Gagal Ginjal Kronik dengan Hemodialysis reguler

Peranan pasien dan keluarga

R Tunggul Sukendar

Divisi Ginjal dan Hipertensi Bagian Ilmu Penyakit Dalam FK USU/ RSUP H. Adam Malik Medan

Mengenali Kelainan Ginjal

Ginjal ada 2 : kiri dan kanan Berat masing-masing : 1/3 kg Renal blood flow : 1-1,5 L/menit

Unit fungsional Ginjal : Nefron Jumlah : masing-masing : 1 juta Glomerulus Tubulus proximal Lengkung Henle Tubulus distal Tubulus pengumpul Calyx Pyelum Ureter Kandung kemih Urethra

RENAL CYSTIC DISEASE

CHRONIC PYELONEPHRITIS

Fungsi Ginjal
1. Fungsi Ekskresi Meneluarkan zat toksis / racun 2. Fungsi Regulasi Mengatur keseimbangan :

air, garam/elektrolit Asam / Basa

3. Fungsi hormonal Hormon renin, prostaglandin Eritropoetin, Kalsitriol dll

Gangguan Ginjal :
Akut :
:

Tiba-tiba, dalam beberapa hari / minggu anuria / Oligouria ataupun tidak Bila anuria / Oligouria terjadi Oedema, Hipertensi, sesak nafas, sindroma uremik : mual, muntah

Kronik :
Terjadi penurunan fungsi ginjal perlahan selama berbulan ataupun bertahun. Awalnya tanpa gejala sampai fungsi ginjal < 25%.

Seluruh organ dan sistem tubuh dikenai

Melvin
46-year-old kidney patient, was diagnosed With polycystic kidney disease 17 years ago and has been on hemodialysis ever since.

Dialysis does not mean stop living, says Melvin Bradford. It means find a new to live.
It means develop skills that are going to help you to live longer.

Tujuan Pengobatan GGT:

Menurunkan mortalitas meningkatkan /memperpanjang lama hidup ( survival) Memperbaiki kualitas hidup (QoL) Mengobati gejala/komplikasi kronik uremia Tindakan rehabilitasi

Dialisis Peritoneal

Kidney undergoing perfusion (in ice) after harvesting

Cooled kidney in Surgical gloves, ready For transplantation

Transplanted kidney after removal on clamps showing pinking up and urine formation

How Often Is Enough ?

Once Weekly ?
Cant control K or volume

Twice Weekly ?
Only if residual function

Thrice weekly ?
Appears adequate

Daily ?
Yet to be proven

The discontinuous time course of serum urea concentration over one week with a thriceweekly dialysis schedule

Volume responses and enhanced frequency dialysis

Volume

Slow Nocturnal Home hemodialysis :

6 x 8 jam (overnight) Dialysate flow : 300 ml/min Blood flow rate : 300 ml/min Hi flux membrane 2 x needles No diet restriction No fluid restriction No BP tablet No Phosphate binder Kadang perlu penambahan Phosphate Atau Ca pada dialysat

Slow Nocturnal Home Hemodialysis

P Pengaturan Nutrisi : Target : Minimal uremik toksisiti Minimalisasi gangguan metabolisme (ca & P) , cairan dan elektrolit (K) Mempertahankan status nutrisi yg baik gn makanan yg cukup menyenangkan (protein, kalori, vitamin dll) Protein Garam dan air Kalim Calsium dan Phosphat

Protein :
Sumber protein : Daging ayam, kalkun, ikan, daging segar yang tak berlemak. Merupakan protein lengkap

Dairy product : susu, keju, yogurt dan telur juga merupakan protein lengkap tetapi : tinggi kolesterol, lemak dan Phosphat Kacang-kacangan, jagung dan biji-bijian (padi, gandum) protein yg tdk lengkap

Terlalu banyak protein :

Mual, muntah Lelah Bingung Kalium darah meningkat Lama HD akan meningkat
Terlalu sedikit protein :

Hilangnya massa otot Lelah BB berkurang Luka sulit sembuh

Garam dan air Target : Capai Berat badan Kering (Dry weight) Pertahankan BB antar dialyisis : 1.5 kg Batasi garam : 2-3 g/hari Jangan tambahkan garam saat memasak Jangan letakkan garam di atas meja Waspadai garam yg tersembunyi di makanan :
Asinan (somboy, ikan asin, telur asin dll) makanan kaleng (corned, sardinnes) kecap, saus tomat dll

Jangan gunakan garam palsu (high K) Untuk memberi kenikmatan gunakan bahan pedas dari tumbuhan alami

Interdialytic Weight Gain

1.5-2 kg UF rate rata-rata 2.0-2.5 kg 0.5 kg : Cairan yg diminum + priming+flushing dll

Kerjasama yg baik dgn Dietitian

1953
Northern Territories

80/40

1997
Northern Territories

170/100

Why did they Migrate ?

Pressure is simple

MC

Volume through the Pipes

Size of the Pipes

Salt restriction and SR + enhanced UF

BW 80 70 60 50 40 30 20 10 0 SBP DBP 180 160 140 120 100 80 60 40 20 0 Body weight kg BP mmHg

Body weight kg

Salt restriction alone: 20/47 = 43% success

64.1 Before Salt restriction only (n=20)

62.2 After

BW 90 80 70 60 50 40 30 20 10 0

SBP

DBP 200 180 160 140 120 100 80 60 40 20 0

Salt restriction + UF+: 37/47 = 79% success

65.5

61.7

Before After Salt restriction plus UF (n=17)

BP mmHg

Improved hypertension control

AHTN SBP DBP

2.5
ANtihypertensive drugs/day 2 1.5 1 0.5 0 0 8 24

180
160 140 120 100 80 60 40 Blood pressure mmHg

Kooistra MP et al Nephrol Dial Transplant 1998; 13: 2853-2860

Udema paru

Kalium
Kalium tinggi : denyut jantung tak teratur dapat berhenti tiba-tiba

Makanan tinggi Kalium : kentang, labu, coklat, pisang, alpokat, jamur, jeruk, Pasta tomat, sayuran, buah kering, high fibre breakfast Cereal dll Bila sayuran tinggi K Potong kecil-kecil, masak dan tiriskan

This fruits should be avoided

This fruits are recommended

Ca dan Posphat

Batasi : Susu Keju Yougurt

Ice cream Coklat Beer Firm Tofu

Hindarkan : Minuman Cola Daging asap Kacang-kacangan Whole grain cereal

Makan pengikat Phosphat saat/bersamaan makan Efek samping : Sulit buang air besar (makan makanan serat tinggi)

Tumoral Calcinosis

1-2 months decrease in size 8-9 months reabsorbed

Koreksi anemia