kuliah aki dan ckd

8/20/2019 Kuliah AKI dan CKD

1/41

Acute renal failure(ARF)/Acute kidney injury

(AKI)

Dr. Atma Gunawan SpPD.KG


2/41

Dia!n"#tic criteria AKI

• A$rupt (wit%in &' %"ur#)• A$#"lute increa#e in t%e #erum creatinine

c"ncentrati"n "f .* m!/d+ (,-.& micr"m"l/+)fr"m $a#eline

• r increa#e in t%e #erum creatinine c"ncentrati"n"f 0 percent

• r "li!uria "f le## t%an .0 m+/k! per %"ur f"rm"re t%an #i1 %"ur#

• 2%e dia!n"#tic criteria #%"uld $e applied "nlyafter 3"lume #tatu# %ad $een "ptimi4ed• 5rinary tract "$#tructi"n needed t" $e e1cluded if

"li!uria wa# u#ed a# t%e #"le dia!n"#tic criteri"n.


3/41

Acute "r c%r"nic 6

• 2%e recent "n#et "f #ympt"m# "r #i!n# #uc% a# fe3erand di#c"l"red urine #u!!e#t# an acute pr"ce##.• +ittle "r n" "utput al#" #u!!e#t# an acute c"mp"nent

#ince pr"l"n!ed "li!uria ("utput le## t%an 0 m+/day)i# a##"ciated wit% ad3anced renal failure.

• An increa#in! pla#ma creatinine c"ncentrati"n after t%einitial e3aluati"n i# indicati3e "f at lea#t an acute "rrapidly pr"!re##i3e c"mp"nent t" t%e di#ea#e w%ile a#ta$le 3alue #u!!e#t# a c%r"nic di#ea#e.

• 2%e pla#ma creatinine c"ncentrati"n tend# t" ri#epr"!re##i3ely (at a rate !reater t%an .* t" .0 m!/d+per day) in acute tu$ular necr"#i#.

• A #l"wer rate "f ri#e i# #u!!e#ti3e "f prerenal di#ea#e.

• 5ltra#"n"!rap%y #%"win! #mall ec%"!enic kidney# i#m"#t c"n#i#tent wit% a c%r"nic di#ea#e . "we3er t%epre#ence "f n"rmal7#i4ed kidney# d"e# n"t e1cludec%r"nic di#ea#e.


4/41

AKI 8riteria $y t%e Acute Kidney Injury 9etw"rk.


5/41

8au#e#


6/41

2%e cau#e# "f AKI

• Acute tu$ular necr"#i# : &0 percent

• Prerenal : ,; percent

• Acute "n c%r"nic kidney di#ea#e : ;*

percent (m"#tly due t" acute tu$ularnecr"#i# and prerenal di#ea#e)

• 5rinary tract "$#tructi"n : ; percent

• Gl"merul"nep%riti# "r 3a#culiti# : & percent• Acute inter#titial nep%riti# : , percent

At%er"em$"li : ; percent

A report from Madrid, for example, evaluated all 748 cases of acuterenal failure at 13 tertiary hospital centers


7/41

How AKI develops

Intra-renal causes Post-renal causesPre-renal Causes

Damage to enal !u"ules

#ntratu"ular

$"struction

%ypoperfusion #ncreased enal

vasoconstriction

&ac'lea' of

!u"ular (luid into

interstitium

Decreased )lomerular

(iltration ate

#ncreased *roximal

!u"ular ea"sorption of

+od#um and ater

#ncreased +ecretion of

Aldosterone and

Antidiuretic %ormone

#ncreased

#ntratu"ular*ressure

-ellularedema

Decreased

)lomerular -apillary

*ermea"ility

Decreased

)lomerular

(iltration ate

!u"ular Dysfunction .ATN/

$"struction of

0rine (lo

&ac'up of urine

-ompression of

enal !u"ules

Acute Kidney Injury


8/41

PATOFISIOLOGI ATN :PATOFISIOLOGI ATN :A. NormalA. Normal

Arteriol aferen Arteriol eferen

Aliran plasma

glomerulus

!e'anan

hidrostati'

glomerulus

(iltrasi glomerulus

!e'anan

dalam tu"ulus


9/41

Contribution of ‘back-Leakage’ of glomerularltrate and intratubule obstruction to enal!ailure in A"#


10/41

Dia!n"#tic f"r t%e cau#e# "fAKI


11/41


12/41

2reatment

• ptimali4ati"n "f 3"lume #tatu# <7 re%ydrati"n7 =uid maintainance < *7& ml/k!>?/day

• Relea#e p"#t renal "$#tructi"n

• 8"rrect electr"lyte and acid7$a#e im$alance<7 acid"#i#7 %yperkalemia %yp"calcemia

• @inimali4e #ec"ndary "r!an dama!e due t" AKI(lun! edema arr%ytmia3"mitin!)

• Special adaptati"n due t" decrea#e "f renalfuncti"n 2 Dru! d"#e# adju#ment 2 +"w acti3ity


13/41

9utriti"nal Supp"rt

• nteral nutriti"n i# t%e rec"mmended maintain !ut inte!rity B !ut atr"p%y andB $acterial and end"t"1in tran#l"cati"n

• General rule < ,7*0 kcal/k!/day and up t"a ma1imum "f ;.C! amin" acid#/k!/day if%ypercata$"lic and recei3in! 8RR2

• lectr"lyte# mu#t $e m"nit"red cl"#ely t"a3"id %yp"kalaemia and/"r%yp"p%"#p%ataemia f"ll"win! t%e initiati"n"f enteral nutriti"n.


14/41

P%armac"l"!ical 2reatment

• +""p diuretic#

• D"pamine

• Fen"ld"pam

• @annit"l• IGF and A9P

Dru! d"#e# need t" $e adju#tedappr"priately

currently n" e3idence t" #upp"rt t%eu#e "f a #pecic p%armac"l"!ical t%erapyin t%e treatment "f AKI


15/41

Indicati"n# t" $tart " in AKI#erum urea E;' m!/dl (kali -;)

/Serum urea !"# m$/dl


16/41

@"dalita# terapi diali#i# padaARF

• Intermiten %em"diali#i#

• 8"ntinu"u# renal replacementt%erapy

• Acut perit"neal dialy#i#


17/41

8%r"nic kidney di#ea#e


18/41

%enition of C&ronic Kidne'%isease

Criteria

!% Kidney dama$e &or ' ( mont)s* as de&ined +y structural or&unctional a+normalities o& t)e ,idney* it) or it)out

decreased GF.* mani&est +yeither :

• Pat)olo$ical a+normalities or

• 0ar,ers o& ,idney dama$e* includin$

A+normalities in t)e com1osition o& t)e +lood orurine* or a+normalities in ima$in$ tests

2% GF. 3 4# mL/min/!%5( m2 &or ' ( mount)s* it) or it)out,idney dama$e


19/41

• 2%e di#tincti"n $etween acute #u$acuteand c%r"nic kidney di#ea#e i# ar$itrary.8learly a ri#e in t%e pla#ma creatinine

c"ncentrati"n "r an a$n"rmality "n t%eurinaly#i# t%at %a# de3el"ped wit%in day#t" week# repre#ent# an acute pr"ce##w%erea# e3idence "f renal di#ea#e

e1tendin! f"r m"nt%# t" year# i# ac%r"nic pr"ce## t%at may $e a##"ciatedwit% acute e1acer$ati"n#.


20/41

Dierentiati"n "f acute fr"mc%r"nic kidney di#ea#e

• Histor' Long-standing &istor' suggestsCK%

• enal osteod'strop&' o( evidence of osteitis brosac'stica or osteomalacia

suggests CK%

• enal si)e *lengt&+-small *, cm+ CK%

-normal AKI

-enlarged*./0 cm+ %iabetec nep&ropat&'

Am'loidosis

1bstructive uropat&'HI2

3K%

• enal biops' Histologic diagnosis


21/41

D$5# 63

Tahapan Penyakit Ginjal Kronik

Ta)a1 Keteran$anGF.

6mL/men/!%5(m27

1 erusa'an ginal dengan )(normal atau

9

6 erusa'an ginal dengan

)( ringan : 2 89

3 )( sedang 3 2 ;9

4 )( "erat 1; 2 69

; )agal ginal < 1; .atau dialisis/

*enya'it ginal 'roni' didefinisi'an se"agai 'erusa'an ginal atau )( < :m=men1>73m6 selama ? 3 months> erusa'an ginal didefinisi'an se"agai 'elainanpatologis atau adanya petanda adanya 'erusa'an, termasu' 'elainan dalam test darahatau urin atau pemeri'saan radiologis


22/41


23/41

3en'ebab CK% terban'ak 'ang membuatpasien men4alani renal replacement t&erap'

*transplant5H%5CA3%+

Penyakit

Dia$ete# mellitu# &

yperten#i"n ,0

Gl"merul"nep%riti# ;0

P"lycy#tic kidney di#ea#e&

5r"l"!ic -

5nkn"wn H mi#cellane"u# ;


24/41

$creening for CK%

• ationale 6 earl' detection5 earl' intervention5 reducedassociated complications5 &ig& prevalence silentkidne' disease

• 7&om 8 %iabetes5 &'pertension5 autoimmune diseases5urinar' tract infection or obstruction5 &eart failure5cirr&osis5 famil' of 9$%5 famil' of nep&ropat&'*%:5H"5glomerulonep&ritis+

• How 8- standart urine dipstick *spot urine+6 proteinuria

&ematuria5 lekosituria- serum creatinine- blood pressure- ultrasound imaging*obstruction5stones5infection53K%+- serum electrol'tes- urinar' concentration


25/41

"&e risk for loss of kidne' function

Ty1e 8e&inition 9am1les

Susce1ti+ility&actors

Increased susce1ti+ility to,idney dama$e

Older a$e* &amily )istory

Initiation &actors 8irecty initiate ,idney dama$e 8ia+etes* )i$) +lood1ressure* autoimmunediseases* systemicin&ections* urinary tractin&ections* urinary stones*loer urinary tracto+struction* dru$ toicity

Pro$ression&actors

Cause orsenin$ ,idneydama$e and &aster decline in

,idney &unction a&ter initiationo& ,idney dama$e

;i$)er la


26/41

Ota, : @ letargi, malaise@ "ingung@ 'oma@ 'eang Konjun$ti


27/41

Manifestasi klinik CKD (biasanya manifes

pada KK!" ml#min$te %&

Anemia

Hipertensi

1verload s'ndrome

;remia


28/41

Perjalanan 8KD

• Keru#akan !injal $er#ifat irre3er#i$le

• Penurunan fun!#i !injal $er#ifatpr"!re#if (& ml/m perta%un)

• Keru#akan !injal le$i% lanjut $i#adiperlam$at/di%am$at den!anmelakukan inter3en#i ter%adapfakt"r7fakt"r y! mempercepatkeru#akan !injal


29/41


30/41


31/41

Koreksi faktor re'ersibel )orre)table

(a'tor pre renal B hipovolemia ,de'ompensasi 'ordis,hipotensi,

stenosis arteri renal

(a'tor post renal B mem"e"as'an o"stru'si post renal oleh 'arena

"atu, prostat, 'eganasan rongga pelvis

Mengo"ati penya'it dasar fa'tor renal B DM, hipertensi, egenerCs

granulomatosis, lupus nefritis dll

radi'asi infe'si 'uman t>u yg di tra'tus urogenitalis B #+, sepsis


32/41


33/41

:easures to prevent t&eprogression of CK% patients 8

• +ife #tyle m"dicati"n < ideal >?%ealtyeatin!re#trict dietary #alt intakecea#e#m"kin!m"derate alc"%"l

c"n#umpti"nincrea#e p%y#ical acti3ity• >P $el"w ;*/'. yperten#i3e dia$etic#

and micr"/macr"al$uminuria treated wit%A8 I "r AR>

• Glycemic c"ntr"l < $A;c C

• Reducti"n "f pr"teinuria < A8IAR>


34/41

:easures to prevent t&eprogression of CK%

• Dietary pr"tein re#tricti"n < - J ' !/k! >>• +ipid l"werin! < c%"le#ter"l t"tal

,+D+;D+E&02G;0• A3"idance "f nep%r"t"1ic a!ent#<

9SAIDamin"!lyc"#ideradi"c"ntra#t mediaAdju#t d"#e# depend "n clearance creatinine

• arly referral t" nep%r"l"!i#t


35/41

Pen*obatan Kh$s$s Gejala Kel$han

GGK

/< Anemia - !e - asam folat - eritropoetin

- transfusi0< =atal - diet renda& protein - difen&idramin>< :ual

- diet renda& protein?< Hiperuricemia 6 alupurinol@< Hiperkalemi 6 glukose dan insulin5diit

renda& kalium5cation ec&ange resinB< Asidosis 6 nabic infus dan tablet< 1verload s'ndrome 6 balans cairan5 diuretik


36/41

$&ould be referred tonep&rologist

• ?%en creatinine clearance *ml/min/;.C*m,

• Patient# at ri#k "f rapid pr"!re##i"n

• In w%"m d"u$t e1i#t# a# t" t%eirdia!n"#i# and pr"!n"#i#


37/41

Klirens ,reatinin 3 ! ml/m 6807

Klirens Kreatinin 3 !# ml/men 6non 807

Sindroma >remi,

;i1er,alemia

Asidosis 0eta+oli,

Kele+i)an Cairan 6overload 7

Kapan dilakukan renalreplacement t%erapy 6


38/41

@"dalita# renal replacementt%erapy

• em"diali#i# (D)

• 8%r"nic am$ulat"ry perit"nealdialy#i# (8APD)

• Kidney tran#plant


39/41

%D


40/41

-A*D


41/41

#DEF

!AE+*=AE!

kuliah aki dan ckd

Documents