Kuliah Faal Ginjal 2010 Edit
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Transcript of Kuliah Faal Ginjal 2010 Edit
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PEMERIKSAAN FUNGSI GINJAL
ANIK WIDIJANTI
LABORATORIUM PATOLOGI KLINIKRSUD Dr SAIFUL ANWAR / F.K. UNIBRAW MALANG
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Ruang Hemodialisa (HD)
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Ginjal homeostasis
Fungsi ginjal turun
Morbiditas & mortalitas naik
Nefronadalah unit fungsional terkecil dr ginjal, tdr atas:
* Glomerulus, Proximal convoluted tubule (PCT), Loop
of henle, Distal convoluted tubule (DCT), Collecting
duct (duktus kolegentus)
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Fungsi ginjalEkskresi Regulasi
Endokrin
HormonalPenyimpanan protein
Pembentukan urine
Sisa metabolismeProtein
KeseimbanganAir & elektrolit
KeseimbanganAsam basa
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FUNGSI EKSKRESI GINJAL
Merupakan proses dasar
pembentukan urine
Melibatkan proses
• Filtrasi
• Reabsorpsi
• Sekresi
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GLOMERULUS
Semi permiabel thd air & elektrolit
Relatif impermiabel thd makromolekul
(protein)
Filtrat normal tidak mengandung protein
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TUBULUS
Reabsorpsi
Sekresi
Nilai ambang ginjal adalah kemampuan
tubulus mereabsorbsi bahan tertentu
T. proksimalis, distalis, loop of henle,
duktus kolegentus
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TUBULUS PROKSIMALIS = PCT
1. Reabsorpsi 60–80 % ultra filtrat
Reabsorbsi aktif : melawan gradien
Reabsorbsi pasif : mengikuti gradien
2. Sekresi : transport ke lumen tubulus
Asam organik, basa, H+
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LOOP OF HENLE
Descending : permiabel air
Filtrat tubulus pekat
Ascending : relatif impermiabel air, aktif
mereabsobsi Na, Cl
Filtrat tubulus encer
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TUBULUS DISTALIS = DCT
Reabsorpsi & sekresi (lebih menonjol)
Diregulasi ADH ( Vasopresin ) & Aldosteron
Sekresi H+, NH3 & Asam urat
Reabsorpsi HCO3-
Sedikit transport bahan organik
Permeabilitas terhadap urea rendah
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DUKTUS KOLEGENTUS
• Diregulasi ADH, Aldosteron
• Relatif permiabel terhadap urea
• Terjadi reabsorpsi K, H & NH3
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FUNGSI ENDOKRIN* Sintesa hormon
* Target hormon yang disintesa
* Degradasi hormon : insulin, aldosteron
SINTESA HORMON
* Eritropoitin, Renin
* Prostaglandin, Tromboksan
•1,25 (OH) vitamin D
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ERITROPOITIN
* 90% diproduksi oleh sel ginjal khusus
* Regulasi produksi eritrosit dlm sumsum tulang
•Eritropoitin rekombinan Tx Anemia pd GGK
(gagal ginjal kronik)
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Prorenin[ Diproduksi hati ]
Di ginjal [ JGA ]Prorenin renin
Sistem renin-angiotensin & kadar K tinggi
Stimulasi produksi aldosteron
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PEMERIKSAAN GFRGlomerular filtration rate
Marker endogen* Urea & Kreatinin
•Protein B.M. rendah
Cystatin-C, RBP, B2M,A1M
Keunggulan marker endogen
* Tak perlu injeksi
* Sampel tunggal
Marker eksogen: Inulin, iohexol, 31Cr-EDTA
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KRITERIA MARKER YANG IDEALUNTUK GFR
• Difiltrasi bebas : glomerulus
• Tak diabsorpsi tubulus ginjal
• Kadar plasma stabil [eksogen & endogen]
CYSTATIN-C ?
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SYARAT UJI GFR YANG BAIK
* Pelaksanaan tak menyulitkan pasien
* Mudah di-interpertasi hasilnya
* Tak toksik, sebaiknya endogen
* Tak dipengaruhi organ lain
* Pem berulang mempunyai nilai Px
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CLEARANCE TEST (KLIRENS)
Untuk mengukur GFR
Rumus: UV (ml/menit)P
U = kadar zat dalam urineP = kadar zat dalam plasmaV = volume urine / menit
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Gold Standard Clearance Test adalah
Inulin Clearance
Inulin adalah:
- Marker eksogen
- Difiltrasi sempurna oleh glomerulus
- Tidak direabsorbsi oleh tubulus
- Perlu diinfuskan agar kadar dalam darah stabil
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KLIRENS UREAKurang ideal untuk GFR
* Hasil Klirens bervariasi dipengaruhi:Gagal jantung kongestif
Penyakit hati
Malnutrisi
Hiperalimentasi
Diet protein
* Direabsorpsi tubulus renalis
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KLIRENS UREA [ 40-70 ml /menit ]
Filtrasi & reabsorbsi bervariasi
Urine > 2 ml/mnt : 50 - 60 % klirens inulin
Urine 2 ml/mnt : Klirens maks 75 ml/mnt
Urine < 2 ml/mnt : Klirens standar 54 ml/mnt
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KLIRENS KREATININ
- Nilai normal: Lk : 125 ml/menit Pr : 115 ml/menit
- Akurasi lebih baik dari klirens urea- CV (Coefficient of variation) : 10 – 20%- Tidak praktis karena perlu urine tampung 24 jam - Sering terjadi kesalahan pd urine tampung 24 jam
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KLIRENS KREATININ Dipengaruhi massa otot, usia, inflamasi, seks,
latihan fisik
Hasil klirens tidak linear GFR.
Tak sensitif untuk penurunan GFR ringan - sedang
Di sirkulasi kreatinin tak terikat protein
Difiltrasi bebas glomerulus, tapi disekresi tubulus
<10%.
Pemeriksaan: interferens banyak
Murah dan mudah
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MENCEGAH KESALAHAN
KLIRENS KREATININ
Hindari latihan fisik berat sebelum tes
Minum cukup diuresis >2 ml /menit
Waktu & volume urine tampung : tepat
Urine tampung + pengawet [ thymol ]
FORMULA COCKCROFT-GAULT
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FORMULA COCKCROFT-GAULT
(Dewasa)[ 140 - USIA ] X BB [ kg ]
GFR = ---------------------------------------
0.825 X Kreat plasma
[ moL/L ]
ATAU
[ 140 - USIA ] X BB [ kg ]GFR = ---------------------------------------
72 X Kreat plasma [mg/dl ]
Pada wanita : dikalikan 0.85
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FORMULA COUNAHAN BARRAT
( PERKIRAAN GFR ANAK )
Tinggi badan ( cm ) X konstante ( 38 )= --------------------------------------------------------
Kreatinin serum ( mol / L )
ATAU
Tinggi badan ( cm ) X konstante ( 0.43 )= ---------------------------------------------------------
Kreatinin serum ( mg / dl )
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Formula Schwartz ( GFR untuk anak )
• GFR ( ml/min) = TB (cm) X konstante
Kreatinin serum (mg/dL)
Konstante :
Infant ( LBW < 1 tahun ) = 0,33
Infant ( Aterm < 1 tahun ) = 0,45
Chlid and aldolescent ( girl) = 0,55
Child and aldolescent ( boy ) = 0,70
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CYSTATIN-C* Marker endogen
* Diproduksi sel bernukleus
* B.M. kecil :13 kDa ; 132 asam amino
* Super famili cysteine protease inhibitor
* Difiltrasi bebas, di-reabsorpsi sempurna,
dikatabolisme Tubulus proksimalis
* Tak dipengaruhi : usia, BB, diet, obat, inflamasi
& keganasan[ kec melanoma, Ca kolorektal ]
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Formula MDRD (Modification of Diet in Renal Disease) :
diperhitungkan kreatinin serum, usia, ras dan seks
GFR = 186.3 X Cr-1.154 (mg/dl) X Usia-0.203
Untuk kulit hitam : X 1.212
Wanita : X 0.742
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WALSER EQUATION
GFR Laki-2 =7.57 X (kreatinin serum X 0.0884)-1 – 0.103 X
usia + 0.906 X BB – 6.66
GFR Wanita =6.06 X (kreatinin serum X 0.0884)-1 – 0.080 X
usia + 0.080 X BB – 4.81
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