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Komponen Anatomis Dasar Saluran Kemih
Komponen Anatomis Dasar Saluran Kemih

Field, Pollock, Harris, The Renal System, 2001

Fungsi Ginjal

Mengeluarkan sisa metabolisme :

ureum,kreatinin,uric acid,aliphatic amine,ß2

microglobulin,PTH,myoglobulin,dll

Mengeluarkan kelebihan air dan elektrolit (K,Na,Al,H,P)

Produksi erythropoietin, renin- angiotensin,vitamin D3 aktif Menjaga keseimbangan asam basa Membuang toksin dan obat

Replaced partially by HD

Apa yang terjadi bila fungsi ginjal

rusak berat ?

Uremia (gejala akibat tertahannya zat-zat toksik dalam tubuh): mual muntah, nafsu makan turun, gatal, kesadaran turun

Tertahannya garam(Na) dan air :bengkak,sesak,hipertensi

Keseimbangan asam basa terganggu:

asidosis

Fungsi hormonal terganggu :anemia, kalsium menurun

Uraemic toxins :

Low MW : urea,creatinine Middle MW : B2 microglobulin, PTH High MW : myoglobulin

Middle MW sulit dihilangkan dgn HD, tapi efektip dgn Peritoneal Dialisis dan Highflux dialisis

Penyebab Gagal Ginjal

Glomerulonephritis Diabetic Nephropathy Urinary Stones Disease Hypertension Analgesic nephropathy Polycystic Kidney

Definition of Chronic Kidney Disease

Criteria

  • 1. Kidney damage for ≥ 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either : Pathological abnormalities; or Markers of kidney damage, including

Abnormalities in the composition of the blood or urine, or abnormalities in imaging tests

  • 2. GFR < 60 mL/min/1.73 m 2 for ≥ 3 mounths, with or without kidney damage

Years Until Kidney Failure (GFR < 15 mL/min/1.73 m 2 ) Based on Level of GFR and Rate of GFR Decline

Rate of GFR Decline (mL/min/1.73 m 2 per year)

Level of GFR (mL/min/1.73 m 2)

10

8

6

4

2

1*

9.4

13

19

38

75

 

8.1

11

16

33

65

 

6.8

9.2

14

28

55

 

5.6

7.5

11

23

45

 

4.4

5.8

8.8

16

35

 

3.1

4.2

6.3

13

25

 

1.9

2.5

3.8

7.5

15

 

0.6

0.8

1.3

2.5

5

  • 90 7.5

  • 80 6.5

  • 70 5.5

  • 60 4.5

  • 50 3.5

  • 40 2.5

  • 30 1.5

  • 20 0.5

The risk for loss of kidney function

Type

Definition

Examples

Susceptibility factors Initiation factors

Increased susceptibility to kidney damage Directy initiate kidney damage

Older age, family history

Diabetes, high blood pressure, autoimmune diseases, systemic infections, urinary tract infections, urinary stones, lower urinary tract

obstruction, drug toxicity

Progression

Cause worsening kidney

Higher lavel of proteinuria,

factors

damage and faster decline in

higher blood pressure

kidney function after initiation

level, poor glycemic

of kidney damage

 

control in diabetes, smoking

Endstage

Increase

morbidity

and

Lower dialysis dase (KW),

factors

mortality in kidney failure

temporary vascular access, anemia, low serum albumin, late referral

Factors influence acute decline on

chronic renal failure

Volume depletion IV radiographic contrast

Antimicrobial agent (aminoglycoside,amphotericine B)

NSAID (including Cox2) ACE/ARB Cyclosporine and tacrolimus Obstruction of the urinary tract Infection of urinary tract

Interventions that have been proven to be effective

Diabetic

Kidney

Disease

Non diabetic Kidney disease

Kidney disease In the transplant

Strict giycemic control

Yes * I:80-120

II:100-140

HbA1C(%):<7

NA

Not tested

ACE inhibitors or angletensin-

Yes

receptor blockers

Yes

Not tested

(greater affect in patients with

proteinuria)

Strict blood pressure control

Yes

< 125/75 mm Hg

Yes <130/80 mm Hg

(greater affect in patients with

proteinuria)

<125/75 mm Hg

(greater affect in patients with proteinuria)

Not tested

* Prevents or delays the onset of diabetic kidney discase.

Interventions that have been studied,

but the result of which are inconclusive

Dietary protein restriction (0.6 0,8

gr/kgBB/day)

Lipid lowering therapy (LDL<100 mg/dl) Partial correction anemia

Renal Replacement Therapy untuk

CKD stage V ?

1. Transplantasi ginjal 2. Hemodialisis (HD)

3. Continuos Ambulatory Perito-

neal dialysis (CAPD)

INDIKASI RENAL

REPLACEMENT THERAPY CHRONIC KIDNEY DISEASE

Kliren kreatinin <10 ml/menit pada non DM, atau <15 ml/menit apabila sudah

terdapat uremia

Kliren kreatinin <15 ml/menit apabila nefropati diabetik

Acute renal failure

(ARF)

Definisi

Penurunan fungsi ginjal (GFR) secara mendadak (dalam 1-7 hari) dan bertahan

> 24 jam.Biasanya disertai penurunan produksi urine.

RIFLE CRITERIA FOR ACUTE RENAL DYSFUNCTION

GFR CRITERIA

URINE OUTPUT CRITERIA

Increased creatinine x1.5 or GFR decrease > 25% UO < 0.5 ml/kg/h x 6 hr Increased
Increased creatinine
x1.5 or GFR
decrease > 25%
UO < 0.5 ml/kg/h
x 6 hr
Increased creatinine
x2 or GFR decrease
UO < 0.5 ml/kg/h
x 12 hr
> 50%
Increased creatinine
x3 or GFR decrease
> 75%
UO < 0.3 ml/kg/h
x 24 hr or Anuria
x 12 hrs
Persistent ARF**= complete loss
of kidney function > 4 weeks
End Stage Kidney Disease
ESKD
(> 3 months)

Loss

Risk

High

Sensitivity

Injury

Failure

High

Specificity

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&

db=PubMed&list_uids=8605788&dopt=Abstract

50-60%

20-30%

15%

Penyebab ARF

Pre renal : volume depletion,inadequate cardiac function, obstruksi arteri renalis

Renal : glomerular, tubulointerstitial disesase, obat, toksin

Post renal :stones, tumor, strictur, kompresi

Treatment of ARF

Pharmacologic :

  • - Fluid

  • - Vasopressor

  • - Loop diuretic

  • - Avoid nephrotoxic drug

  • - treat infection

  • - Treat complication : overload,acidosis, electrolyte disturbance

  • - Atrial natriuretic

  • - Fenoldopam,Insulin-like GF1,Thyroxine

Renal support :

  • - Continuous Renal Replacement Therapy

  • - Intermittent hemodialysis : SLED, SCUF, Daily

HD, Alternate-Day HD

  • - Acute Peritoneal Dialysis

Indications for acute dialysis

  • 1. Creatinine clearance < 25 ml/min :

    • a. uremia

    • b. Progressive fluid overload

    • c. uncontrolled hyperkalemia or me-

tabolic acidosis

  • 2. Creatinine clearance <15 ml/min, BUN

>100 mg/dl

CVVH Continuous veno-venous hemofiltration

heater

PV

V

V

BLD SAD high-flux heparin PA UF R
BLD
SAD
high-flux
heparin
PA
UF
R
CVVH Continuous veno-venous hemofiltration heater PV V V BLD SAD high-flux heparin PA UF R Advantage

Advantage

no arterial access

blood flow sufficient

good elimination of large molecules

exact filtration

Disadvantages

complex machinery

expensive

Percentage of patients in each group achieving urine

output >= 2 L/day during study period

60 50 94/166 (57%) 40 30 54/164 20 (33%) 10 0
60
50
94/166
(57%)
40
30
54/164
20
(33%)
10
0

P< 0.001

Furosemide Placebo
Furosemide Placebo

Furosemide

Placebo