Komponen Anatomis Dasar Saluran Kemih

Field, Pollock, Harris, The Renal System, 2001

Fungsi Ginjal
Mengeluarkan sisa metabolisme : ureum,kreatinin,uric acid,aliphatic amine,2 microglobulin,PTH,myoglobulin,dll Mengeluarkan kelebihan air dan elektrolit (K,Na,Al,H,P) Produksi erythropoietin, reninangiotensin,vitamin D3 aktif Menjaga keseimbangan asam basa Membuang toksin dan obat
Replaced partially by HD

Apa yang terjadi bila fungsi ginjal rusak berat ?

Uremia (gejala akibat tertahannya zat-zat toksik dalam tubuh): mual muntah, nafsu makan turun, gatal, kesadaran turun Tertahannya garam(Na) dan air :bengkak,sesak,hipertensi Keseimbangan asam basa terganggu: asidosis Fungsi hormonal terganggu :anemia, kalsium menurun

Uraemic toxins :
Low MW : urea,creatinine Middle MW : B2 microglobulin, PTH High MW : myoglobulin Middle MW sulit dihilangkan dgn HD, tapi efektip dgn Peritoneal Dialisis dan Highflux dialisis

Penyebab Gagal Ginjal

Glomerulonephritis Diabetic Nephropathy Urinary Stones Disease Hypertension Analgesic nephropathy Polycystic Kidney

Definition of Chronic Kidney Disease

Criteria 1. Kidney damage for 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either : Pathological abnormalities; or Markers of kidney damage, including

Abnormalities in the composition of the blood or urine, or abnormalities in imaging tests

2. GFR < 60 mL/min/1.73 m2 for 3 mounths, with or without kidney damage

Years Until Kidney Failure (GFR < 15 mL/min/1.73 m2) Based on Level of GFR and Rate of GFR Decline
Level of GFR (mL/min/1.73 m2)

Rate of GFR Decline (mL/min/1.73 m2 per year) 10 7.5 6.5 5.5 4.5 3.5 2.5 1.5 0.5 8 9.4 8.1 6.8 5.6 4.4 3.1 1.9 0.6 6 13 11 9.2 7.5 5.8 4.2 2.5 0.8 4 19 16 14 11 8.8 6.3 3.8 1.3 2 38 33 28 23 16 13 7.5 2.5 1* 75 65 55 45 35 25 15 5

90 80

70
60 50 40 30 20

Average age-related GFR decline after age 20-30 year MDRD Study: average rate of decline in GFR is 4 ml/min/year. 85% declined,15% stabile or improvement

The risk for loss of kidney function

Type Susceptibility factors Definition Increased susceptibility to kidney damage Examples Older age, family history

Initiation factors Directy initiate kidney damage Diabetes, high blood pressure, autoimmune diseases, systemic infections, urinary tract infections, urinary stones, lower urinary tract obstruction, drug toxicity Progression factors Cause worsening kidney damage and faster decline in kidney function after initiation of kidney damage Higher lavel of proteinuria, higher blood pressure level, poor glycemic control in diabetes, smoking

Endstage factors

Increase morbidity and Lower dialysis dase (KW), mortality in kidney failure temporary vascular access, anemia, low serum albumin, late referral

Factors influence acute decline on chronic renal failure

Volume depletion IV radiographic contrast Antimicrobial agent (aminoglycoside,amphotericine B) NSAID (including Cox2) ACE/ARB Cyclosporine and tacrolimus Obstruction of the urinary tract Infection of urinary tract

Interventions that have been proven to be effective

Diabetic Kidney Disease Strict giycemic control ACE inhibitors or angletensinreceptor blockers Strict blood pressure control Yes * I:80-120
II:100-140 HbA1C(%):<7

Non diabetic Kidney disease NA

Kidney disease In the transplant Not tested

Yes

Yes (greater affect in patients with proteinuria) Yes <130/80 mm Hg (greater affect in patients with proteinuria) <125/75 mm Hg (greater affect in patients with proteinuria)

Not tested

Yes < 125/75 mm Hg

Not tested

* Prevents or delays the onset of diabetic kidney discase.

Interventions that have been studied, but the result of which are inconclusive
Dietary protein restriction (0.6 0,8
gr/kgBB/day)

Lipid lowering therapy (LDL<100 mg/dl) Partial correction anemia

Renal Replacement Therapy untuk CKD stage V ?

1. Transplantasi ginjal 2. Hemodialisis (HD) 3. Continuos Ambulatory Peritoneal dialysis (CAPD)

INDIKASI RENAL REPLACEMENT THERAPY CHRONIC KIDNEY DISEASE

Kliren kreatinin <10 ml/menit pada non DM, atau <15 ml/menit apabila sudah terdapat uremia Kliren kreatinin <15 ml/menit apabila nefropati diabetik

Acute renal failure (ARF)

Definisi
Penurunan fungsi ginjal (GFR) secara mendadak (dalam 1-7 hari) dan bertahan > 24 jam.Biasanya disertai penurunan produksi urine.

RIFLE CRITERIA FOR ACUTE RENAL DYSFUNCTION

GFR CRITERIA URINE OUTPUT CRITERIA UO < 0.5 ml/kg/h x 6 hr UO < 0.5 ml/kg/h x 12 hr UO < 0.3 ml/kg/h x 24 hr or Anuria x 12 hrs

Risk

Increased creatinine x1.5 or GFR decrease > 25%

Increased creatinine x2 or GFR decrease > 50% Increased creatinine x3 or GFR decrease > 75%

High Sensitivity

Injury

Failure

Loss ESKD

Persistent ARF**= complete loss of kidney function > 4 weeks

End Stage Kidney Disease (> 3 months)

High Specificity

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& db=PubMed&list_uids=8605788&dopt=Abstract

20-30% 50-60%

15%

Penyebab ARF
Pre renal : volume depletion,inadequate cardiac function, obstruksi arteri renalis Renal : glomerular, tubulointerstitial disesase, obat, toksin Post renal :stones, tumor, strictur, kompresi

Treatment of ARF
Pharmacologic : - Fluid - Vasopressor - Loop diuretic - Avoid nephrotoxic drug - treat infection - Treat complication : overload,acidosis, electrolyte disturbance - Atrial natriuretic - Fenoldopam,Insulin-like GF1,Thyroxine Renal support : - Continuous Renal Replacement Therapy - Intermittent hemodialysis : SLED, SCUF, Daily HD, Alternate-Day HD - Acute Peritoneal Dialysis

Indications for acute dialysis

1. Creatinine clearance < 25 ml/min : a. uremia b. Progressive fluid overload c. uncontrolled hyperkalemia or metabolic acidosis 2. Creatinine clearance <15 ml/min, BUN >100 mg/dl

CVVH Continuous veno-venous hemofiltration

heater

PV

Advantage
BLD SAD

no arterial access blood flow sufficient

V heparin

good elimination of large molecules exact filtration

high-flux

V
PA

Disadvantages
complex machinery

UF

expensive

Percentage of patients in each group achieving urine output >= 2 L/day during study period

60 50 40 30
54/164 94/166 (57%)

P< 0.001

Furosemide Placebo

20 10 0

(33%)