Anda di halaman 1dari 29

Pungky Ardanykusuma\

Zappitelli M,Goldstein SL. Acute kidney injury: general aspects.In: Kiessling SG, Goebel J, Somers MJG, eds. Pediatric
Nephrology in the ICU. Berlin: Springer. 2009, 85-97 2
 AKI ≠ ARF
◦ Failure ada kelainan patologi
◦ ARF belum ada kriteria lab yang pasti
 AKI memilikispektrum yang luas dari
penurunan fungsi ginjal yang minimal
sampai penurunan yang membutuhkan
RRT/dialisis, yang
terjadisecaramendadak (akut)

Kellum, 2008
 AKI :
penurunan fungsi gnjal mendadak dengan
akibat hilangnya kemampuan ginjal untuk
mempertahankan homeotasis tubuh 

Peningkatan metabolit persenyawaan


nitrogen (Ureum, kreatinin, gangguan kes
cairan,elektrolit, as basa)
GGA (ARF)  GgGA (AKI)
ADQI: 2001  2007

PERUBAHAN KONSEP

Kenaikan Cr serum minimal  prognosis buruk


Definisi harus mampu mencakup deteksi dini

“injury” lebih mencerminkan patobiologi kelainan ginjal


dibanding istilah “failure” atau “gagal”

“kidney” dlm bhs Inggris lebih mudah dimengerti


dibandingkan “renal”
Kriteria RIFLE
Kellum JA, Bellomo R, Ronco C. The concept of acute kidney injury and the RIFLE criteria. In: Ronco C, Bellomo R,
Kellum JA, eds. Acute Kidney Injury. Contrib Nephrol. Basel: Karger. 2007; 10-6 6
• Modified RIFLE by AKIN (2007):

(Mehta et al, 2007)


COMMUNITY- HOSPITAL- CRITICALLY
ACQUIRED ACQUIRED ILL PATIENTS

• Cardiopulmonary bypass
• Bone marrow transplant • 8-24% in neonates
• Diarrhea + vomiting • Nephrotoxic meds w/ 10-61% mortality
• Acute GN • Nosocomial infections
• 10-15% incidence
• Infections • MOF
• Asphyxiated newborns from 3396 PICU pts
• 23-79% mortality
rate in children
Annual rate : 5-7% of hospitalized requiring dialysis
British= 22 /million pop patients  AKI • ↑ ICU stay 4x
US = 61-288/100,000 pop
• ↑ mortality
11% yearly increase
(1992-2001)
Dr. Sarjito Hospital (from 10% to
Scotland = 50/million pop yogyakarta (Ped 57.1%) in
Spain = 209/million pop Ward): patients with MOF,
Kuwait = 4.1/100,000 pop • 2010-2011 : 214 organ transplant,
Nigeria = 11.7 pediatric cases
ECMO, ARDS

(Himmelfarb, 2007; Askenazi, 2011; Basu, 2011; Li, 2011; Olowu, 2012)
 Vachvanichsana, 2006:
Insidensi AKI
< Thn 1995 : 0,5–3,3/1,000 orang
> Thn1995 : 4,6–9,9/1,000 orang
 Studi prospektif di PICU insidensi AKI
Leteurtre , 2003: 129 / 1,000 pasien masuk PICU
Bailey , 2007 : 44,7/1,000 pasien masuk PICU
 Di negara berkembang : etiologi primer terbanyak 
hemolytic uremic syndrome (Aurora, 1995) dan acute tubular
necrosis and obat – obatan nephrotoxic (Hui-Stickle , 2005)
(Jacob, 2003)
CLINICAL MANIFESTATIONS

SUPPORTIVE EXAMS
AKI ~ pRIFLE
AKI pRIFLE Treatment
•Blood & urine tests
Diagnosis ~~ Stage
•• Diagnosis Stage • Conservative
•Radiology: USG, MAG3, Causes
•• Causes • RRT
CT scan, MRU
CT scan, MRU Complications
•• Complications
•Renal biopsy

DIAGNOSTIC APPROACH
•Define the presence of AKI by pRIFLE criteria
•Differentiate the various causes
•Early diagnosis of pre-renal and obstructive causes is important
 as prompt corrective measures may prevent the onset of
established renal injury
CLINICAL MANIFESTATION

• muntah – diare - poliuria


Hypovolemia • CRT turgor cowong, TD

• oliguria – edema – gross hematuria


Renal
• SLE, HSP, RPGN
Diseases • infeksi

Multi organ • sepsis, heart surgery,


Failure • immunocomprimized, neutropenia

• oliguria > 72 jam


Neonatus
• thrombosis v renalis
Laboratorium
Pencitraan
DL, BUN, Cr, Elektrolit, Asam
basa, ASO, C3, C4, anti ds
DNA Obstruksi, kel anatomi ginjal
Urine: Urinalisis, Na, Cr, biakan USG, CT-scan, MRU
kemih
Feces: biakan feces
Supportive Exams

Biopsi ginjal
Biomarker baru
Hanya pada kasus2 tertentu
(GNPC) NGAL, IL-18, Cystatin C
KIM-1
DD/ AKI dg PGK/aCRF
PGK /
Signs and symptoms AKI
aCRF
Ukuran ginjal N <
Riwayat penyakit ginjal dalam keluarga - +
Riwayat penyakit, onset terjadinya
+ -
simtom
Gagal tumbuh - +
Retinopati hipertensi kronik - +
Gangguan tulang akibat hiperparatiroid - +

Anemia, hipocalcemia, hiperfosfatemia, hiperuricemia


Bukan merupakan faktor pembeda
karena dapat timbul dengan cepat pada AKI
Pediatric modified RIFLE criteria
Estimated CCI Urine Output

Risk eCCI decrease by 25% <0.5 ml/kg/h for 8 h

Injury eCCI decrease by 50% <0.5 ml/kg/h for 16 h

Failure eCCI decrease by 75% or <0.3 ml/kg/h for 24 h or anuric


eCCI <35 ml/min/1.73 m² for 12 h

Loss Persistent failure > 4 weeks

End stage End-stage renal disease (persistent failure >3 months)

tinggi badan (cm) Harga “k”


eCCl = k ------------------------ Bayi LBW = 0.33 Bayi aterm= 0.45
Cr serum (mg/dl) 2-12 tahun + pr 13-21 tahun = 0.55
Laki 13-21 tahun = 0.70

Arikan AA., Zappitelli M, Lotfis LL, Washburn KK, Jefferson LS, Goldstein SL. Modified RIFLE in critically ill children with
acute kidney injury. Kidney Int 2007,71: 1028-35
21
Age GFR (ml/min/1.73 m2)
Birth 20.8 ± 1.9
1 week 46.6 ± 5.2
3-5 week 60.1 ± 4.6
6-9 week 67.5 ± 6.5
3-6 month 73.8 ± 7.2
6-12 month 93.7 ± 14.0
1-2 year 99.1 ± 18.7
2-5 year 126.5 ± 24.0
5-15 year 116.7 ± 20.2
(Alatas H, 2002)
TREATMENT MODALITIES FOR AKI

Maintain adequate renal perfusion


Prevent fluid overload & hypertension
Maintain normal electrolytes and acid base
Conservative Ensure adequate nutrition
Dosage adjustments of meds
Avoid further nephrotoxic insults

Acute Renal PD


Replacement IHD
Therapy CVVHD
ALGORITHM FOR INTERVENTION IN PRE RENAL AKI
Oliguria
Fluid therapy
Restoration of cardiac output
Correction of precipitating factors
Correction of acid-base and electrolyte abnormalities

Diuresis

Persistent Oliguria
Furosemide
Diuresis

Persistent Oliguria

Renal Replacement Therapy

Recovery

Chronic Kidney Disease (Yap, 2010)


CONSERVATIVE TREATMENT FOR AKI

Adequate renal Prevent fluid overload


perfusion & hypertension
 Fluid balance
 Anti-hypertensive  Fluid resuscitation
 Diuretics
 Fenoldopam
Normal electrolytes
& acid base Adequate nutrition
 Caloric requirement
Correction of electrolytes &  Protein intake
acid-base disorders
Avoid nephrotoxic
Adjusted medications insults
 Renal dosage adjustment  Avoid nephrotoxic antibiotics
 ACE-I or ARB
 infection
(Yap, 2012)
Dialisis

Indikasi dialisis pada anak dengan AKI adalah :


1. Tahap Failure dari kriteria RIFLE
2. Hiperkalemia > 7,5 mEq/l
3. Bikarbonat serum < 12 mEq/l
4. Adanya gejala-gejala overhidrasi : edema paru,
dekompensasi jantung, dan hipertensi yang tidak dapat
diatasi dengan obat-obatan.
5. Perburukan keadaan umum dengan gejala uremia berat :
perdarahan, kesadaran menurun sampai koma.
1. Angka kematian pada AKI tergantung kepada
penyebabnya, umur pasien dan tahapan AKI

2. Prognosis pasien AKI juga ditentukan oleh lama


terjadinya gagal ginjal sampai intervensi terapi
diberikan.

3. Meskipun AKI yang terjadi dikatakan ringan, angka


kematian mencapai 30-60%, dan jika pasien tersebut
memerlukan terapi dialisis, maka angka kematian
meningkat sampai 50-90%.