Rensa, MD

Departement of Internal Medicine

Udayana University / Sanglah Hospital
Physiological Review
FUN GSI G INJA L

Fungsi utama ginjal adalah :

mempertahankan keseimbangan internal (milieu
interiour)

Yg dipertahankan adalah :
- keseimbangan air
- keseimbangan elektrolit organ ekskresi
- keseimbangan asam-basa
- keseimbangan metabolisme ----- mensekresikan
hormon
MEKANISM E FUNGSI GIN JA L

Fungsi ginjal dilaksanakan melalui mekanisme :

1. filtrasi (penyaringan)
2. reabsorbsi (penyerapan kembali)
3. sekresi (produksi bahan tertentu)
4. ekskresi (mengeluarkan bahan tertentu)
HORM ON- HORMON YG DIHASI LK AN G INJAL

1. Erythropoitin
- berfungsi utk ”membentuk ” darah
2. Renin
- berfungsi untuk mengatur tekanan darah
3. Calcitriol
- berfungsi utk metabolisme mineral (calsium & fosfat)
4. Prostaglandin
- ikut berfungsi mengatur tekanan darah
EVALUASI FUNGSI GINJAL
• yang bisa dievaluasi hanyalah fungsi
filtrasinya saja
• dengan mengukur Laju Filtrasi Glomerulus
(LFG)

Laju Filtrasi Glomerulus adalah :

Jumlah darah yang dpt difiltrasi oleh ginjal
dalam waktu satu menit
• pada orang yang luas peermukaan tubuhnya
1,73 m2 (satuannya: ml/menit/1,73m2)
• pengukuran dilakukan secara tidak langsung
NILAI N ORMAL
Tergantung pada :
• jenis kelamin
• umur
• berat badan/luas pemukaan tubuh

Umur Laki Perempuan

20 th 117 – 170 104 – 158
50 th 96 – 138 90 – 130
70 th 70 – 110 70 – 114
Hamil 20% lbh banyak

Berkurang ± 1% setiap tahun, di atas umur 30 th

Teknik e valua si fun gsi g inja l

• LFG dievaluasi secara tidak langsung dengan

mengukur clearance (bersihan) bahan tertentu

• Clearance adalah: jumlah ’bahan tertentu” yang

dapat difiltrasi oleh ginjal dalam satu satuan
waktu (ml/mnt)

• ”Bahan tertentu” yg dipakai adalah :

• bahan radioaktif
• inulin
• kreatinin
Yang paling baik adalah inulin, tapi yang paling
mudah dan praktis adalah kreatinin, sehingga
LFG diukur dengan Test Klirens Kreatinin
(Cliearance Creatinin Test =CCT)

Jadi : CCT ∞ LFG

 Men ge valu as i C CT di lak uk an d eng an :
1. Mengukur :
Dengan jalan mengukur; kadar kreatinin urin (U),
volume urine /menit (V) dan kadar kreatinin plasma (P)
Kemudian dimasukkan dalam rumus Van Slyke

UXV
CCT = -------------------- ml/mnt
P

2. Menghitung :
Dengan mengukur, kreatinin plasma (P), berat badan (BB), umur (U)
Kemudian dimasukkan dalam rumus Cockroft - Gault

(140 – U ) X BB
CCT = -------------------------- ml/mnt
72 X P

Catatan : pada  : X 85%

Deraj at fun gs i gin jal di ses uaik an den ga n
CC T

Deraja Kelainan struktur dlm CCT

t 3 bl (ada/tidak)
1 ada ≥ 90 ml/mnt
2 ada/tidak 60 - 89
3 ada/tidak ml/mnt
30 – 59 ml/mnt
4 ada/tidak 15 – 29 ml/mnt
5 ada/tidak < 15 ml/mnt
Gejala gangguan fungsi ginjal :

1. Anemia
2. Hipertensi
3. Edema
4. Peningkatan kadar ureum&kreatinin
plasma
5. Asidosis
 Definition

CKD is a group of kidney disease with

specification :

• Chronic : more than 3 months

• Progressive : become worst time to time
• Persistent : can not completely remission
 Definisi

 Pe faal / struktur ginjal yang

lebih dari 3 bln yang bersifat
menetap dan progresif
Criteria :
• Kidney damage for ≥ 3 month
• structural and functional abnormality
• with or without decreased Glomerular Filration
Rate (GFR)
• manifest by either abnormality of :
• pathology
• blood composition
• urine composition
• imaging trest
3. GFR < 60 ml/min for 3 month, with or without kidney
damage
Explanation :
• Structural abnormality e.g. single kidney,
kidney/ureter stone, cystic kidney,
Prostate hypertrophy, etc
• GFR : calculated by Cockroft-Gault Formula
• Blood composition e.g. ureum, creatinin
• Urine composition e.g. proteinuria, haematura
• Imaging e.g. BNO (plain photo abdomen), USG etc
Ter masu k kelai nan str uktur gin jal an tar a
lain :

• Kelainan makroskopik / mikroskopik urin

• Kelainan anatomis traktus urinarius

• Kelainan ukuran atau jumlah ginjal

• Hidronefrosis

• Batu traktus urinarius

 Kidney disease ≥ 3 month :

GFR (Cockroft Gault)

< 60 ml/mnt/1.73 m2 ≥ 60 ml/mnt/1.73 m2

- CKD

Kidney damage (-) Kidney damage (+)

- normal - CKD
ETIOLOGY OF CKD
Etiology of CKD are :
3. Diabetes Mellitus
4. Chronic Glomerulonephritis
5. Chronic Pyelonephritis
6. Hypertension
7. Urinary tract stone
8. Obstruction (tumor, prostate)
9. Immunological disease (SLE)
10. Congenital (polycystic kidney)
11. Malignancy
12. Others :
• pregnancy
• chronic liver disease
 Etiology of CKD:
(another version)

 Diabetes Mellitus
 Non-Diabetes Mellitus:
 Glomerular (e.g. Autoimmune dis, neoplasia)
 Vascular (e.g.Hypertension)

Tubulo-intersititial ( UTI, Renal stone, drugs)
 Cystic
 Transplantation (e.g.chronic host-rejection)
 Anamnesis
 Urine volume
 Frequency of micturition
 Urine appearance and colour

 Pain:
 in loins, back, abdomen, suprapubic area?

 Constant or intermittent?

 Related to micturition?

 Nonspecific symptoms, including:

 Fatigue

 Nausea-vomiting

 Weight loss

 Pallor

 Oedema

 Dyspneu on effort (associated with heart failure)

 Physical Examination
 Hypertension
 Anemia
 Edema
 Sign of complications e.g. heart hypertrophy,

Ascites
1. Gejala Neurologik
- lelah
Akibat menumpuknya
- sakit kepala toksin uremik, berupa
- kejang – kejang : fosfat, ion hidrogen,
- neuropati perifer urea dan kreatinin,
2. Gastro intestinal
phenol, indol,
- mual, muntah, diare
- singultus, stomatitis
guanidin, hormon
3. Kulit kering paratiroid, oksalat,
- Pruritus homosistein.
Patophysiology of hypertension in CKD
2. -Sodium retention

- fail of the kidney for excreted water and sodium

2. Acceleration of Renin Angiotensin System

- increased secretion of renin

 Angiotensinogen Ischemic
Kidney
(produced by liver)

Renin
(produced by kidney

Angiotensin I

Angiotensin
Converting Enzyme
(ACE)

Suprarenal cortex Angiotensin II

Aldosteron

Renin Angiotensin Aldosterone System

PATHOPHYSIOLOGY OF ANEMIA IN CKD

3. Erythropoitin insufficiency
- decreased of erythropoitin secreted by the kidney

6. Iron deficiency
- chronic bleeding
- low intake

3. Others
- haemolysis / decreased of erythrocyte live spend
- depressed of bone marrow by uraemic substances
Patients with chronic kidney disease should be
evaluated to determine:

2. Diagnosis (type of kidney disease)

3. Comorbid conditions;

4. Severity; assessed by level of kidney function;

5. Complications, related to level of kidney function;

6. Risk for loss of kidney function;

7. Risk for cardiovascular disease

COMPLICATION OF CKD
1. Cardiac diseases
- coronary artery disease
- congestive hearth disease
- acute left hearth failure

2. Metabolic acidosis

9. Electrolyte imbalance
- hyper / hypokalemia
- hyper / hyponatremia

4. Renal osteodystrophy (renal bone disease)

IMPORTANT !!
Treatment for chronic kidney disease should include:
2. Specific therapy, based on diagnosis
3. Evaluation and management of comorbid conditions;
4. Slowing the loss of kidney function
5. Prevention and treatment of cardiovascular disease;
6. Prevention and treatment of complications of decreased
kidney function
7. Preparation for kidney failure and kidney replacement
therapy;
8. Replacement of kidney function by dialysis and
transplantation, if signs and symptoms of uremia are
present
STAGES OF CKD: A CLINICAL ACTION PLAN

Stage Description GFR Actions*

(mL/min/1.73
m2)
I Kidney damage ≥ 90 Diagnosis and treatment.
with normal or ↑ Treatment of comorbid
GFR conditions, Slowing

II Kidney damage 60-89 progression,

Estimating CVD risk
progression
with mild ↓ GFR reduction

III Moderate ↓ GFR 30-59 Evaluating and treating

Severe ↓ GFR complications
IV 15-29 Preparation for kidney
replacement therapy

V Kidney failure < 15 or Replacement (if uremia

dialysis present)

Chronic Kidney Disease is defined as either kidney damage or GFR <

60 mL/min/1.73 m2 for ≥ 3 months. Kidney damage is defined as
pathologic abnormalities or markers of damage, including
abnormalities in blood or urine test or imaging studies
 Ko nse rvatif

Dialisis

Aktif

Transplantasi
1 . Menghilangkan faktor-faktor yang reversibel
2. Mengendalikan faktor-faktor yang ireversibel
3. Nutrisi dan keseimbangan cairan
4. Mengatasi komplikasi
5. Mencegah pemberian obat nefrotoksik
6. Mengatasi keluhan
✏ diet : kalori 35-40 kkal/kg bb/hari
protein 0,8 – 1 gr/kg bb/hari

✏ air : masuk = 500 cc + produksi urin/24 jam

✏ Elektrolit : - rendah garam

- rendah kalium (buah-buahan)
RESUME TERAPI NUTRISI PADA PENDERITA GGK PREDIALISIS

Kalori
• Jumlah : 30-35 kcal/kg bb/hari
• Jenis : 20-25% dalam bentuk lipid

Protein
• Jumlah : 0.8-1.0 g/kg bb/hari
• Jenis : Kombinasi asam amino esensial (AAE) dan
asam amino non esensial (AANE)

Karbohidrat:
• Jumlah : melengkapi kebutuhan kalori
- rata-rata 6-8 g / kg bb / hari

Elektrolit : Natrium 70 meq/L

Kalium : dibatasi
Fosfat 500 - 600 mg/hari
Resume of Nutritional Requirement of Dialytic Patients

Protein 1-1.4 g/kg/day

Energy 35 kcal/kg/day

Water 600-700 cc + urine output during

previous 25 hours
Sodium 65-100 mEq/day
Potassium 40-70 mEq/day

Calcium 1000 mg/day

Phosphorus 800-1000 mg/day

Iron 600 mg/day as ferrous sulphate

Vitamins Water-soluble vitamins which

are lost during dialysis