Pemeriksaan Fungsi Ginjal dan Infeksi saluran Ginjal

Dr Zulfian SpPK Fakultas Kedokteran

Universitas Malahayati

Fungsi Ginjal :
1. Membuang sisa metabolisme 2. Mengatur jumlah cair tekanan darah 3. Mempertahankan keseimbangan kadar H+ dan HCO3keseimbangan asam basa 4. Mengatur jumlah kation dan anion tekanan osmotis cairan tubuh Disamping itu ginjal mampu 1. Memproduksi ertropoetin 2. Renin enzim berfungsi mengatur volume cairan ECS 3. Kalikrein : enzim proteolitik pembentuk kinin, (vasodilator) 4. Postaglandin dan Tromboksan

Dalam menjalankan fungsiny ginjal mempunyai bahagian disebut fungsional unit ginjal disebut nefron

Pada manusia hampir seluruh akhir metabolisme diekskresikan melalui glomerulus Ekskresi melalui tubulus utk bahan sisa metabolisme kurang penting kecuali K+, asam urat, Tubulus ginjal memelihara air dan konstiituen yang larut dalammelalui reabsorbsi menggunakan reabsorbsi aktif

Tes Fungsi Ginjal :

Mempunyai fungsi :

1. Mengetahui kerusakan ginjal 2. Menentuan derajad gangguan fungsi ginjal

Pemeriksaan urin : gangguan pada ginjal dan saluran kemih Pemeeriksaan Klirens : gangguan fungsi ginjal

Spesimen Urin
1. Urin Pagi Kandungan zat dlm urin pekat Aliran pertama dibuang Sangat baik untuk pemeriksaan : Sediment, BJ (S.G.), TES Kehamilan 2. Urin Sewakttu 3. Urin 2 jam post Prandial untuk pemeriksaan GLUKOSA 4. 24 HOURS URINE

Pasien Bangun pagi Dan berkemih (jam 06.00)

jam 06.00 Hari berikutnya

(buang)

Urin dikumpul selama 24 jam Dalam keadaan istirahat

URINE

(Pagi) (Segar)

SHAKE

MAKROSKOPIS

Warna Kejernihan Bau Berawan Keasaman (PH) SPEC. GRAF (BJ)

SEDIMENT SUPERNATANT MIKROSKOPIC ERYTHROCYTE LEUKOCYTE EPHITEL CRYSTAL CAST KIMIA ALBUMIN GLUCOSE UROBILIN BILIRUBIN KETOBODY BENZIDIN

ROUTINE SIMPLE

1 . M A C R O S C O P I C E X A M I N AT I O N O F U R I N E A. WARNA KUNING MUDA COKLAT TUA (the pekat) TES BUSA NORMAL BILIRUBIN (?)

KOCOK (KUAT )

BUSA

YELLOW (JELAS) = F. T + > BIL. + Meragukan

RED

(DARAH ?)

FOUCHET
ERYTHROCYT : (+) = HEMATURI (-) = Hb. UR TES BENZIDIN

PEMERIKSAAN SED.

THE OTHER COLOUR MAKANAN / SAYURAN DRUGS : ANTIPIRIN FENACETIN SUBST. FENOL, SALICYL

GREEN YELLOW DARK GREEN

B. KEKERUHAN

(NORMAL : JERNIH)

REDDISH

SEDIMENT ? (ERYTHROCYT) HALUS (PUTIH) BAKTERI (GRAM) KASAR (WHITE) (ALKALIC / NEUTRAL URINE) - PUS - KRISTALPHOSPHATE / KARBONAT + ACETIC ACID SOL (6%) BERKURANG/ HILANG
SPERMATOZOA VOLUME URIN NORMAL : 800 1600 ml/24 JAM 4 DAY 3X NIGHT POLYURIA D.M., D.I., CHR. NEPHRATIS, EDEMA, RECONV. FROM CHR. DISEASES

PERDARAHAN

OLYGURIA ACUTE NEPHRITIS, ECLAMPSIA, ENTERITIS, BANYAK KERINGAT, DECOMP. CORDIS. ANURIA COLLAPS, KERACUNANHg CL2

C. KEASAMAN (pH) (N. 4.7 - 7.5) RATA2 6.0

KERTAS LITMUS R BLUE RED = ACID BLUE = ALKALINE VIOLET = NEUTRAL ACID URINE MORE EASY

RED
MUST BE DONE ALWAYS : - ALBUMIN TEST - INTERPRETATION :

ADV. : 1. NEW URINE ALKALINE UTI = M.O PEMECAH UREA 2. PEDOMAN TH/ ACIDOSIS / DGN ALKALIN SUBSTANSI D. SMELL NORMAL ABNORMAL

BAU URINE BAUJENGKOL

KERACUNAN JENGKOL

+ ALBUMINURIA HEMATURIA CRYSTALURIA BUAH2AN AMONIAK KETONURIA UREUM DARI BACTERIA

E. PEMERIKSAAN BERAT JENIS ( SPECIFIC GRAVITY =S.G.) BJ. TERGANTUNG DARI TOTAL BAHAN TERLARUT NORMAL : 1.010 - 1.025 (1.020) S.G. RENDAH ( < 1.010 ) = GANGGUAN GINJAL/ENDOKRIN

S.G. TINGGI ( > 1.025) = FEVER, GLYCOSURIA

METHOD & ALAT URINOMETER SILINDER PENGUKUR (50 ml)

1.000
1.020 1.040 KOREKSI TEMP. : EVERY 30 C > 150 C : + 0.001 40 C > 170 C : + 0.001 GLUCOSE : EVERY 270 mg/DL : -0.001 1 % : -0.004 PROTEIN : EVERY 400 mg/DL : -0.001 1% : -0.003

BILA JUMLAH URIN SEDIKIT GUNAKAN : - METODE TETES JATUH - REFRACTOMETER

2. MICROSCOPIC EXAMINATION OF URINE

URIN SEGAR < 6 HOURS SENTRIFUGE PADA 1500 RPM / 5 MINUTE

SEDIMENT

TUTUP DGN COVER GLASS SLIDE

MIKROSKOPE

OBJECTIVE 40 X EYEPIECE 10 X CONDENSOR

PERIKSA ! !

ERITHROCYTE / PEMBESARAN < SEDIMEN ORGANIK LEUKOCYTE / PEMBESARAN > CAST / PEMBESARAN <

SEL EPHITEL
SEDIMEN ANORGANIC CRYSTAL

ERITHROCYTE
MORFOLOGI : A. NORMAL (URINE SEGAR ) : - BULAT , F + 7 m (EQUALLY) - KEKUKING2AN B. CRENATED (BJ URIN TINGGINE) - BGN PINGGIR GELAP - PINGGIRAN BERDURI - CAIRAN KELUAR DARI SEL MANFAAT KLINIS : NORMAL, TIDAK DIJUMPAI ERITROIST DLM URIN ERY (+) URINE : - PERDARAHHAN (KANKER REN, PYELUM) (HEMATURI) - TRAUMA (CALCULUS, CRYSTAL) - RADANG (TBC, GNA) DIBUTUHKAN PEMERIKSAAN LEBIH LANJUT CATATAN : ERY (+) : : ULANGI MIDSTREAM URINE ATAU URIN DGN KATETER NORMAL : 0 - 1 / LPB

LEUCOCYT (WHITE CELLS)

MORPHOLOGIC : CLEAR GRANULAR DISKS ROUND ; F + 11 m (1.5 - 2 E) THE EDGES NOT CLEAR CELLS SURFACES ARE GRANULAR

E
E

IN NEW URINE AMOEBOID MOVEMENT IN NEW ALKALIST CLUMPS IN ALWAYS FOUND 2 - 6 LEUCOCYT OR MORE / LOW POWER

- CATHETER URINE - MEN

>6

/ HIGH POWER = PATOLOGIC

THE CLINICAL VALUE :

N : 0 - 6 / LOW POWER

NOTES : CLEAN VOIDED URINE (GEWASSEN URINE) : - OPEN PREPUTIUM - CLEAN URETHRAE - TAKE MIDSTREAM URINE : - WASH THE AREA AROUND URETHRAE - OPEN LABIA MIDSTREAM URINE

CATHETERIZATION DANGEROUS, INFECTION

EPITHELIAL CELLS

MORPHOLOGIC :
SCUAMOUS EPITHELIAL CELLS (VAGINA) (URETHRAE DIST.)

CAUDATUS ROUND EPITHELIAL EPITHEALIAL CELLS (TUBULUS) (PELVIS R.)

SMALL AMOUNT OF EPITHELIAL : USUALLY, (ESPECIALLY ON WOMAN) DIAGNOSTIC VALUE IS SMALL

CRYSTAL
IN ACID URINE : URIC ACID URATE URATE CRYSTAL / AMMORPHUS URATE Ca OXALATE IN ALKALIST URINE : AMMORPHUS MAGN. PHOSPHAT Ca PHOSPHAT / CARBONATE AMMORPHUS PHOSPHAT AMMONIUM URATE URIC ACID IN FRESH URINE CALCULUS IN THE U.G. OTHERS, THERE HAVE NO CLINICAL VALUE

APPEARENCE OF CRYSTAL - Ca OXALATE : SIZE VARIABLE CLEAR MORPH. LIKE ENVELOPE

CLEAR

- PHOSPHAT :
TRIPLE PHOSPHAT AMMORPHUS PHOSPHAT

CALCIUM PHOSPHAT

- CARBONATE :

CALSIUM CARBONATE

- URIC ACID :

COLOUR IS BROWN - URATE :

NH4 URATE

Na - URATE

AMMORPHUS URATE

CRYSTAL

NORMAL CRYSTALINE DEPOSITE

1. CALCIUM OXALATE (ACID URINE)

A. SHAPE LIKE ENVELOPE SIZE 10 - 20 m m B. SHAPE LIKE PEANUTS SIZE + 50 m m COLOUR : CLEAR / TRANSPARANT ( COLOURLESS ) 2. URIC ACID (ACID URINE)
SHAPE VARIES (SQUARE, DIAMOND SHAPE, CUBICAL/ ROSE SHAPE) SIZE 30 - 150 m m COLOUR YELLOW - BROWNISH RED 3. TRIPLE PHOSPHATES ( NEUTRAL / ALKALINE URINE ) SHAPE : A. RECTANGULAR B. LIKE A TERM LEAF / STAR SIZE 30 - 150 m m COLOUR : COLOURLESS 4. URATES (ALKALINE / CLEAR) SHAPE LIKE : 1. CACTUS 2. A BUNDEL OF NEEDLE 5. LESS COMMON CRYSTAL A. CALCIUM PHOSPHATE (ALKALINE NEUTRAL) B. CALCIUM CARBONATEE (ALKALINE NEUTRAL) C. CALCIUM SULFAT (ACID URINE)

CAST
CAST OF SEDIMENT IS PRECIPITATE OF PROTEIN IN TUBULI IN ACID URINE CYLINDRICAL IN SHAPE AND LONG

PROTEIN
1. HYALINE CASTS : TRASPARENT, SLIGHTLY REFRAQTIL, THE END RONDED OR TAPERED 2. GRANULAR CASTS (COARSE) : RATHER SHORT CASTS FILLED WITH LARGE GRANULES PALLET PALE YELLOW IN COLOUR (GRANULES COME FROM DEGENERATE EPHITELIAL CELLS FROM THE TUBULES OF THE KIDNEY) 3. FINE GRANULAR CAST : GRANULES ARE SMALLER AND DO NOT FILL THE CAST

4. BLOOD CASTS (ERITHROCYTES CASTS) : CASTS DIISI DGN ERITROSIT CELLS BERARNA KECOKLATAN

5. PUS (LEUKOCYTES) CASTS : CAST DIISI DGN LEUKOCYTES

6. EPHITELIAL CASTS : CAST DIISI DGN KUNING PUCAT SEL2 EPHITELIAL

BIOCHEMISTRY EXAMINATION OF URINE 1. PEMERIKSAAN PROTEIN OF URIN ? PRINSIP : PROTEIN

Ph TERTENTU

BERAWAN

? KONDISI URINE : - ASAM DAN JERNIH ? JENIS PEMERIKSAAN : KUALITATIF / SENSITIVITY 5 - 10 mg /dL A. EXTON TEST FOR PROTEIN URINE URIN

REAGEN : SULFOSALISILIC ACID : 25 GR. 50 NA2SO4 : 100 GR. 88 AQUADEST : 500 CC. 1000
SHAKE
REAGENS : 2.5 ml URINE : 2.5 ml

SENTRIFUS

JERNIH = PROTEIN (-) (TDK ADA PRESIPITASI PUTIH) TURBID = EXTON (+) DIIKUTI DGN : 1. BANG TEST 2. ACETO PRECIPITABLE SUBSTANCE TEST

BANDINGKAN DGN URIN YG TDK DI TREATC DGN LATAR BELAKANG HITAM

EXTON (+) : - PROTEIN - PROTEOSEN - BENCE JONES PROTEIN - URIC ACID & OTHERS

B. BANG SEMI QUANTITATIVE TEST FOR PROTEIN URINE 1) REAGEN : SODIUM ACETATE ACETIC ACID GLASIALE AQUADEST 2) METHODS
JERNIH

: 11.8 GR : 5.65 CC ad 100 CC

SYMBOL PROT (mg %)
0

RESULT :

SEDIKIT KERUH KERUH TANPA GRANUL KERUH DENGAN GRANUL KERUH DG FRAGMEN 1000 C
WATER BATCH
10

+
+ ++ +++ ++++

+ 10
10 - 50 50 - 200 200 - 500

BOILED
REAGEN 0.5 ml URINE 5 ml

READ

MENGGUMPAL

>

500

IF THE AMOUNT OF ALBUMIN 3000 mg %

BOILED

CLOTTING

EXTON

PROTEIN : BANG

PROTEOSEN PROTEIN BENCE JONES PROT. TURBID WITHOUT BOILING ACETOPRECIPITABLE

C. QUANTITATIVE PROTEIN URINE EXAMINATION (ESBACH) - UTK KONFIRMASI JUMLAH PROTEIN DLM URIN - URIN DIKUMPULKAN : 24 JAM

REAGENT : > PICRIC ACID : 1 GR > CITRIC ACID : 2 GR > AQUADEST : 100 CC
METHOD TES (ESBACH)
PASANG PENUTUP TABUNG

BACA : TINNGI PRESIPITASI PUTIH

PIPET REAGEN

PIPET URINE

KOCOK

5
5 GR / L / 24 HOURS

ALBUMINOMETER

GERAKAN TABUNG (10 X)

LETAKKAN : PADA TEMPERATUR KAMAR SELAMA 24 JAM CEGAH CAHAYA MATAHARI POSISI TEGAK

DETEKSI PERDARAHAN TERSEMBUNYI DLM URIN IF : HEMATURIA SEDIMENT EXAM. ERI (+)

Hb. URIA
BENZIDINE/HEMA TEST PRINSIP :

SEDIMENT EXAM

ERI (- )

BLOOD PEROKSIDASE ACTIVITY

H2O2
METOD : PREPARE :
1. BENZIDINE SOLUTION

H2O + On

BENZIDINE OXIDATION

3. H202 SOLUTION
5ml ACETIC ACID GLACIAL 1 gr BENZIDINE

TEST

2. URINE
PANASKAN

BACA DLM 5 URINE

DINGINKAN

THIS TEST IS VERY SENSITIVE GIVE + RESULT BY OXYDASE FROM LUEKOCYTE

- URINE MUST BE HEATED - EQUIPMENT CLEAN

URINE TEST STRIP CHARACTERISTIC OF THE TEST : CEPAT, MUDAH, DAN MURAH MATERIALS : TEST STRIP
SPECIFIC GRAVITY
NITRITE pH PROTEIN GLUCOSE KETOBODY UROBILINOGEN BILIRUBIN BLOOD

PLASTIK ROD NYLON COVER TEST FIELD (PAPER CONTAIN REAGENT) FILTER PAPER

PROCEDUR OF THE TEST : 1. CELUP STRIP DLM URIN KIRA2 1 DETIK 2. BUANG URIN BERLEBIH DARI STRIP

URINE

READ :

COMPARE THE COLOUR CHART

UROTRON

Proses yg terjadi di nefron ginjal

1. Fungsi Filtrasi 2. Fungsi Absorbsi 3. Fungsi Ekskresi

Pemeriksaan fungsi ginjal

1. Filtrasi : kadar kreatinin/inulin dalam darah 2. Absorbsi : glukosa dlm urin 3. Sekresi : PAH (Para Amino Hypuric Acid)

INULIN : - Tidak diabsorbsi - Tidak disekresi - Bahan eksogen G.F.R. X P = U X V P U V : Konsentrasi inulin plasma : Konsentrasi inulin urin : Diuresis ( volume urine / minute )
UXV

GFR

=
P

INULIN UREA

: Bahan Eksogen Tdk di reabsorbsi dan tdk disekresi. : Bahan enogen, direabsorbsi

Kreatinin
Sebagian besar difiltrsi, hanya sedikit di sekresi

KREATININ KLIRENS UXV P

140 ml / menit

Klirens Kreatinin =

Keuntungan : waktu panjang12 24 jam lebih akurat Kerugian : human error krn waktu yg panjang selama pengumpulan urine

Correction factor ( f )
Diuresis dipengaruhi oleh berat badan dan tinggi badan Diuresis dikoreksi (V) V fV

Rumus sederhana untuk klirens :

( 140 - age ) x Berat Badan (kg) Creatinine clearance = P x 72 P : kadar Kreatinin darah Wanita, nilai dikali dgn 0,85 Renal Plasma Flow (R.P.F.) : R.P.F. = PAH clearance ( Paraaminohippurate ) Renal Blood Flow ( R.B.F) : 100

R.B.F =
( 100-Ht) Filtration Fraction = G.F.R. R.P.F.

x R.P.F.

Hubungan Kadar kreatinin dgn GFR

Kreatinindlm darah (mg/dl) 14 12 10 8 6 4 2

30

60

90

120

G.F.R. ml / minute