Dr.dr.Krisni Subandiyah, SpA(K)Curriculum Vitae

Anggota IDAI Cabang Jawa Timur, sejak tahun 1997Riwayat Pendidikan Tinggi1. Pendidikan Dokter (S1)–Universitas Airlangga, lulus tahun 19892. Pendidikan Spesialis Anak – Universitas Airlangga, lulus tahun 19973. Konsultan Nefrologi Anak - Universitas Airlangga, lulus tahun 20034. Program Doktor (S3) Ilmu Kedokteran – Universitas Brawijaya, lulus tahun 2008Pelatihan Profesional 2007 - Pediatric Neurologic Up date 2007 - Innovative Assesment in Pediatrics Training Program 2007 - Pelatihan Staf pengajar dalam OSCE dan Mini CEX 2007 - Pelatihan tata laksana edema pada anak 2007 - Manajemen Bayi Berat Lahir Rendah Level 3 (NICU) 2008 - Pelatihan dalam rangka Konika 14 2009 - Workshop Evidence Based Medicine (EBM) 2009 - Workshop Kegiatan PKB Anak XXXVIII 2009 - Workshop Penanganan Terpadu Infeksi HIV pada bayi & Anak 2009 - Workshop Penanganan Terpadu Infeksi HIV pada bayi & Anak 2010 - Pelatihan Resusitasi Neonatus 2010 - Pelatihan Motivasor Laktasi 2010 - Pelatihan UKK Infeksi dan Penyakigt Tropis 2011 - Workshop Antibiotic usage in Children Pengalaman JabatanSPS Ilmu Kesehatan Anak Fakultas Kedokteran Universitas Brawijaya, tahun 2005- 2012KPS Ilmu Kesehatan Anak Fakultas Kedokteran Universitas Brawijaya, tahun 2012 -sekarang

Nama : Dr. dr.Krisni Subandiyah,Sp.A(K)Agama : IslamStatus : Menikah Suami : Dr.dr.Edi Handoko,Sp.THT-KL Anak : dr.Rizki Ekaputra HandokoTTL : Surabaya, 19 Juli 1964NIP : 19640719 198910 2 001 Pangkat / Gol. : Pembina/ IV AAlamat Kantor : Jl. JA Soeprapto 2 , MalangTelp : (0341) 362101, 343343,Fax : (0341) 369393 Email : idaimlg @ yahoo.comAlmat Praktek : Jl. Bunga Cengkeh 63, MlgTelp : (0341) 486214 Alamat Rumah : Jl. Bunga Cengkeh 63, MlgTelp : (0341) 486214Email : krisdika2002 @ yahoo.comJabatan : Staf Pengajar Divisi Nefrologi

Anak Lab/SMF Ilmu Kesehatan Anak FK. UNIBRAW / RSU Dr. Saiful Anwar Malang

UKK NEFROLOGI IKATAN DOKTER ANAK INDONESIA

Krisni S Handoko

CONSERVATIVE THERAPY

OF ACUTE KIDNEY INJURY

ETIOLOGY OF AKI

Prerenal

Renal/ intrinsic

Postrenal

..................... Etiology

THE MAJOR CAUSES OF AKI IN CHILDREN

Indian J Pediatr. 2012;79(8):1069–1075

MANAGEMENT OF AKI

Therapy

Conservative therapy

Renal replacement therapy (RRT)

..................... Management

• Early goal – directed fluid therapy

• Fine control of acidosis & •Electrolyte balance

• Dietary

• Blood presure management

CONSERVATIVE THERAPY

Kidney International Supplements. 2012; 2(2)

Fluid Management

Volume status• Hypovolemia• Euvolemia• Fluid overload and pulmonary edema

Oliguria• Adults & older children : Urine output < 400 mL/day• Infant & younger children : Urine output

< 0,5-1.0 mL/kg/h

Anuria

• Complete absence of urine output

Indian J Pediatr. 2012;79(8):1069–1075

..................... Conservative Therapy

Textbook of Clinical Pediatrics. 2012

..................... Conservative Therapy

Fluid Management

Fluid Management

Fluid Management of Oliguric-Anuric Child

. ...................Conservative Therapy

Pedatr and Child Health, 2012; 22(8): 341-345.

Severe dehydration↓

Infusion 20–30 ml/kg (maximum 60– 80 ml/kg)

isotonic saline or Ringer’s lactate , boluses↓

Vital sign, CVP↓

If urine output increases andCVP is still low, infusion may be

continued↓

If fluid replacement is accomplished → furosemide

Pre-Renal Failure ..................... Conservative Therapy

Management of Acute Kidney Problems. 2010

Maintenance of Fluid Balance

• Modulate renal perfusion pressure

• Optimize the renal preload

To limit ischemic injury

• D5,D10 : 20-30 mL/100 kcal/day (about 25–30% of maintenance fluid requirements) or 500 mL/M 2 /day.

• D5½NS : depend results electrolyte

Insensible losses plus any ongoing losses

Clin J Am Soc Nephrol. 2011; 6: 966–973

..................... Conservative Therapy

................Conservative Therapy

FUROSEMIDE• Doses : (1-5 mg/kg/dose)• Force diuretic→ controversy

Contra indications :Dehidration Urinary tract obstruction (Postrenal AKI)

Side effects :• Promote excretion of sodium and

potassium• Ototoxicity

DIURETIC

May be used but ONLY after adequate volume

resuscitation

The Cochrane Library. 2011

................Conservative Therapy

MANNITOL• 0.5-1 g/kg delivered over

30 minutes• Increase intratubular urine flow →

limit tubular obstruction

Side effects :• Congestive heart failure• Hyperosmolarity.

DIURETIC

The Cochrane Library. 2011

DOPAMINE•Renal dose” dopamine(0.5-5μg/kg/min)• Improve renal perfusion after an ischemic insult

• Increases renal blood flow by promoting vasodilatation

• Improve urine output by promoting natriuresis

• Can induce tachy-arrhythmia’s, myocardial ischaemia, and extravasation out of the vein can cause severe necrosis

VASOACTIVE AGENTS..................... Conservative Theraphy

Pediatr Nephrol. 2013; 13: 2425-8

................Conservative Therapy

The Cochrane Library, 2011

Nabic = (desired-observed bicarbonate) x kg x 0,3 (mEq)

or2-3 mEq/kg/day every 12 hours

Hypocalcemia and tetanyKidney International Supplements. 2012; 2(2)

Metabolic Acidosis

ACID-BASE AND ELECTROLYTE BALANCE:

Hyponatremia

Due to : dehydration & fluid overload with dillutional hyponatremic

ACID-BASE AND ELECTROLYTE BALANCE:

Sodium < 130 mEq/L : fluid restriction Sodium < 120 mEq/L : NaCl 3% (0,5 mEq/ml)

- (125-serum Na ) x 0,6 X BW, slowly, 1-4 hours Corrected to at least 125 mEq/L

Kidney International Supplements. 2012; 2(2)

Hyponatremia

..................... Conservative Theraphy

With Seizures :

- NaCl 3% :10-12 mL/kg, iv, 1 hr

- NaCl 3% : (125- serumNa) x 0,6 + (0.513 mEq Na/mL NaCl 3%), rapidly

Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

The Cochrane Library, 2011

Hyperkalemia

a. Decrease filtration

b. Impaired tubular secretion

c. Altered distribution of K+ by acidosis, which shifts potassium from the intracellular to the extracellular compartment

d. Release of intracellular K+ due to the associated catabolic state

Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

The Cochrane Library, 2011

Hyperkalemia

Symptoms : Malaise, nausea Progressive muscle weakness.

Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

The Cochrane Library, 2011

Mild – Moderate• K : 6.0 – 7.0 mEq/L (6.0 and 7.0 mmol/L)• Kation exchange resin (resonium A) :

- Kayexalat 1gm/kg/po or per rectal 4x /day Or

• Kalitake 3x2,5 gram

Hyperkalemia

Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

The Cochrane Library, 2011

• K : > 7.0 mEq/L (7.0 mmol/L) + abnormal ECG or cardiac arrhythmias

• Ca glukonas 10% : 0,5-1 mL/kg, iv, 10-15 mnt

• Nabic 7,5% : 1-2 mEq/kg, iv, 30-60 minute

Severe Hyperkalemia

• Glucosa 0,5-1.0 g/kg + insulin 0,1unit/kg, iv, 30 minute or subcutan

• Insulin 0,2 unit/kg → dialysis should be initiated• Salbutamol 2,5 mg (BW< 25 kg), 5 mg (BW >

25 kg)

Not improvement

Kidney International Supplements. 2012; 2(2)

................Conservative Therapy

The Cochrane Library, 2011

Indian J Pediatr. 2012; 79(8): 1069-75

Hyperphosphatemia

- Skeletal resistance to

parathyroid hormone

- Overcorrecting the acidosis

- Dietary phosphorus restriction

- Calcium carbonate: 45-65 mg/kg/day,po

................Conservative Therapy

Hypocalcemia

☺ Hyperphosphatemia☺ Inadequate GI Ca absorption due to in adequate 1,25-dihydroxy vitamin D production by the kidney☺ Skeletal resistance to the action of PTH

☺ Calcium carbonate: 45-65mg/kg/day,po☺ Severe hypocalcemia : Calcium gluconate 10%, 0,5-1 mL/kg

(maximal : 10 mL), 30-60 min → ECG☺ 1,25-dihydroxyvitamin D3 (calcitriol), 0,01-0,05

mcg/kg/day, po (<3 tahun) or 0,25 mcg-0,75 mcg per day (>3 tahun)

................Conservative Therapy

The Cochrane Library, 2011

Volume overload → diuretic (furosemide) or dialysis

ACE inhibitor : captopril 0,3mg/kg/x, 2-3 x/day

Crisis hypertension → Calcium channel blocker (nifedipine) 0,25-1 mg/kg/dose, sublingual, maximal 10 mg/dose

Hypertension

Indian J Pediatr. 2012; 79(8): 1069-75

Hypertension

Pediatrics in Review . 2008. 29 (9 ) : 299-308

Nutritional Support

NDT Plus . 2010. 3: 1–7

................Conservative Therapy

Nutritional Support

• A diet of high biologic value protein

1

• Low phosphorus, low potassium food

2

• Maintaining appropriate fluid balance

3

................Conservative Therapy

The Cochrane Library . 2010

Calorie

kcal/kgBW

Protein kcal/kg

Conservative treatment 0 – 2 years

Child/teenager

95 - 100Minimal by age

1.0 - 1.81.0

Peritoneal Dyalisis 0 – 2 years

Child / teenager

95 - 100Minimal by age

2.0 - 2.51.0 - 2.5

Haemodialysis 0 – 2 years

Child / teenager

95 - 150

Minimal by body height

1.5 - 2.11.0 - 1.8

Nutritional Support................Conservative Therapy

The Cochrane Library . 2010

Risk of infection:

- Azotemia → depressed imunity

- Underlying nutritional status

Avoid :

Long term catheterization

Initial antibiotic ≈ level of renal

function

All procedures → aseptic techniques

Infections

................Conservative Therapy

Indian J Pediatr. 2012; 79(8): 1069-75

Withdrawal or replacement of offending medication (e.g., aminoglycosides, non-

steroidal anti-inflammatory drugs)

Anti microbial therapy ( e.g., malaria, leptospirosis, sepsis, urinary tract infection)

Surgical intervention for obstruction (e.g., removal of stones)

Diuretics and alkalinization of urine in crush injury/myoglobinuria/hemoglobinuria

Plasmapheresis in non diarrheal hemolytic uremic syndrome, rapidly progressive

glomerulonephritis, vasculitis

Pulse steroids in rapidly progressive glomerulonephritis, vasculitis, drug induced

acute interstitial nephritis

Treatment for Underlying Cause of AKI

Indian J Pediatr. 2012; 79(8): 1069-75

Prevention of AKI

Indian J Pediatr. 2012; 79(8): 1069-75

Indic

ati

on

When conservative

medical management is unsuccessful

in restoring renal function

Mod

aliti

es o

f R

RT - Hemodialysis

Peritoneal Dialysis

Renal Replacement Therapy

52