SKRIPSI

LAURA MAYANG LESTARI

STUDI PENGGUNAAN OBAT GOLONGAN

KORTIKOSTEROID PADA PASIEN SINDROM NEFROTIK

(Penelitian Dilakukan di Rumah Sakit Umum Daerah

Dr. Saiful Anwar Malang)

PROGRAM STUDI FARMASI

FAKULTAS ILMU KESEHATAN

UNIVERITAS MUHAMMADIYAH MALANG

2019

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Lembar Pengesahan

iii

Lembar Penguji

131

Lampiran 1 Surat Pernyataan

iv

KATA PENGANTAR

Assalamualaikum Wr. Wb.

Puji syukur ke hadirat Allah SWT yang telah melimpahkan berkah dan

nikmat ke hamba-Nya, karena dengan pertolongan-Nya skripsi yang berjudul

Studi Penggunaan Obat Golongan Kortikosteroid pada Pasien Sindrom Nefrotik

(Penelitian Dilakukan di Rumah Sakit Umum Dr. Saiful Anwar Malang) dapat

diselesaikan tepat waktu dan dengan sebaik-baiknya.

Selanjutnya penulis ingin mengucapkan terima kasih yang tidak terhingga kepada:

1. Orang tua Bapak Johan dan Ibu Foejianty, dan kedua adik saya Fidel Ilyas

Kautsar dan Kevin Akbar Algiffari yang telah menjadi motivasi terbesar saya

untuk menyelesaikan skripsi ini.

2. Bapak Faqih Ruhyanudin M.Kep., Sp. Kep.MB selaku dekan Fakultas Ilmu

Kesehatan Universitas Muhammadiyah Malang.

3. Direktur dan staf Rumah Sakit Umum Dr. Saiful Anwar Malang yang telah

membantu kelancaran penilitian skripsi.

4. Bapak Drs. Didik Hasmono, Apt., MS selaku pembimbing I yang telah banyak

membantu dalam membimbing, mengarahkan, memberi semangat, motivasi,

serta menginspirasi penulis selama menempuh pendidikan sampai

terselesaikannya tugas akhir ini, semoga Allah selalu melimpahkan kesehatan

dan rahmat-Nya.

5. Ibu Hidajah Rachmawati, S.Si., Apt., Sp. FRS selaku Pembimbing II yang

tidak sedikit mengorbankan waktu untuk membimbing, selalu sabar dalam

mengarahkan dan memotivasi hingga tugas akhir ini dapat diselesaikan dengan

baik dan tepat waktu, semoga Allah selalu melimpahkan kesehatan dan rahmat-

Nya.

6. 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 banyak memberikan

masukan dan saran demi terselesaikannya tugas akhir ini dengan sebaik-

baiknya, semoga Allah selalu melimpahkan kesehatan dan rahmat-Nya.

v

7. Seluruh jajaran prodi, dosen dan staf tata usaha farmasi yang telah memberikan

dedikasi yang besar kepada penulis.

8. Teman sekelompok skripsi sindrom nefrotik Wika, Jeny, Richa dan Rian yang

telah berjuang bersama, saling menyemangati, memotivasi satu sama lain

hingga terselesaikannya skripsi ini.

9. Seluruh teman-teman farmasi C 2015 yang telah berjuang bersama dalam

menyelesaikan pendidikan di Program Studi Farmasi Universitas

Muhammadiyah Malang.

10. Dan yang terakhir, teman-teman yang telah membantu saya selama proses

pembuatan skripsi ini, teman saya Achmad Ilham Rizwani yang banyak sekali

membantu saya dalam menyelesaikan skripsi ini, terimakasih banyak atas

waktu yang selalu disempatkan untuk membantu saya. Teman saya Khairun

Ni’mah yang selalu menjadi teman dalam berkeluh kesah dan selalu menemani

saya serta memberikan semangat dalam pengerjaan skripsi ini. Kepada teman-

teman saya yang tidak bisa saya sebutkan satu persatu yang juga menyemangati

dan selalu memotivasi saya dalam pengerjaan ini, terimakasih banyak kalian

sangat berarti bagi saya.

Akhir kata, penulis mohon maaf atas kekurangan dan ketidaksempurnaan

penulisan skripsi dan dengan senang hati menerima kritik dan saran yang

membangun. Semoga skripsi ini bermanfaat dalam mengembangkan ilmu

pengetahuan bidang farmasi klinis bagi penulis maupun pembaca.

Wassalamualaikum Wr. Wb.

Malang, 13 Juli 2019

Laura Mayang Lestari

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DAFTAR ISI

Halaman

Lembar Pengesahan ................................................................................................ ii

Lembar Penguji ...................................................................................................... iii

KATA PENGANTAR ........................................................................................... iv

RINGKASAN ........................................................................................................ vi

ABSTRAK ........................................................................................................... viii

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

DAFTAR TABEL ................................................................................................ xiii

DAFTAR GAMBAR ........................................................................................... xiv

DAFTAR LAMPIRAN ........................................................................................ xvi

DAFTAR SINGKATAN .................................................................................... xvii

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. Manfaat Bagi RSUD Dr. Saiful Anwar Malang ............................... 5

1.4.2. Manfaat Bagi Ilmu pengetahuan ....................................................... 5

BAB II TINJAUAN PUSTAKA ........................................................................... 6

2.1 Ginjal Normal ........................................................................................... 6

2.1.1 Fisiologi ............................................................................................ 6

2.1.2 Struktur Lapisan Glomerulus ............................................................ 7

2.1.3 Filtrasi Glomerular ............................................................................ 8

2.2 Sindrom Nefrotik ...................................................................................... 9

2.2.1 Definisi Sindrom Nefrotik................................................................. 9

2.2.2 Epidemiologi Sindrom Nefrotik ........................................................ 9

2.2.3 Etiologi Sindrom Nefrotik .............................................................. 11

2.2.4 Patofisiologi Sindrom Nefrotik ....................................................... 17

2.2.5 Manifestasi Klinik Sindrom Nefrotik ............................................. 21

2.2.6 Komplikasi Sindrom Nefrotik ......................................................... 24

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2.2.7 Penatalaksanaan Sindrom Nefrotik ................................................. 26

2.3 Kortikosteroid ......................................................................................... 32

2.3.1 Definisi Kortikosteroid.................................................................... 32

2.3.2 Mekanisme Kerja Kortikosteroid .................................................... 35

2.3.3 Efek Farmakologi Kortikosteroid ................................................... 37

2.3.4 Indikasi Kortikosteroid.................................................................... 38

2.3.5 Kontraindikasi Kortikosteroid ......................................................... 39

2.3.6 Farmakokinetik dan Farmakodinamik Kortikosteroid .................... 40

2.3.7 Efek samping Kortikosteroid .......................................................... 42

2.3.8 Interaksi dan Manajemen Efek........................................................ 43

2.4 Kortikosteroid pada Sindrom Nefrotik ................................................... 44

2.4.1 Mekanisme Kortikosteroid pada Sindrom Nefrotik ........................ 45

2.4.2 Pemberian Kortikosteroid pada Sindrom Nefrotik ......................... 46

2.4.3 Obat Golongan Kortikosteroid pada Sindrom Nefrotik .................. 53

BAB III KERANGKA KONSEPTUAL ............................................................ 62

3.1 Kerangka Konseptual ............................................................................. 62

3.2 Kerangka Operasional ............................................................................ 63

BAB IV METODE PENELITIAN .................................................................... 64

4.1 Rancangan Penelitian ............................................................................. 64

4.2 Populasi dan Sampel .............................................................................. 64

4.2.1 Populasi ........................................................................................... 64

4.2.2 Sampel ............................................................................................. 64

4.2.3 Kriteria Inklusi ................................................................................ 64

4.2.4 Kriteria Ekslusi................................................................................ 64

4.3 Bahan Penelitian ..................................................................................... 64

4.4 Instrumen Penelitian ............................................................................... 64

4.5 Tempat dan Waktu ................................................................................. 68

4.6 Metode Pengumpulan Data .................................................................... 68

4.7 Penyajian Data ........................................................................................ 68

4.8 Definisi Operasional ............................................................................... 68

BAB V HASIL PENELITIAN ........................................................................... 71

5.1 Data Demografi Pasien ............................................................................... 71

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5.1.1. Distribusi Berdasarkan Usia ............................................................ 71

5.1.2. Distribusi Berdasarkan Jenis Kelamin ............................................ 72

5.1.3. Distribusi Berdasarkan Status Pengobatan Pasien .......................... 72

5.3 Pola Penggunaan Kortikosteroid pada Pasien Sindrom Nefrotik .............. 72

5.3.1 Pola Terapi Tunggal Golongan Kortikosteroid pada Sindrom

Nefrrotik ........................................................................................................ 73

5.3.2 Pola Penggunaan Kortikosteroid Kombinasi Dua pada Sindrom

Nefrotik …………………………………………………………………….74

5.3.3 Pola Penggunaan Kortikosteroid Kombinasi Tiga pada Sindrom

Nefrotik………….. ....................................................................................... 77

5.3.4 Pola Penggunaan Kortikosteroid Kombinasi Empat pada Sindrom

Nefrotik ……………………………………………………………………..80

5.4 Pola Penggunaan Kortikosteroid dengan Pergantian (Switching) pada

Sindrom Nefrotik .............................................................................................. 82

5.5 Lama Pemberian Kortikosteroid pada Pasien Sindrom Nefrotik .............. 102

5.6 Terapi Selain Kortikosteroid pada Pasien Sindrom Nefrotik .................... 102

5.7 Lama Perawatan Pasien Sindrom Nefrotik ............................................... 106

BAB VI PEMBAHASAN .................................................................................. 107

BAB VII KESIMPULAN ................................................................................. 118

DAFTAR PUSTAKA ........................................................................................ 119

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DAFTAR TABEL

Tabel Halaman

II. 1 Parameter Proteinuria pada Sindrom Nefrotik ............................................. 22

II. 2 Interpretasi Hasil Dipstik Urin ..................................................................... 27

II. 3 Data Farmakokinetik Kortikosteroid ............................................................ 41

II. 4 Interaksi dan Manajemen Efek pada Kortikosteroid .................................... 43

V. 1 Distribusi berdasarkan usia…………………………………………………71

V. 2 Distribusi berdasarkan Jenis kelamin ............................................................ 72

V. 3 Distribusi berdasarkan status pengobatan pasien .......................................... 72

V. 4 Pola penggunaan kortikosteroid pada pasien sindrom nefrotik .................... 73

V. 5 Pola terapi tunggal golongan kortikosteroid ................................................. 73

V. 6 Pola Terapi Kombinasi dua ........................................................................... 74

V. 7 Pola kortikosteroid Kombinasi Tiga ............................................................. 77

V. 8 Pola Penggunaan Kortikosteroid Kombinasi Empat ..................................... 81

V. 9 Pola Pergantian (Switching) Terapi Proteinuria............................................ 82

V. 10 Lama Pemberian Pasien Sindrom Nefrotik ............................................... 102

V. 11 Terapi Selain Kortikosteroid pada Pasien Sindrom Nefrotik .................... 102

V. 12 Lama Perawatan Pasien Sindrom Nefrotik ............................................... 106

V. 13 Kondisi Pasien Keluar Rumah Sakit ......................................................... 106

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DAFTAR GAMBAR

Gambar Halaman

2. 1 Anatomi Ginjal ................................................................................................. 6

2. 2 Membran Filtrasi Glumerular .......................................................................... 6

2. 3 Lapisan Membran Glomerulus ........................................................................ 7

2. 4 Hispatologi Minimal change nephropathy .................................................... 11

2. 5 Hispatologi Focal Segmental Glomerulosclerosis ........................................ 12

2. 6 Hispatologi Focal Segmental Glomerulosclerosis ........................................ 13

2. 7 Hispatologi Diabetik Nefropati Glomerulosklerosis Nodular........................ 15

2. 8 Hispatologi Sindrom Nefrotik pada Amiloidosis ........................................... 16

2. 9 Hispatologi Glomerulus pada Lupus Nefritis ............................................... 17

2. 10 Skema pandangan dari podosit foot process ................................................ 18

2. 11 Mekanisme proteinuria ................................................................................ 18

2. 12 Patofisiologi Sindrom Nefrotik ................................................................... 19

2. 13 Patofisiologi Edema Pada sindrom nefrotik ................................................ 20

2. 14 Struktur Kimia Aldosteron .......................................................................... 33

2. 15 Struktur Kimia Kortisol ............................................................................... 33

2. 16 Struktur Umum Kortikosteroid ................................................................... 34

2. 17 Mekanisme Antiinflamasi pada Kortikosteroid .......................................... 36

2. 18 Mekanisme Efek Terapeutik Glukokortikoid pada Sindrom Nefrotik ........ 45

2. 19 Tata laksana sindrom nefrotik ..................................................................... 46

2. 20 Pemberian Kortikosteroid pada Sindrom Nefrotik ..................................... 48

2. 21 Pengobatan SN relaps sering dan Dependen Steroid ................................... 48

2. 22 Diagram pengobatan SN relaps sering atau dependen steroid ..................... 50

2. 23 Pengobatan sindrom nefrotik resisten steroid ............................................. 51

2. 24 Struktur Kimia Prednison ............................................................................ 53

2. 25 Struktur Kimia Prednisolon . ....................................................................... 55

2. 26 Struktur Kimia Metilprednisolon ................................................................. 57

2. 27 Struktur Kimia Dexametason ...................................................................... 59

3. 1 Skema Kerangka Operasional……………………………………………….62

3. 2 Skema Kerangka Operasional ........................................................................ 63

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5. 1 Skema Sampel yang Memenuhi Kriteria Inklusi…………………………….71

xvi

DAFTAR LAMPIRAN

Lampiran Halaman

1 Daftar Riwayat Hidup…………………………………………………………130

2 Surat Pernyataan............................................................................................... 131

3 Surat Perizinan ................................................................................................. 132

4 Surat Laik Etik ................................................................................................. 133

119

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