiologi: Infeksi streptococcus Group A
type: 1, 4, 6, 12, 23, 49
----------> Tonsillitis, Pharyngitis, Caries gigi dll.
PATOGENESE: Dinding kuman = Antigen (Ag)
terbentuk Antibody (Ab).
Ikatan Ab dengan Ag oleh bantuan
Complemen (C3) ---- Ab-C3-Ag =
Immmune Complex = Ix
Deposisi di GBM ------> Peradangan ----->
GN
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Penyebab lain SNA.
Auto-immun
ANTI-GBM GN = GOOD-PASTURE SYNDROM
BM ginjal dan alveoli paru menjadi AG
membentuk AB ----> AB+AG complex
(immun-complex)
Staphylo-coccus
Salmonella
Virus
Malaria
terminologi lain: POST-INFECTIOUS GN
INFEKSI LAIN
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MASA INKUBASI: 10-14 hari
20-30% infeksi Streptococc ---> PSGNIndividual: = renal-susceptibility = type dari streptococc. (nefro-toxic)
Beratnya infeksi tidak berkorelasi dengan beratnya SNA
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GEJALA dan TANDA KLINIK:
ANAMNESE: 10-14 hari setelah infeksi (demam, batuk, dysfagi dll) Hematuria Sembab. Mulai sekitar orbita FISIK: Tekanan darah , oedema Kepala: sembab Leher: tvj? Thorax: jantung besar? Desah? Pulmo: basal rales? Abdomen: ascites? Extremitas: oedema ?
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Lab. Rutin: Darah: kadang anemia, leukositosis
Urinalisis: oliguria, merah,
proteinuria
Sedimen: eritrosit, silinder eri dll
Penunjang:
Ureum, kreatinin, komplemen, ASTO, Na, K dll
X-RAY: BNO, X - thorax
Histopatologi: hipersellular seluruh bagian glom.
Sedikit infiltrasi sel radang di interstium
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TERAPI SNA 1. Selama hematuria: bed-rest Diet: Kalori: cukup Cairan: 600 +vol.urine + eckresi
- Garam: nihil Protein: 20 gram/hr (Giovanetti) (nilai biologis tinggi)Ingat: Bila kalori kurang --> sindr.uremik Muntah : Parenteral Feeding, infus lar. Dextrose 40-50% di vena sentral
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MEDIKAMENTOSA:
Tidak ada yang spesifik.
Antibiotik bila masih ada sisa infeksi
streptococcus: Penicillin 1-2 juta unit/hr, 5-7 hr
SIMPTOMATIS:
Loop-diuretics untuk oliguria/oedema
Furosemide, Bumetanide, AS. Ethacrin
Anti-hipertensi
Ca-glukonas, Dextrose-Insulin bila hiperkalemia
DIALISIS: bila sudah ada indikasi.
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PERJALANAN PENYAKIT:
Masa inkubasi: 10-14 hari
Fase gagal ginjal akut renal: oliguria, sembab,
oedema, oedema pulmonum, payah jantung dll
80--85% Sembuh (bila ditata-laksana dengan baik)
10% Fatal
5--10% Sub-akut dan Kronis.
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Rapidly Progressive GNGNA tidak membaik dalam 2-4 minggu
Tanda tanda berkurang tetapi menetap.
Hematuria, hipertensi, ureum , kreatinin ringan
Dalam tempo 3-18 bulan kambuh kembali
Hematuria, hipertensi, ureum , kreatinin
berat. PA: Proliferasi sel sel epith, Caps Bowmann
Crescent formation
Dapat terjadi lansung, tanpa didahului GNA
yang jelas.
INFEKSI LAIN
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Glomerulonefritis kronik (GNK):
Glomerulonefritis dengan persistensi
kelainan urine.
PA: 1: kelainan proliferatif
2: kelainan membranous
3: kelainan membranoproliferatif
4: kelainan minimal
Mikroskop biasa: tak
Mikr. Immunofluorescense: deposit Ix
Mikroskop elektron : dese deposits pd MB
Klinik: GGK