Definition

Acute renal failure is a rapid decrease in renal

function over days to weeks, causing an
accumulation of nitrogenous products in the
blood (azotemia). (www.kidney fun.org
/American Kidney )
Acute renal failure (also called acute kidney
injury) means that your kidneys have suddenly
stopped working
Acute
sudden onset
rapid reduction in urine output
Usually reversible
Tubular cell death and regeneration

ANATOMY OF KIDNEY

PHYSIOLOGY

Aliran darah di ginjal

Etiology???

Penyebab Yg Mungkin

Masalah

Berkurangnya aliran
darah ke ginjal

Penyumbatan aliran
kemih

Trauma pada ginjal

Kekurangan darah akibat perdarahan, dehidrasi atau cedera fisik yg

menyebabkan tersumbatnya pembuluh darah
Daya pompa jantung menurun (kegagalan jantung)
Tekanan darah yg sangat rendah (syok)
Kegagalan hati (sindroma hepatorenalis)

Pembesaran prostat
Tumor yg menekan saluran kemih

Reaksi alergi (misalnya alergi terhadap zat radioopak yg digunakan

pada pemeriksaan rontgen)
Zat-zat racun
Keadaan yg mempengaruhi unit penyaringan ginjal (nefron)
Penyumbatan arteri atau vena di ginjal
Kristal, protein atau bahan lainnya dalam ginjal

Causes of ARF
Pre-renal =
vomiting, diarrhea, poor fluid intake, fever, use of
diuretics, and heart failure
cardiac failure, liver dysfunction, or septic shock

Intrinsic
Interstitial nephritis, acute glomerulonephritis, tubular
necrosis, ischemia, toxins

Post-renal =
prostatic hypertrophy, cancer of the prostate or
cervix, or retroperitoneal disorders
neurogenic bladder
bilateral renal calculi, papillary necrosis, coagulated
blood, bladder carcinoma, and fungus

Fase klinis GGA

1. Initiating phase
adanya pencetus s/d timbul gejala oliguria
2. Oliguria (Vol. Urin <400 cc/hari)1-2 minggu
peningkatan BUN, creatinin, as. Organik,as.
Organik,as. Urat, magnesium, potasium.
Problem
retensi cairan
Hiperkalemi, hipermagnesia
Asidosis metabolik
Resti infeksi
Perdarahan saluran cerna
Perubahan nutrisi
Resti drug toxicity

3. Diuresis : self limiting diuresis (1-2

mgg); output urin 1-3 L/hari
Problem
defisit volume cairan tubuh
hipokalemia
alkalosis metabolik
4. Pemulihan: GFR normal (6-12 bln)/
kronik
Problem
Pengetahuan episode ARF
follow-up care
Pencegahan episode berulang

What are the symptoms?

Symptoms of acute renal failure may include:
Little or no urine when you urinate.
Swelling, especially in your legs and feet.
Not feeling like eating.
Nausea and vomiting.
Feeling confused, anxious and restless, or sleepy.
Pain in the back just below the rib cage. This is called flank pain.
Some people may not have any symptoms.

weakness, seizures, confusion, and coma; asterixis and

hyperreflexia may be present on examination. Chest pain (typically
worse with inspiration or when recumbent), a pericardial friction
rub, and findings of pericardial tamponade may occur if uremic
pericarditis is present. Fluid accumulation in the lungs may cause
dyspnea and crackles on auscultation.

Assesment
HISTORY:
Take note of the following findings during the
physical examination:

Hypotension
Volume contraction
Congestive heart failure
Nephrotoxic drug ingestion
History of trauma or unaccustomed exertion
Blood loss or transfusions
Evidence of connective tissue disorders or
autoimmune diseases
Exposure to toxic substances, such as ethyl alcohol or
ethylene glycol
Exposure to mercury vapors, lead, cadmium, or other
heavy metals, which can be encountered in welders
and miners

 People with the following comorbid

conditions are at a higher risk for
developing ARF:
Hypertension
Congestive cardiac failure
Diabetes
Multiple myeloma
Chronic infection
Myeloproliferative disorder
Orang dengan riwayat adanya penyakit pada
ginjal, spt glomerulonefritis, hiperplasi
prostat, etc

Physical Assesment
Skin
Petechiae, purpura, ecchymosis, and livedo
reticularis provide clues to inflammatory and
vascular causes of AK
Infectious diseases, thrombotic thrombocytopenic
purpura (TTP), disseminated intravascular
coagulation (DIC), and embolic phenomena can
produce typical cutaneous changes.

Eyes
Evidence of uveitis may indicate interstitial
nephritis and necrotizing vasculitis.
Ocular palsy may indicate ethylene glycol
poisoning or necrotizing vasculitis.
Findings suggestive of severe hypertension,
atheroembolic disease, and endocarditis may be
observed on careful examination of the eyes.

 Cardiovascular system

The most important part of the physical examination is the

assessment of cardiovascular and volume status.
The physical examination must include pulse rate and
blood pressure recordings measured in both the supine
position and the standing position; close inspection of the
jugular venous pulse; careful examination of the heart,
lungs, skin turgor, and mucous membranes; and
assessment for the presence of peripheral edema.
In hospitalized patients, accurate daily records of fluid
intake and urine output and daily measurements of patient
weight are important.
Blood pressure recordings can be important diagnostic
tools.
Hypovolemia leads to hypotension; however, hypotension
may not necessarily indicate hypovolemia.
Severe congestive cardiac failure (CHF) may also cause
hypotension. Although patients with CHF may have low
blood pressure, volume expansion is present and effective
renal perfusion is poor, which can result in AKI.
Severe hypertension with renal failure suggests
renovascular disease, glomerulonephritis, vasculitis, or
atheroembolic disease.

Pemeriksaan laboratorium
1. Darah : ureum, kreatinin, elektrolit, serta osmolaritas.
2. Urin : ureum, kreatinin, elektrolit, osmolaritas, dan berat jenis.
3. Kenaikan sisa metabolisme proteinureum kreatinin dan asam urat.
4. Gangguan keseimbangan asam basa : asidosis metabolik.
5. Gangguan keseimbangan elektrolit : hiperkalemia, hipernatremia
atau hiponatremia, hipokalsemia dan hiperfosfatemia.
6. Volume urine biasanya kurang dari 400 ml/24 jam yang terjadi
dalam 24 jam setelah ginjal rusak.
7. Warna urine : kotor, sedimen kecoklatan menunjukan adanya
darah, Hb, Mioglobin, porfirin.
8. Berat jenis urine : kurang dari 1,020 menunjukan penyakit ginjal,
contoh : glomerulonefritis, piolonefritis dengan
kehilangankemampuan untuk memekatkan; menetap pada
1,010menunjukan kerusakan ginjal berat.
9. PH. Urine : lebih dari 7 ditemukan pada ISK., nekrosis tubular
ginjal, dan gagal ginjal kronik.
10. Osmolaritas urine : kurang dari 350 mOsm/kg menunjukan
kerusakan ginjal, dan ratio urine/serum sering 1:1.

11. Klierens kreatinin urine (CCT): mungkin secara

bermakna menurun sebelum BUN dan kreatinin
serum menunjukan peningkatan bermakna.
12. Natrium Urine : Biasanya menurun tetapi dapat
lebih dari 40 mEq/L bila ginjal tidak mampu
mengabsorbsi natrium.
13. Bikarbonat urine : Meningkat bila ada asidosis
metabolik.
14. SDM urine : mungkin ada karena infeksi, batu,
trauma, tumor, atau peningkatan GF.
15. Protein : protenuria derajat tinggi (3-4+) sangat
menunjukan kerusakan glomerulus bila SDM dan
warna tambahan juga ada. Proteinuria derajat rendah
(1-2+) dan SDM menunjukan infeksi atau nefritis
interstisial. Pada NTA biasanya ada proteinuria
minimal.
16. Warna tambahan : Biasanya tanpa penyakit ginjal
ataui infeksi. Warna tambahan selular dengan pigmen
kecoklatan dan sejumlah sel epitel tubular ginjal

Pemeriksaan darah
1. Hb. : menurun pada adanya anemia.
2. Sel Darah Merah : Sering menurun mengikuti peningkatan
kerapuhan/penurunan hidup.
3. PH : Asidosis metabolik (kurang dari 7,2) dapat terjadi karena penurunan
kemampuan ginjal untuk mengeksresikan hidrogen dan hasil akhir
metabolisme.
4. BUN/Kreatinin : biasanya meningkat pada proporsi ratio 10:1
5. Osmolaritas serum : lebih beras dari 285 mOsm/kg; sering sama dengan
urine.
6. Kalium : meningkat sehubungan dengan retensi seiring dengan
perpindahan selular ( asidosis) atau pengeluaran jaringan (hemolisis sel
darah merah).
7. Natrium : Biasanya meningkat tetapi dengan bervariasi.
8. Ph; kalium, dan bikarbonat menurun.
9. Klorida, fosfat dan magnesium meningkat.
10. Protein : penurunan pada kadar serum dapat menunjukan kehilangan
protein melalui urine, perpindahan cairan, penurunan pemasukan, dan
penurunan sintesis,karena kekurangan asam amino esensial
11. CT.Scan
12. MRI
13. EKG mungkin abnormal menunjukan ketidakseimbangan elektrolit dan
asam/basa.

Komplikasi
Possible Complications
Chronic (long-term) kidney failure
Damage to the heart or nervous
system
End-stage kidney disease
High blood pressure
Loss of blood in the intestines

Acute Renal Failure

Management
Make/think about the diagnosis
Treat life threatening conditions
Hipoperfusi renal:
- Normovolemia : resusitasi cairan CVP 12
- Normotensi: norepinefrin
- furosemid

Identify the cause if possible

Hypovolemia
Toxic agents (drugs, myoglobin)
Obstruction

Treat reversible elements

Hydrate
Remove drug
Relieve obstruction

Nursing Diagnosis
1. Perubahan kelebihan volume cairan b/d gagal
ginjal dengan kelebihan air.
2. Resiko tinggi terhadap menurunnya curah jantung
berhubungan dengan ketidakseimbangan cairandan
elektrolit, gangguan frekuensi, irama, konduksi
jantung, akumulasi/penumpukan urea toksin,
kalsifikasi jaringan lunak.
3. Gangguan pemenuhan nutrisi kurang dari
kebutuhan tubuh berhubungan dengan katabolisme
protein
4. Kelelahan berhubungan dengan penurunan
produksi energi metabolik/pembatasan diet, anemia.
5. Resiko tinggi terhadap infeksi b/d depresi
pertahanan imunologi.
6. Resiko tinggi terhadap kekurangan volume cairan
b/d kehilangan cairan berlebihan.
7. Kurang pengetahuan tentang kondisi,prognosis
dan kebutuhan pengobatan b/d kurang mengingat.