Gagal Ginjal Kronik dengan Hemodialysis reguler

“Peranan pasien dan keluarga”

R Tunggul Sukendar

Divisi Ginjal dan HipertensiBagian Ilmu Penyakit Dalam FK USU/

RSUP H. Adam Malik Medan

Mengenali Kelainan Ginjal

Ginjal ada 2 : kiri dan kananBerat masing-masing : 1/3 kgRenal blood flow : 1-1,5 L/menit

Unit fungsional Ginjal : NefronJumlah : masing-masing : 1 juta

GlomerulusTubulus proximalLengkung HenleTubulus distalTubulus pengumpul

CalyxPyelumUreterKandung kemihUrethra

RENAL CYSTIC DISEASE

CHRONIC PYELONEPHRITIS

 Fungsi Ginjal 

1.    Fungsi EkskresiMeneluarkan zat toksis / racun

 2.    Fungsi Regulasi

Mengatur keseimbangan : air, garam/elektrolit Asam / Basa

3.    Fungsi hormonalHormon renin, prostaglandinEritropoetin, Kalsitriol dll

Gangguan Ginjal :

Akut : :

Tiba-tiba, dalam beberapa hari / minggu anuria / Oligouria ataupun tidakBila anuria / Oligouria terjadi Oedema, Hipertensi, sesak nafas, sindroma uremik : mual, muntah

Kronik : Terjadi penurunan fungsi ginjal perlahan selama berbulan ataupun bertahun. Awalnya tanpa gejala sampai fungsi ginjal < 25%.

Seluruh organ dan sistem tubuh dikenai

46-year-old kidney patient, was diagnosed With polycystic kidney disease 17 years ago andhas been on hemodialysis ever since.

“Dialysis does not mean stop living,”

says Melvin Bradford.” It means find a new to live.It means develop skills that are going to help you to live longer.”

Melvin

Tujuan Pengobatan GGT:

Menurunkan mortalitas meningkatkan /memperpanjang lama hidup ( survival)

Memperbaiki kualitas hidup (QoL) Mengobati gejala/komplikasi kronik uremia Tindakan rehabilitasi

Dialisis Peritoneal

Kidney undergoing perfusion(in ice) after harvesting

Cooled kidney inSurgical gloves, ready For transplantation

Transplanted kidney afterremoval on clamps showing“pinking up” and urine formation

How Often Is Enough ?

• Once Weekly ?

Can’t control K or volume

• Twice Weekly ?

Only if residual function

• Thrice weekly ?

Appears adequate

• Daily ?

Yet to be proven

30

20

10

0

30

20

10

00 1 2 3 4 5 60 1 2 3 4 5 6

Time (days)Time (days)

Ure

a co

ncen

tratio

n(m

mol

/L)

Ure

a co

ncen

tratio

n(m

mol

/L)

HD1HD1 HD2HD2 HD3HD3

The discontinuous time course of serum urea concentration over one week with a thrice-

weekly dialysis schedule

The discontinuous time course of serum urea concentration over one week with a thrice-

weekly dialysis schedule

Volume responses and enhanced frequency dialysis

Mon

TuesW

ed

Thurs FriSat

SunM

on

Vo

lum

e

Slow Nocturnal Home hemodialysis :

6 x 8 jam (overnight) Dialysate flow : 300 ml/min Blood flow rate : 300 ml/min Hi flux membrane 2 x needles

No diet restrictionNo fluid restrictionNo BP tabletNo Phosphate binder

Kadang perlu penambahan PhosphateAtau Ca pada dialysat

Slow Nocturnal Home Hemodialysis Slow Nocturnal Home Hemodialysis

PPengaturan Nutrisi :

Target : Minimal uremik toksisiti Minimalisasi gangguan metabolisme (ca & P) ,

cairan dan elektrolit (K)

Mempertahankan status nutrisi yg baik gn makanan yg cukup menyenangkan (protein, kalori, vitamin dll)Protein

Garam dan airKalimCalsium dan Phosphat

Protein :

Sumber protein :

Daging ayam, kalkun, ikan, daging segar yang tak berlemak. Merupakan protein lengkap

Dairy product : susu, keju, yogurt dan telur juga merupakan protein lengkap tetapi :

tinggi kolesterol, lemak dan Phosphat

Kacang-kacangan, jagung dan biji-bijian (padi, gandum) protein yg tdk lengkap

Terlalu banyak protein :

Mual, muntah Lelah Bingung Kalium darah meningkat Lama HD akan meningkat

Terlalu sedikit protein :

Hilangnya massa otot Lelah BB berkurang Luka sulit sembuh

Garam dan air

Target : Capai Berat badan Kering (Dry weight) Pertahankan BB antar dialyisis : 1.5 kg Batasi garam : 2-3 g/hari

Jangan tambahkan garam saat memasak Jangan letakkan garam di atas meja Waspadai garam yg tersembunyi di makanan :

Asinan (somboy, ikan asin, telur asin dll) makanan kaleng (corned, sardinnes) kecap, saus tomat dll

Jangan gunakan garam palsu (high K) Untuk memberi kenikmatan gunakan bahan pedas

dari tumbuhan alami

Interdialytic Weight GainInterdialytic Weight Gain

1.5-2 kgUF rate rata-rata 2.0-2.5 kg0.5 kg : Cairan yg diminum + priming+flushing dll

Kerjasama yg baik dgn Dietitian

1953

Northern Territories

80/40

1997

Northern Territories

170/100

Why did they Migrate ?

Pressure is simple

V

MC Volume through the Pipes

Size of the Pipes

Salt restriction and SR + enhanced UF

64.1 62.20

1020304050607080

Before Salt restriction only

(n=20)

After

Bo

dy

we

igh

t k

g

020406080100120140160180

BP

mm

Hg

BW SBP DBP

65.5 61.70

102030405060708090

Before Salt restriction plus UF

(n=17)

After

Bo

dy

we

igh

t k

g

020406080100120140160180200

BP

mm

Hg

BW SBP DBP

Salt restriction alone:20/47 = 43% success

Salt restriction + UF+:37/47 = 79% success

Improved hypertension control

0

0.5

1

1.5

2

2.5

0 8 24

AN

tih

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ns

ive

d

rug

s/d

ay

40

60

80

100

120

140

160

180

Blo

od

pre

ssu

re m

mH

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AHTN SBP DBP

Kooistra MP et al Nephrol Dial Transplant 1998; 13: 2853-2860

Udema paru

Kalium

Kalium tinggi : denyut jantung tak teratur dapat berhenti tiba-tiba

Makanan tinggi Kalium :kentang, labu, coklat, pisang, alpokat, jamur, jeruk,Pasta tomat, sayuran, buah kering, high fibre breakfastCereal dll

Bila sayuran tinggi KPotong kecil-kecil, masak dan tiriskan

This fruits should be avoided

This fruits are recommended

Ca dan Posphat

Batasi : Susu Keju Yougurt

Ice cream Coklat Beer Firm Tofu

Hindarkan : Minuman Cola Daging asap Kacang-kacangan Whole grain cereal

Makan pengikat Phosphat saat/bersamaan makanEfek samping : Sulit buang air besar

(makan makanan serat tinggi)

Tumoral CalcinosisTumoral Calcinosis

• 1-2 months decrease in size• 8-9 months reabsorbed

Koreksi anemia