Dr Zulfian SpPKFakultas Kedokteran Universitas Malahayati

Fungsi Ginjal :Membuang sisa metabolismeMengatur jumlah cair tekanan darahMempertahankan keseimbangan kadar H+ dan HCO3- keseimbangan asam basaMengatur jumlah kation dan anion tekanan osmotis cairan tubuh

Disamping itu ginjal mampu Memproduksi ertropoetinRenin enzim berfungsi mengatur volume cairan ECSKalikrein : enzim proteolitik pembentuk kinin, (vasodilator)Postaglandin dan Tromboksan

Dalam menjalankan fungsiny ginjal mempunyai bahagian disebut fungsional unit ginjal disebut nefron

Pada manusia hampir seluruh akhir metabolisme diekskresikan melalui glomerulusEkskresi melalui tubulus utk bahan sisa metabolisme kurang penting kecuali K+, asam urat,Tubulus ginjal memelihara air dan konstiituen yang larut dalammelalui reabsorbsi menggunakan reabsorbsi aktif

Tes Fungsi Ginjal :Mempunyai fungsi :Mengetahui kerusakan ginjalMenentuan derajad gangguan fungsi ginjalPemeriksaan urin : gangguan pada ginjal dan saluran kemihPemeeriksaan Klirens : gangguan fungsi ginjal

Spesimen Urin

1. Urin Pagi Kandungan zat dlm urin pekat Aliran pertama dibuang Sangat biak untuk pemeriksaan : Sediment, BJ (S.G.), TES Kehamilan2. Urin Sewakttu3. Urin 2 jam post Prandial untuk pemeriksaan GLUKOSa4. 24 HOURS URINE

URINE (Pagi)(Segar)SHAKEMAKROSKOPIs

WarnaBauBerawanKeasamanSPEC. GRAF (BJ)SEDIMENTMIKROSKOPIC

ERYTHROCYTELEUKOCYTEEPHITELCRYSTALCASTKIMIA

ALBUMINGLUCOSEUROBILINBILIRUBINKETOBODYBENZIDINROUTINESIMPLESUPERNATANT

KUNING MUDA NORMAL COKLAT TUA (the pekat) BILIRUBIN (?)

TES BUSAKOCOK(KUAT )BUSAYELLOW (JELAS)= F. T +> BIL. +

Meragukan

FOUCHET RED (DARAH ?)

PEMERIKSAAN SED. ERYTHROCYT : (+) = HEMATURI (-) = Hb. UR

TES BENZIDIN THE OTHER COLOURMAKANAN / SAYURAN GREENDRUGS : ANTIPIRIN YELLOW FENACETINSUBST. FENOL, SALICYL DARK GREENA. WARNA1. MACROSCOPIC EXAMINATION OF URINE

B. KEKERUHAN (NORMAL : JERNIH)

REDDISH PERDARAHAN SEDIMENT ? (ERYTHROCYT) HALUS (PUTIH) BAKTERI (GRAM) KASAR (WHITE) (ALKALIC / NEUTRAL URINE) - PUS - KRISTALPHOSPHATE / KARBONAT

+ ACETIC ACID SOL (6%)

BERKURANG/ HILANG SPERMATOZOA

VOLUME URIN NORMAL : 800 1600 ml/24 JAM 4 DAY 3X NIGHTPOLYURIA D.M., D.I., CHR. NEPHRATIS, EDEMA, RECONV. FROM CHR. DISEASES

OLYGURIA ACUTE NEPHRITIS, ECLAMPSIA, ENTERITIS, BANYAK KERINGAT, DECOMP. CORDIS.

ANURIA COLLAPS, KERACUNANHg CL2

C. KEASAMAN (pH) (N. 4.7 - 7.5) RATA2 6.0

KERTAS LITMUS R

BLUE RED = ACID BLUE = ALKALINE RED VIOLET = NEUTRALMUST BE DONE ALWAYS : - ALBUMIN TEST ACID URINE - INTERPRETATION : MORE EASY

ADV. : 1. NEW URINE ALKALINE UTI = M.O PEMECAH UREA 2. PEDOMAN TH/ ACIDOSIS / DGN ALKALIN SUBSTANSI D. SMELLNORMAL BAU URINE ABNORMAL BAUJENGKOL KERACUNAN JENGKOL

+ ALBUMINURIA HEMATURIA CRYSTALURIA

BUAH2AN KETONURIA AMONIAK UREUM DARI BACTERIA

E. PEMERIKSAAN BERAT JENIS ( SPECIFIC GRAVITY =S.G.) NORMAL : 1.010 - 1.025 (1.020) S.G. RENDAH ( < 1.010 ) = GANGGUAN GINJAL/ENDOKRIN S.G. TINGGI ( > 1.025) = FEVER, GLYCOSURIAMETHOD & ALAT URINOMETER SILINDER PENGUKUR (50 ml) TEMP. : EVERY 30 C > 150 C : + 0.001 40 C > 170 C : + 0.001 GLUCOSE : EVERY 270 mg/DL : -0.001 1 % : -0.004 PROTEIN : EVERY 400 mg/DL : -0.001 1% : -0.003BILA JUMLAH URIN SEDIKITGUNAKAN : - METODE TETES JATUH - REFRACTOMETER BJ. TERGANTUNG DARI TOTAL BAHAN TERLARUT 1.0001.040

2. MICROSCOPIC EXAMINATION OF URINEURIN SEGAR < 6 HOURSSENTRIFUGE PADA 1500 RPM / 5 MINUTESEDIMENTTETES TUTUP DGNCOVER GLASSSLIDEMIKROSKOPE OBJECTIVE 40 X EYEPIECE 10 X CONDENSORPERIKSA ! !CRYSTALSEL EPHITEL SEDIMENORGANIKSEDIMENANORGANIC

ERITHROCYTEA. NORMAL (URINE SEGAR ) : - BULAT , F + 7 m (EQUALLY) - KEKUKING2AN

B. CRENATED (BJ URIN TINGGINE) - BGN PINGGIR GELAP - PINGGIRAN BERDURI - CAIRAN KELUAR DARI SEL MANFAAT KLINIS :CATATAN : ERY (+) : : ULANGI MIDSTREAM URINE ATAU URIN DGN KATETER NORMAL : 0 - 1 / LPB

MORFOLOGI :

LEUCOCYT (WHITE CELLS)MORPHOLOGIC : CLEAR GRANULAR DISKS ROUND ; F + 11 m (1.5 - 2 E) THE EDGES NOT CLEAR CELLS SURFACES ARE GRANULAR IN NEW URINE AMOEBOID MOVEMENT IN NEW ALKALIST CLUMPS IN ALWAYS FOUND 2 - 6 LEUCOCYT OR MORE / LOW POWERTHE CLINICAL VALUE : N : 0 - 6 / LOW POWEREE

NOTES :CLEAN VOIDED URINE (GEWASSEN URINE) : - OPEN PREPUTIUM - CLEAN URETHRAE - TAKE MIDSTREAM URINE: - WASH THE AREA AROUND URETHRAE - OPEN LABIAMIDSTREAM URINECATHETERIZATIONDANGEROUS, INFECTION

EPITHELIAL CELLSMORPHOLOGIC :SCUAMOUSEPITHELIAL CELLS(VAGINA)(URETHRAE DIST.)ROUND EPITHELIAL(TUBULUS)CAUDATUSEPITHEALIAL CELLS(PELVIS R.) SMALL AMOUNT OF EPITHELIAL : USUALLY, (ESPECIALLY ON WOMAN) DIAGNOSTIC VALUE IS SMALLCRYSTALIN ACID URINE : URIC ACID URATE URATE CRYSTAL / AMMORPHUS URATE Ca OXALATEIN ALKALIST URINE : AMMORPHUS MAGN. PHOSPHAT Ca PHOSPHAT / CARBONATE AMMORPHUS PHOSPHAT AMMONIUM URATE URIC ACID IN FRESH URINE CALCULUS IN THE U.G.OTHERS, THERE HAVE NO CLINICAL VALUE

- Ca OXALATE : SIZE VARIABLE CLEAR MORPH. LIKE ENVELOPE- PHOSPHAT :TRIPLEPHOSPHATCALCIUMPHOSPHATAMMORPHUS PHOSPHATCLEAR- CARBONATE :CALSIUM CARBONATE- URIC ACID :- URATE :NH4 URATENa - URATEAMMORPHUS URATECOLOURIS BROWNAPPEARENCE OF CRYSTAL

CRYSTALNORMAL CRYSTALINE DEPOSITE1. CALCIUM OXALATE (ACID URINE)A. SHAPE LIKE ENVELOPE SIZE 10 - 20 m mB. SHAPE LIKE PEANUTS SIZE + 50 m m COLOUR : CLEAR / TRANSPARANT ( COLOURLESS )5. LESS COMMON CRYSTAL A. CALCIUM PHOSPHATE (ALKALINE NEUTRAL) B. CALCIUM CARBONATEE (ALKALINE NEUTRAL) C. CALCIUM SULFAT (ACID URINE)

CAST CAST OF SEDIMENT IS PRECIPITATE OF PROTEIN IN TUBULI IN ACID URINE CYLINDRICAL IN SHAPE AND LONGPROTEIN1. HYALINE CASTS : TRASPARENT, SLIGHTLY RE- FRAQTIL, THE END RONDED OR TAPERED2. GRANULAR CASTS (COARSE) : RATHER SHORT CASTS FILLED WITH LARGE GRANULES PALLET PALE YELLOW IN COLOUR (GRANULES COME FROM DE- GENERATE EPHITELIAL CELLS FROM THE TUBULES OF THE KIDNEY)3. FINE GRANULAR CAST : GRANULES ARE SMALLER AND DO NOT FILL THE CAST

4. BLOOD CASTS (ERITHROCYTES CASTS) : CASTS DIISI DGN ERITROSIT CELLS BERARNA KECOKLATAN5. PUS (LEUKOCYTES) CASTS : CAST DIISI DGN LEUKOCYTES6. EPHITELIAL CASTS : CAST DIISI DGN KUNING PUCAT SEL2 EPHITELIAL

BIOCHEMISTRY EXAMINATION OF URINE1. PEMERIKSAAN PROTEIN OF URIN PRINSIP : PROTEIN BERAWAN

KONDISI URINE : - ASAM DAN JERNIH JENIS PEMERIKSAAN : KUALITATIF / SENSITIVITY 5 - 10 mg /dL Ph TERTENTUA. EXTON TEST FOR PROTEIN URINEREAGEN : SULFOSALISILIC ACID : 25 GR. 50 NA2SO4 : 100 GR. 88 AQUADEST : 500 CC. 1000URIN

SENTRIFUSSHAKEREAGENS : 2.5 mlURINE : 2.5 mlEXTON (+) : - PROTEIN - PROTEOSEN - BENCE JONES PROTEIN - URIC ACID & OTHERS JERNIH = PROTEIN (-)(TDK ADA PRESIPITASI PUTIH) TURBID = EXTON (+) DIIKUTI DGN : 1. BANG TEST 2. ACETO PRECIPITABLE SUBSTANCE TESTBANDINGKAN DGN URIN YG TDK DI TREATC DGN LATAR BELAKANG HITAM

B. BANG SEMI QUANTITATIVE TEST FOR PROTEIN URINE1) REAGEN : SODIUM ACETATE : 11.8 GR ACETIC ACID GLASIALE : 5.65 CC AQUADEST ad 100 CC 2) METHODSIF THE AMOUNT OF ALBUMIN 3000 mg % CLOTTINGBOILEDEXTONPROTEIN : BANGPROTEOSENPROTEINBENCE JONES PROT. TURBID WITHOUT BOILING ACETOPRECIPITABLEREAGEN 0.5 mlURINE 5 ml1000 C WATER BATCHBOILED10READ++++++-

C. QUANTITATIVE PROTEIN URINE EXAMINATION(ESBACH)- UTK KONFIRMASI JUMLAH PROTEIN DLM URIN- URIN DIKUMPULKAN : 24 JAM

REAGENT : > PICRIC ACID : 1 GR > CITRIC ACID : 2 GR > AQUADEST : 100 CCMETHOD TES (ESBACH)PASANG PENUTUP TABUNGLETAKKAN :PADA TEMPERATUR KAMARSELAMA 24 JAMCEGAH CAHAYA MATAHARIPOSISI TEGAKALBUMINOMETER5

DETEKSI PERDARAHAN TERSEMBUNYI DLM URINIF : HEMATURIA SEDIMENT EXAM. ERI (+) Hb. URIA SEDIMENT EXAM ERI (- )BENZIDINE/HEMA TESTPRINSIP :H2O2 H2O + On BENZIDINE OXIDATIONMETOD :1. BENZIDINE SOLUTION5ml ACETIC ACID GLACIAL1 gr BENZIDINE2. URINEPANASKAN3 ml2 mlTEST1 mlURINE DINGINKANBACA DLM 53. H202 SOLUTIONGREEN +BLUE + (HARD) THIS TEST IS VERY SENSITIVE GIVE + RESULT BY OXYDASE FROM LUEKOCYTE- URINE MUST BE HEATED- EQUIPMENT CLEANBLOOD PEROKSIDASE ACTIVITYPREPARE :

URINE TEST STRIPCHARACTERISTIC OF THE TEST :CEPAT, MUDAH, DAN MURAHMATERIALS :TEST STRIPSPECIFIC GRAVITYNITRITEpHPROTEINGLUCOSEKETOBODYUROBILINOGENBILIRUBINBLOODPLASTIK RODNYLON COVERTEST FIELD(PAPER CONTAIN REAGENT)FILTER PAPER

PROCEDUR OF THE TEST :

1. CELUP STRIP DLM URIN KIRA2 1 DETIK2. BUANG URIN BERLEBIH DARI STRIP URINEREAD :COMPARETHE COLOUR CHARTUROTRON

Proses yg terjadi di nefron ginjalFungsi FiltrasiFungsi AbsorbsiFungsi Ekskresi

Pemeriksaan fungsi ginjalFiltrasi : kadar kreatinin/inulin dalam darahAbsorbsi : glukosa dlm urinSekresi : PAH (Para Amino Hypuric Acid)

INULIN : - Tidak diabsorbsi - Tidak disekresi - Bahan eksogenG.F.R. X P = U X VP : Konsentrasi inulin plasmaU : Konsentrasi inulin urinV: Diuresis ( volume urine / minute ) =

INULIN: Bahan Eksogen Tdk di reabsorbsi dan tdk disekresi.UREA: Bahan enogen, direabsorbsiU X VP

KreatininSebagian besar difiltrsi, hanya sedikit di sekresi

KREATININ KLIRENS U X VKlirens Kreatinin = P

140 ml / menit Keuntungan : waktu panjang12 24 jam lebih akurat Kerugian : human error krn waktu yg panjang selama pengumpulan urine Correction factor ( f )Diuresis dipengaruhi oleh berat badan dan tinggi badan Diuresis dikoreksi ( V ) V f V

Rumus sederhana untuk klirens :

( 140 - age ) x Berat Badan (kg)Creatinine clearance = P x 72

P : kadar Kreatinin darahWanita, nilai dikali dgn 0,85Renal Plasma Flow (R.P.F.) :R.P.F. = PAH clearance ( Paraaminohippurate )

Renal Blood Flow ( R.B.F) : 1 0 0R.B.F = x R.P.F. ( 100-Ht)G.F.R.Filtration Fraction =R.P.F.

Hubungan Kadar kreatinin dgn GFRKreatinindlm darah (mg/dl)