GAGAL GINJAL

Lita Septina
Bagian Penyakit Dalam FK UISU

Functions of the Kidney

Manifold Tasks of the Kidney

Bone BoneStructure Structure Metabolic Metabolic End EndProducts Products Blood BloodFormation Formation Calcium Balance Vitamin D Activation Erythropoietin Synthesis

Removal of Urea, Creatinine etc.

Functions
Water Balance Potassium Balance Recovery of Bicarbonate Cardiac CardiacActivity Activity Sodium Removal Blood BloodPressure Pressure Regulation Regulationof ofBlood BloodpH pH

G RENAL FAILURE

Acute

Acute on Chronic

Chronic

ACUTE RENAL FAILURE

Rapid decline Renal Function over hours or days rise ureum and creatinine plasma levels with or without oliguria/anuria

ACUTE RENAL FAILURE

Pre Renal (renal hypoperfusion) Renal Post Renal (obstructive)

ACUTE RENAL FAILURE Pre Renal (Renal Hypoperfusion) ATN Cardiovascular failure Pump failure : - myocardial infarc - tamponade - pulmonary embolism Vascular pooling : sepsis, anaphylactic Hypovolemia -Skin losses - G I losses - Renal losses - Hemorrhage

ACUTE RENAL FAILURE Renal Acute Tubular Necrosis (ATN) Postischemic : includes all pre renal causes Pigment : Hb from intravascular hemolysis myoglobin from rhabdomyolysis Nephrotoxic : aminoglycosides, radiocontrast Pregnancy related : septic abortion Urine in ATN is ISOTONIC or HYPOTONIC to plasma with a high sodium and low urea concentration

ACUTE RENAL FAILURE Renal Primary renal Vascular :Glomerulonephritis, malignant hypertension, vasculitis, embolism/thrombosis Interstitial : - drug induced (PNC, Cephalosporine, rifampicin, sulphonamid, NSAIDs, traditio nal medication) - hypercalcemia, hypokalemia, pyeonephritis Intratubular : crystal, myeloma

ACUTE RENAL FAILURE Post Renal (obstructive) Calculi Clots Tumour Fibrosis Oedema Functional surgical

ACUTE RENAL FAILURE Oliguric phase (1 6 weeks) Polyuric phase (1 2 weeks, urine 4-6 l/days) Recovery phase (6-12 moonths)

ACUTE RENAL FAILURE

Clinical feature Nausea, vomitus Oedema Convulsion, coma Kusmaull, acidosis Hypertension Cardiac failure

ACUTE RENAL FAILURE

Management : Fluid and electrolyte - Intake 500 cc + Out put - diuretic Infection : antibiotic Anti hypertension, Anti emetic, Symptomatic Nutrition : low salt, low kalium, Prot. 20 gr/day, calori optimal (for hypercatabolic) hemodialysis

G RENAL FAILURE

Acute

Acute on Chronic

Chronic

ACUTE on CHRONIC RENAL FAILURE Oliguric phase Polyuric phase Recovery phase

Infection
Dehydration

ACUTE on CHRONIC

Obstruction Electrolite imbalance Malignant Hiyertension

PROGRESSIVITY of CKD
If nephron reduced, other nephron will take over function through kidney reserve function. Creatinine will stable with sclerotic glomerulus cost. If damage nephron >50%, the rest of glomerulus will no able to take over all kidney function ------> creatinine End stage renal failure happen. (GGT =ESRD=ESRF) If the damage on nephron reversible, then increased of cretinine will be temporarily, and if nephron back to normal, then kidney will back to normal too. acute on chronic RF

MANAGEMENT Acute on Chronic

ARF

PRECIPITATING

G RENAL FAILURE

Acute

Acute on Chronic

Chronic

CHRONIC RENAL FAILURE Progressive deterioration Slow but sure End stage renal function Uremic syndroma

CHRONIC RENAL FAILURE CHRONIC KIDNEY DISEASE (CKD)

THE PAST NOW

Tabel 1. Definisi penyakit ginjal kronik menurut KDIGO

CHRONIC RENAL FAILURE CAUSES Chronic glomerulonephritis Lupus glomerulonephritis Chronic obstructive uropathy Hypertensive nephrosclerosis Hypertensi essensial Diabetes mellitus Chronic pyelonephritis Polycystic kidney disease Analgesic nephropathy unknown

CHRONIC RENAL FAILURE Parenchymal Glomerulonephritis Diabetic nephropathy Chronic Pyelonephritis Polycystic kidney disease Lupus Nephritis Renal tuberculosis Obstructive Stone Prostate stricture

CHRONIC RENAL FAILURE

Clinical feature - general : malaisse, lethargy, irritability - Gastrointestinal : anorexia, nausea, vomiting, hiccough, gastro enteritis, foetor ex ore, hematemesis / melena - Respiratory : kussmauls, pulmonary oedema - Cardiovascular : fluid overload/depletion, pericarditis, hyperten sion - Skin : pruritus, uremic frost - Neuromuscular : convulsion, coma, restless legs, cramps - Genitourinary : nocturia, oligouria, hematuria - Metabolic : Carbohydrate intolerance, hyperlipidemia - Hematoligical : anemia, bleeding tendency - Psychic : Psychosis

CHRONIC RENAL FAILURE Marker of chronicity Anemia Contracted kidney Calcification of soft tissue

Schoolwerth A, ANNA Meeting,2002

Eknoyan G, ASN Symp,Philadelphia,2002

PROGRESIVITAS

Eknoyan G, ASN Symp,Philadelphia,2002

Rencana kerja berdasarkan stadium penyakit ginjal kronik

Stadium 1 Deskripsi Kerusakan ginjal dengan LFG normal LFG (ml/men. /1.73 m2) 90 Aksi Diagnosis dan pengobatan, Terapi penyakit penyerta, Penghambatan progresifitas, Penurunan risiko PKV Perkiraan progresifitas

Kerusakan ginjal dengan penurunan ringan LFG

60 - 89

3
4 5

Penurunan sedang LFG

Penurunan berat LFG Gagal ginjal

30 - 59
15 - 29 < 15

Evaluasi & pengobatan komplikasi

Persiapan terapi pengganti ginjal Terapi pengganti ginjal

LFG = Laju Filtrasi Glomerulus ;

PKV = Penyakit kardiovaskular

Indikasi HD pada PGK

CHRONIC RENAL FAILURE

Goals of Conservative management Correct reversible factors Maintain fluid electrolite balance Reduce the quantity of accumulated nitrogenous waste Maintain protein nutrition Prevent or minimize the rate of progression to terminal renal failure Prevent and treat bone disease Controle of anemia, pruritus, hyperuricemia and neuropathy Preparation for renal replacement therapy

CHRONIC RENAL FAILURE

Fluid Over Load - Low salt diet - Loop Diuretik : Furosemid Hyperkalemia - Low potassium diet - Kation exchange resin-Kayexalate Metabolic acidosis - Sodium bicarbonat

CHRONIC RENAL FAILURE

Anemia
- EPO - Erythropoetin - 2 x /week - Target : Hb 11 12 g/dl - Iron Suplement Renal Osteodystrophy - CaCO3 oral - Vit D - PO4 - Low PO4 (600 800 mg/dl) - Parathyroidectomy

Renal Replacement Therapy

a. Dialysis
1. Peritoneal dialysis (CAPD/CEPD) 2. Hemodialysis

b. Transplantation
Donor : living related kadaveric

Recipient

Type-HLA-Match