Dr.dr.

Krisni Subandiyah, SpA(K)

Anggota IDAI Cabang Jawa Timur, sejak tahun 1997

Riwayat Pendidikan Tinggi

1. Pendidikan Dokter (S1)Universitas Airlangga, lulus tahun 1989 2. Pendidikan Spesialis Anak Universitas Airlangga, lulus tahun 1997 3. Konsultan Nefrologi Anak - Universitas Airlangga, lulus tahun 2003 4. Program Doktor (S3) Ilmu Kedokteran Universitas Brawijaya, lulus tahun 2008

Pelatihan Profesional
2007 2007 2007 2007 2007 2008 2009 2009 2009 2009 2010 2010 2010 2011 Pediatric Neurologic Up date Innovative Assesment in Pediatrics Training Program Pelatihan Staf pengajar dalam OSCE dan Mini CEX Pelatihan tata laksana edema pada anak Manajemen Bayi Berat Lahir Rendah Level 3 (NICU) Pelatihan dalam rangka Konika 14 Workshop Evidence Based Medicine (EBM) Workshop Kegiatan PKB Anak XXXVIII Workshop Penanganan Terpadu Infeksi HIV pada bayi & Anak Workshop Penanganan Terpadu Infeksi HIV pada bayi & Anak Pelatihan Resusitasi Neonatus Pelatihan Motivasor Laktasi Pelatihan UKK Infeksi dan Penyakigt Tropis Workshop Antibiotic usage in Children

Pengalaman Jabatan
SPS Ilmu Kesehatan Anak Fakultas Kedokteran Universitas Brawijaya, tahun 2005- 2012 KPS Ilmu Kesehatan Anak Fakultas Kedokteran Universitas Brawijaya, tahun 2012 -sekarang

Nama : Dr. dr.Krisni Subandiyah,Sp.A(K) Agama : Islam Status : Menikah Suami : Dr.dr.Edi Handoko,Sp.THT-KL Anak : dr.Rizki Ekaputra Handoko TTL : Surabaya, 19 Juli 1964 NIP : 19640719 198910 2 001 Pangkat / Gol. : Pembina/ IV A Alamat Kantor : Jl. JA Soeprapto 2 , Malang Telp : (0341) 362101, 343343, Fax : (0341) 369393 Email : idaimlg @ yahoo.com Almat Praktek : Jl. Bunga Cengkeh 63, Mlg Telp : (0341) 486214 Alamat Rumah: Jl. Bunga Cengkeh 63, Mlg Telp : (0341) 486214 Email : krisdika2002 @ yahoo.com Jabatan : Staf Pengajar Divisi Nefrologi Anak Lab/SMF Ilmu Kesehatan Anak FK. UNIBRAW / RSU Dr. Saiful Anwar Malang

ETIOLOGY OF AKI

..................... Etiology
Prerenal

Renal/ intrinsic

Postrenal

THE MAJOR CAUSES OF AKI IN CHILDREN

Indian J Pediatr. 2012;79(8):10691075

MANAGEMENT OF AKI

..................... Management

Therapy

Conservative therapy Renal replacement therapy (RRT)

CONSERVATIVE THERAPY

Early goal directed fluid therapy

Fine control of acidosis & Electrolyte balance

Dietary Blood presure management
Kidney International Supplements. 2012; 2(2)

..................... Conservative Therapy

Fluid Management
Volume status
Hypovolemia Euvolemia Fluid overload and pulmonary edema

Oliguria
Adults & older children : Urine output < 400 mL/day Infant & younger children : Urine output < 0,5-1.0 mL/kg/h

Anuria Complete absence of urine output

Indian J Pediatr. 2012;79(8):10691075

..................... Conservative Therapy

Fluid Management

Textbook of Clinical Pediatrics. 2012

Fluid Management

. ...................Conservative Therapy

Fluid Management of Oliguric-Anuric Child

Pedatr and Child Health, 2012; 22(8): 341-345.

..................... Conservative Therapy Pre-Renal Failure

Severe dehydration Infusion 2030 ml/kg (maximum 60 80 ml/kg) isotonic saline or Ringers lactate , boluses Vital sign, CVP If urine output increases and CVP is still low, infusion may be continued If fluid replacement is accomplished furosemide
Management of Acute Kidney Problems. 2010

Maintenance of Fluid Balance

To limit ischemic injury
Modulate renal perfusion pressure Optimize the renal preload Insensible losses plus any ongoing losses D5,D10 : 20-30 mL/100 kcal/day (about 2530% of maintenance fluid requirements) or 500 mL/M 2 /day. D5NS : depend results electrolyte
Clin J Am Soc Nephrol. 2011; 6: 966973

..................... Conservative Therapy

................Conservative Therapy
FUROSEMIDE Doses : (1-5 mg/kg/dose) Force diuretic controversy Contra indications : Dehidration Urinary tract obstruction (Postrenal AKI)

Side effects :

Promote excretion of sodium and potassium The Cochrane Library. 2011 Ototoxicity

May be used but ONLY after adequate volume resuscitation

................Conservative Therapy
MANNITOL
0.5-1 g/kg delivered over 30 minutes Increase intratubular urine flow limit tubular obstruction Side effects : Congestive heart failure Hyperosmolarity.
The Cochrane Library. 2011

..................... Conservative Theraphy

DOPAMINE

Renal dose dopamine(0.5-5g/kg/min) Improve renal perfusion after an ischemic insult Increases renal blood flow by promoting vasodilatation Improve urine output by promoting natriuresis Can induce tachy-arrhythmias, myocardial ischaemia, and extravasation out of the vein can cause severe necrosis
Pediatr Nephrol. 2013; 13: 2425-8

................Conservative Therapy

Metabolic Acidosis

Nabic = (desired-observed bicarbonate) x kg x 0,3 (mEq) or 2-3 mEq/kg/day every 12 hours

The Cochrane Library, 2011

Hypocalcemia and tetany

Kidney International Supplements. 2012; 2(2)

Hyponatremia
Due to : dehydration & fluid overload with dillutional hyponatremic

Sodium < 130 mEq/L : fluid restriction

Sodium < 120 mEq/L : NaCl 3% (0,5 mEq/ml) - (125-serum Na ) x 0,6 X BW, slowly, 1-4 hours Corrected to at least 125 mEq/L
Kidney International Supplements. 2012; 2(2)

..................... Conservative Theraphy

Hyponatremia

With Seizures : - NaCl 3% :10-12 mL/kg, iv, 1 hr - NaCl 3% : (125- serumNa) x 0,6 + (0.513 mEq Na/mL NaCl 3%), rapidly
Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

Hyperkalemia
a. Decrease filtration b. Impaired tubular secretion c. Altered distribution of K+ by acidosis, which shifts potassium from the intracellular to the extracellular compartment d. Release of intracellular K+ due to the associated catabolic state
The Cochrane Library, 2011 Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

Hyperkalemia
Symptoms : Malaise, nausea Progressive muscle weakness.

The Cochrane Library, 2011

Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

Hyperkalemia
Mild Moderate
K : 6.0 7.0 mEq/L (6.0 and 7.0 mmol/L) Kation exchange resin (resonium A) : - Kayexalat 1gm/kg/po or per rectal 4x /day

Or

Kalitake 3x2,5 gram

The Cochrane Library, 2011 Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

Severe Hyperkalemia
K : > 7.0 mEq/L (7.0 mmol/L) + abnormal ECG or cardiac arrhythmias Ca glukonas 10% : 0,5-1 mL/kg, iv, 10-15 mnt Nabic 7,5% : 1-2 mEq/kg, iv, 30-60 minute

Not improvement
Glucosa 0,5-1.0 g/kg + insulin 0,1unit/kg, iv, 30 minute or subcutan The Cochrane Library, 2011 Insulin 0,2 unit/kg dialysis should be initiated Salbutamol 2,5 mg (BW< 25 kg), 5 mg (BW > 25 kg)
Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

The Cochrane Library, 2011

Indian J Pediatr. 2012; 79(8): 1069-75

................Conservative Therapy

Hyperphosphatemia

- Skeletal resistance to parathyroid hormone

- Dietary phosphorus restriction

- Overcorrecting the acidosis

- Calcium carbonate: 45-65 mg/kg/day,po

Hypocalcemia
Hyperphosphatemia Inadequate GI Ca absorption due to in adequate 1,25-dihydroxy vitamin D production by the kidney Skeletal resistance to the action of PTH Calcium carbonate: 45-65mg/kg/day,po Severe hypocalcemia : Calcium gluconate 10%, 0,5-1 mL/kg (maximal : 10 mL), 30-60 min ECG 1,25-dihydroxyvitamin D3 (calcitriol), 0,01-0,05 mcg/kg/day, po (<3 tahun) or 0,25 mcg-0,75 mcg per day (>3 tahun)

Hypertension

................Conservative Therapy

Volume overload diuretic (furosemide) or dialysis

ACE inhibitor : captopril 0,3mg/kg/x, 2-3 x/day

Crisis hypertension

Calcium channel blocker (nifedipine)

0,25-1 mg/kg/dose, sublingual, maximal 10 mg/dose The Cochrane Library,

2011

Indian J Pediatr. 2012; 79(8): 1069-75

Hypertension

Pediatrics in Review . 2008. 29 (9 ) : 299-308

Nutritional Support

................Conservative Therapy

NDT Plus . 2010. 3: 17

Nutritional Support
1 2

................Conservative Therapy

A diet of high biologic value protein Low phosphorus, low potassium food

Maintaining appropriate fluid balance

The Cochrane Library . 2010

Nutritional Support
Calorie
kcal/kgBW
Conservative treatment 0 2 years Child/teenager Peritoneal Dyalisis 0 2 years Child / teenager Haemodialysis 0 2 years 95 - 100 Minimal by age

................Conservative Therapy
Protein kcal/kg
1.0 - 1.8 1.0

95 - 100 Minimal by age

95 - 150 Minimal by body height

2.0 - 2.5 1.0 - 2.5

1.5 - 2.1 1.0 - 1.8

Child / teenager

The Cochrane Library . 2010

................Conservative Therapy
Risk of infection: - Azotemia depressed imunity - Underlying nutritional status Avoid : Long term catheterization

Infections
All procedures aseptic techniques
Indian J Pediatr. 2012; 79(8): 1069-75

Initial antibiotic level of renal function

Treatment for Underlying Cause of AKI

Withdrawal or replacement of offending medication (e.g., aminoglycosides, nonsteroidal anti-inflammatory drugs) Anti microbial therapy ( e.g., malaria, leptospirosis, sepsis, urinary tract infection)

Surgical intervention for obstruction (e.g., removal of stones)

Diuretics and alkalinization of urine in crush injury/myoglobinuria/hemoglobinuria Plasmapheresis in non diarrheal hemolytic uremic syndrome, rapidly progressive glomerulonephritis, vasculitis Pulse steroids in rapidly progressive glomerulonephritis, vasculitis, drug induced acute interstitial nephritis
Indian J Pediatr. 2012; 79(8): 1069-75

Prevention of AKI

Indian J Pediatr. 2012; 79(8): 1069-75

Renal Replacement Therapy

Modalities of RRT

Indication

- Hemodialysis

When conservative medical management is unsuccessful in restoring renal function

Peritoneal Dialysis

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