CKD & ARF(Kuliah)Edit
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Transcript of CKD & ARF(Kuliah)Edit
Komponen Anatomis Dasar Saluran KemihKomponen 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
GlomerulonephritisDiabetic NephropathyUrinary Stones DiseaseHypertensionAnalgesic nephropathyPolycystic 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 m2 for ≥ 3 mounths, with or without kidney damage
Years Until Kidney Failure (GFR < 15 mL/min/1.73 m2)Based on Level of GFR and Rate of GFR Decline
Level of GFR (mL/min/1.73 m2)
Rate of GFR Decline (mL/min/1.73 m2 per year)
10 8 6 4 2 1*
90 7.5 9.4 13 19 38 75
80 6.5 8.1 11 16 33 65
70 5.5 6.8 9.2 14 28 55
60 4.5 5.6 7.5 11 23 45
50 3.5 4.4 5.8 8.8 16 35
40 2.5 3.1 4.2 6.3 13 25
30 1.5 1.9 2.5 3.8 7.5 15
20 0.5 0.6 0.8 1.3 2.5 5•Average age-related GFR decline after age 20-30 year
•MDRD Study: average rate of decline in GFR is 4 ml/min/year. 85% declined,15% stabile or improvement
The risk for loss of kidney function
Type Definition Examples
Susceptibility factors
Increased susceptibility to kidney damage
Older age, family history
Initiation factors Directy initiate kidney damage Diabetes, high blood pressure, autoimmune diseases, systemic infections, urinary tract infections, urinary stones, lower urinary tract obstruction, drug toxicity
Progression factors
Cause worsening kidney damage and faster decline in kidney function after initiation of kidney damage
Higher lavel of proteinuria, higher blood pressure level, poor glycemic control in diabetes, smoking
Endstage factors
Increase morbidity and mortality in kidney failure
Lower dialysis dase (KW), 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-
receptor blockers
Yes Yes
(greater affect in patients with proteinuria)
Not tested
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
1. Transplantasi ginjal
2. Hemodialisis (HD)
3. Continuos Ambulatory Perito-
neal dialysis (CAPD)
Renal Replacement Therapy untuk CKD stage V ?
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.
Increased creatininex1.5 or GFR
decrease > 25%
UO < 0.5 ml/kg/h x 6 hr
UO < 0.5 ml/kg/h x 12 hr
UO < 0.3 ml/kg/h x 24 hr or Anuria
x 12 hrs
Increased creatininex2 or GFR decrease
> 50%
Increased creatininex3 or GFR decrease
> 75%
Persistent ARF**= complete loss of kidney function > 4 weeks
End Stage Kidney Disease (> 3 months)
Risk
Injury
Failure
Loss
ESKD
High Sensitivity
High Specificity
URINE OUTPUT CRITERIAGFR CRITERIA
RIFLE CRITERIA FOR ACUTE RENAL DYSFUNCTION
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. uremiab. Progressive fluid overloadc. uncontrolled hyperkalemia or me-
tabolic acidosis2. Creatinine clearance <15 ml/min, BUN
>100 mg/dl
heparinV
V
PV
PA
Disadvantages complex machinery
expensive
Advantage no arterial access
blood flow sufficient
good elimination of large molecules
exact filtration
UF R
BLD
SAD
heater
high-flu
x
CVVH Continuous veno-venous hemofiltration
0
10
20
30
40
50
60
Percentage of patients in each group achieving urine output >= 2 L/day during study period
Furosemide
Placebo
94/166
(57%)
54/164
(33%)
P< 0.001