Penyakit pada Ginjal dan Saluran Kemih

Nur Samsu, dr, SpPD-KGH

Divisi Ginjal dan Hipertensi Lab/SMF Ilmu Penyakit Dalam FKUB RS Dr Saiful Anwar Malang

Bahasan

Sistem Urinarius Gangguan Fungsi Ginjal Akut dan Penyakit Ginjal Kronik

Glomerulonefritis

Infeksi Saluran Kemih

Anatomi Ginjal

Sistem Filttrasi Glomerulus

kidney

Glomerulus

Glomerular capillary

Slit diaphragm

Filtration barrier

GBM

Fenestrated endothelium

Anatomi dan Fisiologi

Urinary system terdiri atas: ginjal, ureter, bladder, dan urethra. Ginjal terletak di aspek posterior abdomen (Retroperitoneal), antara T-12 dan L3 Bentuk seperti kacang, ukuran: 10-12 x 5-7,5 x 2,5 cm - dibagi 3 area: Cortex, Medulla, Renal pelvis. 1/4 of blood diverted from aorta into kidneys

blood is filtered 20-25 times/day!

Fungsi Sistem Urinarius

Menjaga homeostasis dengan Elimination of waste products and acids Regulation of body water Regulation of blood pressure Stimulate red blood cell production by the marrow Help to keep bones strong and healthy

Urine Formation

Glomerular filtration - Beginning of urine formation Tubular reabsorption Tubular secretion 1,200 ml of blood flow through the kidney every minute - 20 - 25% of cardiac output required for glomerular filtration to occur

Gangguan Fungsi Ginjal Akut dan Penyakit Ginjal Kronik

Definisi Gangguan Fungsi Ginjal Akut

Rapid (hours to weeks) decline in GFR and retention of waste products. Lack a uniform definition Classic laboratory definition of creatinine of >0.5 mg/dl in <72hrs in more than 50% over baseline Cr. in calculated Cr Cl by more than 50%. Any in renal function that requires dialysis Creatinine > 1.5 x, urine output <0.5ml/kg/hr Creatinine 1.0 mg/dl/2d

Definisi Gangguan Fungsi Ginjal Akut

Etiology/Risk factors
General risk factors

Thadhani R, Pascual M, Bonventre JV. Acute renal failure. NEngl J Med 1996;334:14481460.

Definisi Penyakit Ginjal Kronik

Laju Filtrasi Glomerulus (LFG) atau Glomerular Filtration Rate (GFR) < 60 ml/min/1,73 m2 dan berlangsung 3 bulan GFR bisa ditentukan dengan Kliren kreatinin (KK)

KK (rumus Cockcroft-Gault) (ml/m):

(140-usia) x BB

72 x kreatinine serum
Pada wanita : hasil diatas X 0,82

Classification of Renal Function

Chronic Kidney Disease (CKD) Kidney Function GFR (mL/min/1.73m2) CrCl (mL/min)

Stage I
CKD Risk Factors/Damage with Preserved GFR

Stage II
Mild Kidney Function

Stage III
Moderate Kidney Function

Stage IV
Severe Kidney Function

Stage V
Kidney Failure ESRD

130 120 110 100

90

80

70

60

50

40

30

20

15

10

Chronic Kidney Disease

ESRD, end stage renal disease

National Kidney Foundation. Am J Kid Dis. 2004;43(Suppl 1):S16-S41.

Penyebab Penyakit Ginjal Kronik

Glomerulonephritis Diabetes Mellitus Urinary Stones Disease Hypertension Analgesic nephropathy Polycystic Kidney

Subclavian vein

internal jugular vein

A HD patient in the USA

Glomerulonephritis:
Acute Nephritic Syndrome and Nephrotic Syndrome

Major Clinical Manifestations of Glomerular Diseases

Acute

nephritic syndrome The nephrotic syndrome Persistent urinary abnormalities with few or no symptoms Chronic glomerulonephritis

Nephrotic vs Nephritic
Nephrotic Syndrome MASSIVE proteinuria SEVERE edema Hyperlipidemia Hypercholesterolemia NO hematuria, azotemia, or HTN at onset Nephritic Syndrome Azotemia Hematuria Red cell casts Hypertension Mild edema Mild proteinuria

Clinical Features of the Acute Nephritic Syndrome

haematuria

oliguria
oedema hypertension raised

urea and creatinine proteinuria

Etiology of the Nephritic Syndrome

Membranoproliferative glomerulonephritis Post-infection GN (post-strep) Rapidly progressive GN (crescentic) IgA nephropathy (Berger disease)

Henoch-Schonlein purpura SLE

Alport syndrome

The Nephrotic Syndrome

Is not a disease but a group of signs and symptoms seen in patients with heavy proteinuria presents with oedema proteinuria usually > 3.5g / 24hrs (>0.05g / kg / 24hrs in children) serum albumin < 30g/l other features: hyperlipidaemia, and hypercoaguable state

Systemic Diseases that Cause Nephrotic Syndrome

Neoplasm Heavy Metals Post Strep Infection Hep B & C HIV Endocarditis Syphillis Schistosomiasis Malaria Filaria

Vasculitis

Lupus HSP Polyarteritis Nodosa Wegners

Amyloid Diabetes Drugs

Heroin NSAIDS Penicillamine Gold

Urinary Tract Infections (UTI)

Definition

Urinary Tract Infection : A microbial colonization of the urine and infection of the structure of urinary tract. Bacteriuria : the presence of the bacteria in the urine Significant bacteriuria 100.000 cfu/ml Frequent recurrent > 4 events every year

Relaps same organism, after eradication Re-infection different organism, after eradication

Persistent is the continued infection of the same microorganism despite therapy

PATHWAY OF RENAL INFECTION

HEMATOGENOUS INFECTION Common agents : Staphylococcus E.coli
Bacteremia

AORTA

Intrarenal reflux

Vesicoureteral reflux

ASCENDING INFECTION Common agents : E.coli Proteus Enterobacter

Deranged vesicoureteral junction Bacteria enter bladder Bacterial colonization

PATHWAY OF HEMOTOGENOUS INFECTION TO RENAL

Infection Skin, Throat, Lung, Intestine, Urinary Tract Influence Diphtheria Shigella dysentery Ascending pyelonephritis

Lymph Node Lymphatic Dengue Malaria Typhus Hepatitis B Yellow Fever Liver Lung Kidney Salivary Gland

Bloodstream

Brain

Skin

Poliomyelitis Mumps Rabies Chickenpox Yaws Measles Rubella Hematogenous Pyelonephritis

Clinical Presentation

Suprapubic pain, pain or burning during urination frequency and urgency of urination Dysuria Nocturia Hematuria Cloudy urine Foul or strong urine odor Upper: fever, chills, malaise, N/V, weight loss, flank or back pain

Diagnosis of UTI

Determination of the number and type of bacteria important diagnostic procedure. Symptomatic 105 CFU bacteria/ml Asymptomatic 105 CFU bacteria/ml on 2 consecutive specimens Catheterized patients 102 CFU bacteria/ml

Urinalysis
Parameter Normal values UTI

Appearance
pH Protein Nitrite test RBC WBC Cast Bacteria

Yellow
4.5-8.5 Negative Negative Negative 0-5 / hpf Negative Absent

Cloudy
Alkaline Positive Positive Positive > 5 / hpf Positive Many present

Thank you