SKRIPSI

JENY RINDIANTIKA

STUDI PENGGUNAAN OBAT GOLONGAN

ANGIOTENSIN CONVERTING ENZYME INHIBITORS
(ACE-I) PADA PASIEN SINDROM NEFROTIK
(Penelitian dilakukan di RSUD Dr. Saiful Anwar Malang)

PROGRAM STUDI FARMASI

FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH MALANG
2019
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Surat Pernyataan

117
 KATA PENGANTAR
Assalamu’alaikum Wr.Wb.
Puji dan syukur penulis panjatkan ke hadirat Allah Subhanahu Wa Ta’ala
yang telah melimpahkan rahmat dan karunia-Nya kepada kita, sehingga skripsi
dengan judul Studi Penggunaan Obat Golongan Angiotensin Converting
Enzyme Inhibitors (ACE-I) pada Pasien Sindrom Nefrotik (Penelitian
Dilakukan di Rumah Sakit Umum Daerah Dr. Saiful Anwar Malang) dapat
diselesaikan dengan baik dan tepat waktu.
Selanjutnya penulis ingin mengucapkan terima kasih yang tidak terhingga kepada:

1. Ibu Hidajah Rachmawati, S.Si., Apt., Sp. FRS selaku pembimbing I yang
telah meluangkan banyak waktu, tenaga, dan pikiran untuk membimbing,
memotivasi, menginspirasi, serta memberikan semangat dan dorongan
kepada penulis selama menempuh pendidikan hingga terselesaikannaya
tugas akhir ini, semoga Allah selalu memberikan kesehatan.
2. Bapak Drs. Didik Hasmono, M.S., Apt selaku Pembimbing II yang tidak
sedikit menyediakan waktu dan tempat untuk membimbing dan
mengarahkan hingga tugas akhir ini dapat diselesaikan dengan baik dan
tepat waktu, semoga Allah selalu memberikan kesehatan.
3. Ibu Ika Ratna Hidayati, S.Farm., M.Sc., Apt. dan Ibu Firasti Agung N.S., M.
Biotech., Apt. selaku penguji I dan II yang telah memberikan kritik dan
saran untuk membantu memperbaiki tugas akhir ini dengan sebaik-baiknya,
semoga Allah selalu memberikan kesehatan.
4. Bapak Faqih Ruhyanudin M.Kep., Sp. Kep.MB selaku dekan Fakultas Ilmu
Kesehatan Universitas Muhammadiyah Malang.
5. Ibu Hj. Dian Ermawati, S.Farm., Apt., M.Farm. selaku Ketua Program Studi
Farmasi Universitas Muhammadiyah Malang beserta seluruh jajaran prodi,
antara lain Bapak/Ibu dosen serta staf tata usaha Farmasi yang telah
memberikan dedikasi yang besar kepada penulis.
6. Direktur dan staf dari Rumah Sakit Umum Daerah Dr. Saiful Anwar Malang
beserta jajarannya, khususnya bagian Diklit, dan seluruh staf pegawai
bagian Rekam Medik yang telah memberikan izin, waktu, dan tempat dalam
kelancaran penelitian skripsi.

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7. Orang tua tercinta, Mama Watinah dan Bapak Baris sebagai motivasi utama
penulis untuk menyelsaikan skripsi ini. Terima kasih untuk segala do’a,
dukungan, baik secara moril dan materi.
8. Kakak tersayang, Eni Purwanti, S.E, Kapt. Pnb. Endrik Purwanto dan Mala
Richa Triastutik, A.Md yang telah memberikan semangat, dan motivasi
untuk penulis demi kelancaran penulisan skripsi. Semoga Allah selalu
melimpahkan rahmat dan hidayah-Nya.
9. Teman skripsi Sindrom Nefrotik, yang telah banyak memberikan bantuan
dan berjuang bersama demi terselesaikannya penulisan skripi ini.
Khususnya kepada Wika Tanika, Laura Mayang Lestari, Richa Faidhatul
Laily, dan Rian Norahman.
10. Sahabat “Mantan Sultan”, Afsana Nadhila Uma S.H, Eriza Nur Rahmi, dan
Arsy Rahman yang senantiasa memberikan semangat kepada penulis.
11. Seluruh teman-teman Farmasi angkatan 2015 khususnya Farmasi C yang
telah berjuang bersama penulis untuk menyelesaikan pendidikan di Program
Studi Farmasi Universitas Muhammadiyah Malang.
Akhir kata, penulis memohon maaf apabila terdapat kekurangan dan
ketidaksempurnaan dalam penulisan skripsi ini dan penulis dengan senang hati
untuk menerima kritik dan saran yang membangun. Semoga skripsi ini dapat
memberikan manfaat dalam perkembangan ilmu dalam bidang farmasi klinis bagi
penulis dan pembaca.
Wassalamu’alaikum Wr.Wb.
Malang, 10 Juli 2019

Jeny Rindiantika

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 DAFTAR ISI
Halaman

DAFTAR ISI ........................................................................................................... x

DAFTAR TABEL ................................................................................................ xiii
DAFTAR GAMBAR ........................................................................................... xiv
DAFTAR LAMPIRAN ......................................................................................... xv
DAFTAR SINGKATAN ..................................................................................... xvi
BAB I PENDAHULUAN ...................................................................................... 1
1.1 Latar Belakang ...........................................................................................1
1.2 Rumusan Masalah ......................................................................................5
1.3 Tujuan Penelitian ........................................................................................5
1.3.1 Tujuan Umum .......................................................................................5
1.3.2 Tujuan Khusus ......................................................................................5
1.4 Manfaat Penelitian .......................................................................................5
1.4.1 Bagi RSUD Dr. Saiful Anwar Malang .................................................5
1.4.2 Bagi Ilmu Pengetahuan .........................................................................5
BAB II TINJAUAN PUSTAKA........................................................................... 6
2.1 Tinjuan Glomerulus ....................................................................................6
2.2 Sindrom Nefrotik ........................................................................................8
2.2.1 Definisi Sindrom Nefrotik ....................................................................8
2.2.2 Epidemiologi Sindrom Nefrotik ...........................................................9
2.2.3 Etiologi Sindrom Nefrotik ..................................................................10
2.2.4 Patofisiologi Sindrom Nefrotik ...........................................................15
2.2.5 Manifestasi Klinik Sindrom Nefrotik .................................................17
2.2.6 Komplikasi ..........................................................................................22
2.2.7 Terapi Sindrom Nefrotik .....................................................................24
2.3 Angiotensin Converting Enzyme Inhibitors ..............................................36
2.3.1 Mekanisme Kerja Angiotensin Converting Enzyme Inhibitors ...........37
2.3.2 Efek Farmakologis Angiotensin Converting Enzyme Inhibitors .........37
2.3.3 Farmakokinetika dan Farmakodinamika Angiotensin Converting
Enzyme Inhibitors ................................................................................39
2.3.4 Kegunaan Terapeutik Angiotensin Converting Enzyme Inhibitors .....40

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 2.3.5 Kontraindikasi Angiotensin Converting Enzyme Inhibitors................41
2.3.6 Efek Samping Angiotensin Converting Enzyme Inhibitors ................41
2.3.7 Interaksi Angiotensin Converting Enzyme Inhibitors .........................42
2.4 Angiotensin Converting Enzyme Inhibitors pada Sindrom Nefrotik ........43
2.4.1 Mekanisme Kerja Angiotensin Converting Enzyme Inhibitors pada
Sindrom Nefrotik.................................................................................44
2.4.2 Penggunaan Angiotensin Converting Enzyme Inhibitors pada Sindrom
Nefrotik ...............................................................................................47
BAB III KERANGKA KONSEPTUAL ............................................................ 61
3.1 Kerangka konseptual ................................................................................61
3.2 Kerangka Operasional ..............................................................................62
BAB IV METODE PENELITIAN .................................................................... 63
4.1 Rancangan Penelitian ...............................................................................63
4.2 Populasi dan Sampel ................................................................................63
4.2.1 Populasi ..................................................................................................63
4.2.2 Sampel....................................................................................................63
4.2.3 Kriteria inklusi .......................................................................................63
4.3.4 Kriteria Eksklusi ....................................................................................63
4.3 Bahan Penelitian .......................................................................................63
4.5 Tempat dan Waktu ...................................................................................63
4.6 Metode Pengumpulan Data ......................................................................64
4.7 Analisa Data .............................................................................................64
4.8 Definisi Operasional .................................................................................64
BAB V HASIL PENELITIAN ........................................................................... 66
5.1 Data Demografi Pasien ............................................................................66
5.1.1 Distribusi Berdasarkan Jenis Kelamin ..................................................66
5.1.2 Distribusi Berdasarkan Usia .................................................................67
5.1.3 Distribusi Berdasarkan Status Pasien....................................................67
5.2 Pola Terapi Obat Golongan Angiotensin Converting Enzyme Inhibitors
(ACE-I) pada Pasien Sindrom Nefrotik ...................................................68
5.2.1Pola Penggunaan Obat Golongan Angiotensin Converting Enzyme
Inhibitors (ACE-I) Tunggal pada Pasien Sindrom Nefrotik ...............68
5.2.2Pola Penggunaan Kombinasi Dua pada Pasien Sindrom Nefrotik .........68

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 5.2.3 Pola Penggunaan Kombinasi Tiga pada Pasien Sindrom Nefrotik ........69
5.2.4 Pola Penggunaan Kombinasi Empat pada Pasien Sindrom Nefrotik .....73
5.2.5 Pola Penggunaan Switch Golongan Angiotensin Converting Enzyme
Inhibitors (ACE-I) pada Pasien Sindrom Nefrotik ............................74
5.2.6 Lama Pemberian Terapi Golongan Angiotensin Converting Enzyme
Inhibitors (ACE-I) pada Pasien Sindrom Nefrotik ............................87
5.3 Terapi Lain yang Diterima Pasien Sindrom Nefrotik ............................88
5.4 Lama Perawatan Pasien Sindrom Nefrotik di Rumah Sakit....................90
5.5 Status Keluar Rumah Sakit (KRS) Pasien Sindrom Nefrotik .................90
BAB VI PEMBAHASAN.................................................................................... 91
BAB VII KESIMPULAN DAN SARAN ......................................................... 105
7.1 Kesimpulan ............................................................................................105
7.2 Saran ......................................................................................................105
DAFTAR PUSTAKA ........................................................................................ 106
LAMPIRAN ....................................................................................................... 120

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 DAFTAR TABEL
Tabel Halaman

II. 1 I ntepretasi hasil urinalisis dipstik untuk proteinuria .................................. 18

II. 2 Protokol pemberian metilprednisolon puls .................................................. 27
V. 1 Distribusi berdasarkan jenis kelamin .......................................................... 67
V. 2 Distribusi berdasarkan usia ......................................................................... 67
V. 3 Distribusi berdasarkan status pasien ........................................................... 67
V. 4 Pola terapi golongan ACE-I pada pasien sindrom nefrotik......................... 68
V. 5 Pola penggunaan obat golongan ACE-I tunggal ......................................... 68
V. 6 Pola penggunaan ACE-I kombinasi dua pada pasien sindrom nefrotik ..... 68
V. 7 Pola penggunaan ACE-I kombinasi tiga pada pasien sindrom nefrotik..... 70
V. 8 Pola penggunaan ACE-I kombinasi empat pada pasien sindrom nefrotik 73
V. 9 Pola penggunaan switch golongan ACE-I pada pasien sindrom nefrotik .. 74
V. 10 Lama pemberian terapi ACE-I pada pasien sindrom nefrotik..................... 87
V. 11 Terapi selain ACE-I yang diterima pasien sindrom nefrotik ...................... 88
V. 12 Lama Perawatan Pasien Sindrom Nefrotik di Rumah Sakit ....................... 90
V. 13 Status Keluar Rumah Sakit (KRS) Pasien Sindrom Nefrotik ..................... 90

xii
 DAFTAR GAMBAR
Gambar Halaman

2. 1 Anatomi glomerulus dan jukstaglomerular apparatus.................................... 6

2. 2 Struktur sel intrinsik glomerulus .................................................................... 7
2. 3 A. Glomerulus normal. B & C. Minimal change disease ............................ 11
2. 4 A. Histopatologi FSGS primer. B. FSGS dengan hialinosis ........................ 12
2. 5 A & B. Histopatologi MN dengan deposit sel - sel imun ............................ 12
2. 6 Respon imun innate dan adaptif yang memediasi kerusakan jaringan ........ 13
2. 7 Patofisiologi sindrom nefrotik...................................................................... 16
2. 8 Patogenesis kerusakan ginjal progresif ........................................................ 18
2. 9 Mekanisme edema pada sindrom nefrotik ................................................... 20
2. 10 Manajemen sindrom nefrotik resisten steroid .............................................. 28
2. 11 Algoritma pemberian diuretik ...................................................................... 33
2. 12 Diagram skematis mekanisme yang berlawanan dalam RAS. ..................... 38
2. 13 Peran angiotensin II dalam patofisiologi penyakit ginjal ............................. 44
2. 14 Efek Angiotensin Converting Enzyme Inhibitors (ACE-I)........................... 45
2. 15 Mekanisme renoprotektif Angiotensin Converting Enzyme Inhibitors ........ 46
2. 16 Struktur kimia captopril ............................................................................... 49
2. 17 Struktur kimia enalapril................................................................................ 50
2. 18 Struktur kimia lisinopril ............................................................................... 52
2. 19 Struktur kimia benazepril. ............................................................................ 53
2. 20 Struktur kimia ramipril................................................................................. 55
2. 21 Struktur kimia quinapril ............................................................................... 57
2. 22 Struktur kimia fosinopril .............................................................................. 58
3. 1 Skema kerangka konseptual ..........................................................................61
3. 2 Skema kerangka operasional .........................................................................62
5. 1 Skema sampel yang memenuhi kriteria inklusi ............................................66

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 DAFTAR LAMPIRAN
Lampiran Halaman
1 Daftar Riwayat Hidup ...................................................................................... 120
2 Surat Pernyataan............................................................................................... 121
3 Surat Ijin Penelitian .......................................................................................... 122
4 Surat Laik Etik ................................................................................................. 123

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Sertifikat Plagiasi