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