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System
WIDODO
BAGIAN ANESTESIOLOGI,
PERAWATAN INTENSIF, DAN
PENANGANAN NYERI
RSUP WAHIDIN
SUDIROHUSODO
MAKASSAR
Introduction
Organ system that produces, stores, and carries
urine
Humans produce about 1.5 liters of urine over 24
hours, although this amount may vary according to
the circumstances.
Increased fluid intake generally increases urine
production.
Increased perspiration and respiration may
decrease the amount of fluid excreted through the
kidneys.
Some medications interfere directly or indirectly
with urine production, such as diuretics.
Components of system
Kidneys
Ureters
Bladder
Urethra
Renal Vein
B.
Renal Artery
C.
Ureter
D.
Medulla
E.
Renal Pelvis
F.
Cortex
1.
2.
3.
Peritubular capillaries
4.
Proximal tubule
5.
Glomerulus
6.
Distal tubule
The Nephron
Functional unit of the kidney (1,000,000)
Responsible for urine formation:
Filtration
Secretion
Reabsorption
Components of the
nephron
Glomerulus
Afferent and Efferent
arterioles
Proximal Tubule
Loop of Henle
Distal Tubule
Collecting Duct
From http://www.emc.maricopa.edu/faculty/farabee/BIOBK/BioBookEXCRET.html
Filtration
THE GLOMERULUS
Reabsorption
and secretion
Reabsorption
Factors influencing
Reabsorption
Secretion
Proximal tubule uric acid, bile salts,
metabolites,
some
drugs,
some
creatinine
Distal tubule Most active secretion
takes place here including organic
acids, K+, H+, drugs, TammHorsfall protein (main component
of hyaline casts).
Countercurrent exchange
Loop of Henle
Goal= make isotonic filtrate
into hypertonic urine (dont
waste H20!!)
Counter-current multiplier:
Renin:
Released from juxtaglomerular apparatus when low blood
flow or low Na+. Renin leads to production of angiotensin II,
which in turn ultimately leads to retention of salt and water.
Erythropoietin:
Stimulates red blood cell development in bone marrow. Will
increase when blood oxygen low and anemia (low
hemoglobin).
Vitamin D3:
Enzyme converts Vit D to active form 1,25(OH)2VitD.
Involved in calcium homeostasis.
Aldosterone
Secreted by the adrenal glands in
response to angiotensin II or high
potassium
Acts in distal nephron to increase
resorption of Na+ and Cl- and the
secretion of K+ and H+
NaCl resorption causes passive
retention of H2O
Ureters
Slender tubes that convey urine from
the kidneys to the bladder
Ureters enter the base of the bladder
through the posterior wall
Ureters
Urinary Bladder
Smooth, collapsible, muscular sac that
temporarily stores urine
It lies retroperitoneally on the pelvic floor
posterior to the pubic symphysis
Urinary Bladder
30
Urinary Bladder
3125.18a, b
Figure
Urethra
Urethra
Urethra
The female urethra is tightly bound to the
anterior vaginal wall
Its external opening lies anterior to the
vaginal opening and posterior to the clitoris
The male urethra has three named regions
34
Urethra
3525.18a. b
Figure
Micturition (Voiding or
Urination)
Chemical Composition of
Urine
Urine is 95% water and 5% solutes
Nitrogenous wastes include urea, uric acid,
and creatinine
Other normal solutes include:
WIDODO
RSUP WAHIDIN
sUDIROHUSODO
MAKASSAR
Pendahuluan
Gagal ginjal akut
(ARF)
Salah satu kondisi yang paling sering terjadi
pada kasus-kasus trauma dan penyakit kritis.
Pendahuluan
Disfungsi
Ginjal
Berat
Memerlukan RRT
Ringan Perubahan kecil nilai
kreatinin atau produksi urin
Mempengaruhi morbiditas
dan mortalitas pasien
Pendahuluan
Jaringan Kolaborasi berbagai kelompok :
ADQI= the Acute Dialysis Quality Initiative
ASN = American Society of Nephrology
NKF = the National Kidney Foundation
dan European Society of Intensive Care Medicine
AKIN
AKI
DEFINISI
Acute Kidney Injury
Belum ada konsensus terhadap berapa besar disfungsi
ginjal yg dsb AKI.
ADQI
klasifikasi Risk, Injuri, Failure, Loss and End Stage
Kidney RIFLE
DEFINISI
mendefenisikan 3 tingkatan
keparahan
Risk ( kelas R )
Injuri ( Kelas I )
Failure ( Kelas
F)
Loss dan End
Stage Kidney
Disease
Gagal ginjal
kelas outcome
Kelas
Tingkatan
DEFINISI
Pasien Masuk RS
Tidak ada data awal
fungsi ginjal
Usul
ADQI
Asumsi GFR
awal normal
Gunakan Nilai
Kreatinin Serum
Age (years)
Black males
(mg/dl [mol/l])
Other males
(mg/dl [mol/l])
Black females
(mg/dl [mol/l])
Other females
(mg/dl [mol/l])
2024
1.5 (133)
1.3 (115)
1.2 (106)
1.0 (88)
2529
1.5 (133)
1.2 (106)
1.1 (97)
1.0 (88)
3039
1.4 (124)
1.2 (106)
1.1 (97)
0.9 (80)
4054
1.3 (115)
1.1 (97)
1.0 (88)
0.9 (80)
5565
1.3 (115)
1.1 (97)
1.0 (88)
0.8 (71)
>65
1.2 (106)
1.0 (88)
0.9 (80)
0.8 (71)
DEFINISI
AQDI
AKIN
DEFINISI
AKIN
RIFLE
< 48 jam
Kreatinin
26,2umol/l
Memerlukan
RRT
Termasuk AKI
Termasuk AKI Stadium I
AKI Stadium III
DEFINISI
<0,5 mL/kg/h 6
Peningkatan Cr serum1,5x baseline atau penurunan GFR25% jam
Risk
Injury
Failure
AKIN
Kriteria kreatinin serum
Kriteria
Peningkatan Cr serum 26,2umol/L atau 150-199%(1,5Stage 1 1,9kali)baseline
Stage 2
Stage 3
<0,5 mL/kg/h
12jam
<0,5 mL/kg/h
24jam
atau anuria 12
jam.
Kriteria Urin Output
<0,5 mL/kg/h 6 jam
<0,5 mL/kg/h 12jam
<0,5 mL/kg/h 24jam
atau anuria 12 jam
Tabel 2: Perbandingan Definisi dan Skema Klasifikasi AKI berdasarkan RIFLE dan AKIN
DEFINISI
EPIDEMIOLOGI
AKI
berat
perlu RRT
ARF
20
terakhir
&
tahun
5% di ICU
61 288 per 100.000 populasi
ARF
yang
memerlukan RRT
20 tahun terakhir
AKI di USA
periode penelitian
15 tahun
AKI di Australia
18%
AKI di AS
ETIOLOGI
Bersifat fungsional dan secara definisi tidak
disertai perubahan histopatologi.
Jika sdh terjadi kerusakan pada struktur
nefron sprti: glomerulus,tubulus,pembuluh
darah dan interstisial.
ETIOLOGI
Pre Renal Volume
responsive
Intrinsik
Post renal
Hipovolemia
Glomerular
Obstruksi
-Glomerulonefritis
-Batu ginjal
-Perdarahan
Glomerular endothelium
-Fibrosis retroperitoneal
Berkurangnya
volume -Vaskulitis
-Hypertrophy prostat
sirkulasi efektif
-HUS
-Carcinoma
-Gagal jantung
-Hipertensi maligne
-Striktur uretra
-Septic shock
Tubular
-Neoplasma bladder
-Sirosis
-ATN
-Neoplasma pelvis
Obat
- Rhabdomyolisis
-Neoplasma retroperitoneal
- ACE inhibitors
- Myeloma
Intersisial
- Nefritis intersisial
OUTCOME
19 83%.
Kematian di
RS dgn RIFLE
Klas R 8,8%,
Klas I 11,4%,
Klas F 26,3%
Pasien tanpa AKI 5,5%
Lama Perawatan
ICU dan RS
Morbiditas
End Stage
PENATALAKSANAAN
Konsensus Mengenai Terapi AKI Yang Efektif
Belum ada karena:
1. Penyebab AKI yang multifaktorial
2. Bervariasinya definisi AKI.
3. Penilaian penurunanGFR yang tergantung pada
perubahan kreatinin serum.
4. Tingginya angka mortalitas AKI
5. Tidak ada konsensus kapan dan jenis dialisis apa
yang tepat untuk penderita AKI.
PENATALAKSANAAN
Penelitian pd Hewan agent yg terbukti
efektif utk AKI
Penelitian secara
Loop diuretik
klinis tidak ada yg
Low-dose dopamin
terbukti efektif
ANP
Hormon tyroid
IGF-1
PENATALAKSANAAN
Renal Replacment Therapy (RRT)
Pengganti ginjal ( Renal Replacement)
Pendukung fungsi ginjal/organ lainnya (Renal/multi-organ
support
Berdasarkan mekanisme pengeluaran cairan/solud dan
Intermitten atau Kontinyu
Semua RRT kecuali PD dicapai dengan Ultrafiltrasi
Gradient tekanan akan mendorong cairan
melewati membran semipermiabel.
Laju UF dipegaruhi oleh:
gradien tekanan trensmembran,
permeabiltas air membran, dan
luas permukaan membran.
PENATALAKSANAAN
Renal Replacment Therapy (RRT)
Berdaarkan mekanisme utama removal solute difusi dan
konveksi
Removal solute yang Predominan pada masing-masing jenis RRT
1.
2.
3.
4.
PENATALAKSANAAN
Renal Replacment Therapy (RRT)
(UO < 200 ml/12 jam
Inisiasi:1.2. Oliguria
Anuria ( UO : 0-50 ml/12jam)
3. Urea > 35 mmol/l
4. Creatinin > 400 umol/l
5. K > 6,5 mmol/L atau peningkatan yang cepat
6. Udem pulmo yang refrakter dengan diuretik
7. Asidosis metabolik yang tak terkompensasi ( pH<7,1)
8. Na < 110 dan > 160 mmol/l
9. Temperatur > 40C
10. Komplikasi uremia : ( ensefalopati,miopati, neuropati dan perikarditis)
11. Overdosis obat/ toksin yang dialyzable
Jika ada satu kriteria, RRT harus dipertimbangkan. Jika ada dua kriteria
secara bersamaan, RRT sangat dianjurkan
PENATALAKSANAAN
Renal Replacment Therapy (RRT)
Grade D
Grade E
Grade C
Tetapi pada kebanyakan kasus, RRT dimulai sebelum urea
mencapai 20-30 mmol/L).
RRT harus dimulai berdasarkan balans cairan, jumlah
urin, kadar kalium ataupun derajat asidosis tergantung
kondidi klinis pasien.
PENATALAKSANAAN
IHD
CRRT
SLED
Ultrafiltrasi
Ultrafiltrasi
Ultrafiltrasi
removal cairan
Mekanisme
removal Difusi
solute
Difusi
dan
atau Difusi
konveksi
200 ml/menit
200 ml/menit
500 ml/menit
17-34 ml/menit
300 ml/menit
Durasi
3-4 jam
24 jam/ hari
6-12 jam/hari
PENATALAKSANAAN
Hiperkalemia berat
CRRT
SLED
GFR 90 ml/min/1.73
m2
Stage 2
GFR 60-89
Stage 3
Moderate GFR
GFR 30-59
Stage 4
Severe GFR
GFR 15-29
Stage 5
Kidney failure
Measurement of GFR
Gold standard is Inulin Iothalamate.
Creatinine Clearance calculated by timed (24h) urine
collection along with serum collection for Creatinine.
Overestimate GFR when CKD is severe due to an
increase in tubular secretion of creatinine.
This factor can be corrected by cimetidine.
Estimation of GFR
More than 10 formulae for estimation of GFR.
MDRD most widely accepted now.
Diabetes Mellitus
Hypertension
Cardiovascular Disease
Obesity
Metabolic Syndrome
Age and Race
Acute Kidney Injury
Malignancy
CKD - Causes
Diabetic
Non Diabetic
Glomerular
Nephritic: PIGN, IgA, MPGN
Nephrotic: FSGS, Membranous, Amyloidosis
CKD - Causes
CKD - Manifestations
CKD - Management
CKD - Evaluation
CKD - Evaluation
Serum electrolytes
Urine spot protein analysis (24 hour no longer
recommended).
ANA, C3, C4
SPEP, UPEP
Kidney Ultrasound
Urine sediment analysis
Biopsy
Evidence of glomerular disease without diabetes
Sudden onset of nephrotic syndrome or glomerular
hematuria
CKD - Hypertension
Anti-Hypertensive Agents
Single most important measure could be adequate BP
control
Target BP <130/80 with minimal proteinuria and
BP<125/75 with significant proteinuria (>1g).
ACEIs and ARBs have been demonstrated to slow both
diabetic and non-diabetic renal disease in both
experimental and human studies.
Decrease the sodium intake to 2.5 g /day
Usually requires more than 2 medications.
Diuretics enhance the antihypertensive and
antiproteinuric effects of other agents..
CKD - Dyslipidemia
CKD - Anemia
Decreased quality of
life with anemia.
Diagnosis of exclusion.
Mostly apparent in the
stage 4 and 5 of CKD.
Due to decrease in EPO
production in the
kidney.
CKD - Anemia
Erythropoietin
Epoetin alfa :Procrit , Epogen
Darbepoietin Alpha: ARANESP
CKD - Hyperphosphatemia
Control of Hyperphosphatemia
Due to decreased excretion in urine.
Control of hyperphosphatemia by dietary measures slow
progression in experimental models of CKD.
Hyperphosphatemia leads to pruritus, calcification in
synovial membranes, blood vessels and even cardiac
valves.
Therapy includes Phosphorus restriction to 800mg/day
and use of phosphrous binders with food.
disease
Hyperparathyroidism:
High phosphorus and low Vitamin D
causing low calcium.
Monitor Intact PTH levels and keep
between 100 and 500.
Maintain Phosphorus and Calcium within
normal ranges.
Vitamin D analog paricalcitol.
Calcimimetic agents like cinacalcet.
CKD - Nephrotoxics
CKD - RRT
CKD - RRT
Indications (Absolute):
Indications (Relative):
CKD - RRT
Transplantation:
Preemptive transplant
carries both patient and
graft survival
advantage.
Graft survival better
with living donor
kidneys.
Immunosuppresion is
almost always a must.
CKD - RRT
Transplantation:
Diseases like FSGS may reccur early in the
transplanted kidney.
Increased risk for infection, bone loss,
cardiovascular disease.
Contraindications:
Malignancy (recent or metastatic)
Current infection
Severe extra renal disease
Active use of illicit drugs