ACUTE KIDNEY INJURY

Definisi
• Acute kidney injury (AKI) merupakan suatu
sindrom yang ditandai dengan gangguan
fungsi ginjal dalam mengatur komposisi cairan
dan elektrolit tubuh, serta pengeluaran
produk sisa metabolisme, yang terjadi tiba-
tiba dan cepat.Definisi AKI didasarkan kadar
serum kreatinin (Cr) dan produksi urin (urine
output/ UO).
Klasifikasi
 Epidemiologi
Penelitian meta-analisis mencakup 154 studi
pada lebih dari 3.000.000 individu
menyatakan bahwa 1 dari 5 orang dewasa dan
1 dari 3 anak di seluruh dunia mengalami AKI
selama perawatan di rumah sakit.
Insidens AKI pada pasien yang dirawat di ruang
perawatan intensif (ICU) adalah sekitar 20-
50%
Etiologi

Patogenesis
• Gangguan ginjal pra-renal menggambarkan
reaksi ginjal akibat kekurangan cairan. Pada
keadaan ini fungsi ginjal sebelumnya normal.
Berkurangnya perfusi ginjal dan volume efektif
arterial, akan menstimulasi aktivitas saraf
simpatis dan RAAS.
Stimulasi RAAS akan meningkatkan kadar
angiotensin II  vasokonstriksi arteriol efferent
glomerulus ginjal untuk menjaga tekanan
kapiler intra glomerulus serta LFG.
Selain meningkatkan kadar angiotensin II, sistem • AKI post-renal
sara simpatis juga terangsang  terjadi
reabsorbsi air dan garam di tubulus ginjal. Pada
keadaan tersebut terjadi perangsangan sekresi
aldosteron dan hormon antidiuretik  terjadi
peningkatan reabsorbsi natrium, urea, dan air
pada nefron.
• Gangguan utama AKI intrinsik renal adalah • Pada anak, sumbat tingkat atas umumnya karena striktur
nekrosis tubular akut (TNA).
Prosesnya terbagi menjadi dua : proses iskemik
dan proses nefrotoksik.
Apabila hipoperfusi berkelanjutan maka akan terjadi kerusakan
pada sel sel tubulus yang ditandai dengan ditemukannya sel
epitel tubulus yang nekrosis dan apoptosis. Gangguan
iskemik reperfusi tersebut tidak hanya terjadi pada epitel
tubulus, tetapi juga pada endotel pembuluh darah serta terjadi
pula aktivasi dari sel sel nflamasi serta mediator humoral.
Patogenesis :
• Tahap inisisasi : ditandai dengan kerusakan sel epitel dan
endotel
• Tahap ekstensi : terjadi kerusakan endotel mikrovaskular dan
aktivasi jalur inflamasi.
• Tahap maintanance : perbaikan dan re differensiasi dari sel
epitel dan endotel
• Fase perbaikan (recovery)
Akibat sumbatan dari traktus urogenitalis. Sumbatan terbagi
menjadi 2 :
• Sumbatan pada buli-buli dan uretra : sumbatan tingkat bawah
• Sumbatan ureter, pelvis ginjal : sumbatan tingkat atas.
Bila terjadi pada tingkat atas, sumbatannya harus Bilateral atau
pada hanya 1 buah ginjal yang masih berfungsi sedangkan yg
1 lagi tidak berfungsi.
ureter kongenital atau striktur katup ureter.
• Pada wanita dewasa: keganasan pada organ di retropertoneum
atau panggul
• Pada laki-laki : pembesaran/keganasan prostat
Diagnosis
1. Etiologi Pra Renal
Diagnosis
2. Etiologi Renal
Diagnosis
3. Etiologi Post Renal

Pemeriksaan Penunjang
• Complete blood count (CBC) with
platelets.
The white blood cell (WBC) count helps
evaluate for infection or interstitial
nephritis.
Anemia may indicate more chronic kidney
disease or bleeding from uremia.
Eosinophilia is associated with allergic
interstitial nephritis.
• Electrolyte panel (including Na , K , Cl , A urinalysis is an essential part of the evaluation
HCO , CaPO , Mg , and glucose).
Common electrolyte or metabolic
derangements include hyponatremia,
hyperkalemia, hypocalcemia,
hyperphosphatemia, and
hypermagnesemia as well as a mixed
anion and nonanion gap acidosis.
• Blood urea nitrogen/creatinine (BUN/Cr) ratio.
The normal BUN/Cr ratio is about 10. In prerenal
states, urea gets passively reabsorbed along with
sodium and water from the proximal tubules,
whereas creatinine does not. Therefore, a BUN/Cr
ratio greater than 10 (and certainly one greater
than 20) helps support a prerenal diagnosis.
Remember, an important factor that can influence
this ratio is the rate of BUN production, which can
be increased by resorption of blood, steroid use, or
a high protein diet.
• Urinalysis.
because an active urinary sediment (i.e., one that
has red or white cells or associated cellular casts),
implies an intraparenchymal cause of kidney
disease.
1. Red blood cell (RBC) casts or dysmorphic red
cells suggest glomerulonephritis.
2. WBC casts are usually a sign of infection (i.e.,
pyelonephritis) or inflammation (i.e., interstitial
nephritis).
3. Coarse granular or “muddy” brown casts may
signify ATN.
• Urine electrolytes can be 2. Fractional excretion of sodium
a useful diagnostic test in (FENa). FENa is another way of
patients with AKI. diagnosing prerenal physiology
and can also help evaluate
tubulointerstitial dysfunction
1. Urinary sodium and when a patient is oliguric
chloride can be used to - A value less than 1% usually
signifies prerenal physiology,
help delineate a prerenal
whereas one greater than 1%–
cause from an intrarenal 2% usually indicates
one. Values less than 20 tubulointerstitial disease
mEq/L imply a prerenal (because there is a defect in
etiology; values lower sodium reabsorption).
than 10 mEq/L are even 3. Fractional excretion of urea
(FEUrea).
more specific for prerenal
kidney injury.
 Pemeriksaan Penunjang
• Renal ultrasound. In addition to ruling out
obstruction, renal ultrasound helps to
• Renal biopsy is usually
distinguish acute from chronic kidney unnecessary but may be
disease.
1. The kidneys are usually normal in size in warranted for
patients with AKI.
2. They are usually small in patients with
unresolving acute renal
chronic kidney disease. However, some failure of unknown
chronic kidney diseases can lead to
enlarged kidneys. A useful mnemonic for etiology or to define the
these conditions is:
need for potentially
MNEMONIC: (“SHAPE” is large) Scleroderma toxic treatment of
HIV-associated nephropathy
Amyloidosis/infiltrative diseases Polycystic
glomerulonephritis.
kidney disease Endocrinopathy (i.e.,
diabetes mellitus, acromegaly)
 Tatalaksana
Secara garis besar ada 2 : konservatif dan terapi pengganti
ginjal
• Tujuan terapi konservatif pada AKI adalah :
• Mencegah progresifitas penurunan fungsi ginjal
• Meringankan keluhan akibat akumulasi toksin azotemia
• Mempertahankan dan memperbaiki metabolisme
secara optimal
• Memelihara keseimbangan cairan, elektrolit, dan asam
basa
 Pre renal Cause
1. Prerenal causes
Fluids are usually indicated because
hypovolemia is the predominant prerenal
cause of AKI.
2. Post Renal
- Catheterization.
- Percutaneous drainage
 Renal Cause
Renal causes are treated based on the specific pathology, but there are
general treatments that are common to all.
 General measures
a. Fluid restriction.
Fluids may need to be restricted to 1–1.5 L/day. Volume status should be
monitored by daily weights and input/output measurements.
b. Diet.
The diet should be low salt, low potassium, and low phosphorus.
c. Adjust medication dosages.
The dosages of medications that are excreted by the kidneys must be
adjusted.
Magnesium- and phosphorus- containing medications should be avoided
because these will accumulate in the setting of limited renal function.
 Specific measures
• ATN
- Fluids may help prevent further ischemic insult and may also dilute the effects of
certain toxins (i.e., myoglobin, contrast dye).
- Furosemide in high doses is sometimes successful in converting oliguric to
nonoliguric renal failure, but this has not been shown to change clinical outcomes.
If used, diuretics such as furosemide can be helpful to maintain a reasonable
volume status in patients with ATN. They should be given to reduce or avoid overt
volume overload but should not be given to such a degree that renal blood flow is
compromised. They should not be used to delay the initiation of dialysis. Consider
consulting a nephrologist if considering diuretics in the setting of AKI.
• Acute interstitial nephritis is usually treated by discontinuing offending medications
and administering fluids as tolerated.
A short course of corticosteroids (1 mg/kg/day of prednisone to a maximum dose of
60 mg daily for 1–2 weeks with a rapid taper) is occasionally used. d. Vasculitis.
Treatment is discussed in Chapter 76.

 Acute dialysis. The following indications often warrant dialysis, regardless of the
cause of kidney disease.
• MNEMONIC: Indications for Acute Dialysis (“AEIOU”) Acidosis Electrolytes (e.g.,
hyperkalemia, hypercalcemia) Intoxication Overload (fluid) Uremia