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dr. Heru Prasanto, Bambang Djarwoto
Sub bagian Ginjal Hipertensi, Bag Penyakit Dalam FK UGM / RSUP DR Sardjito, Yogyakarta
ACUTE RENAL FAILURE
• ACUTE renal failure is characterized by a deterioration of renal function over a period of hours to days, resulting in the failure of the kidney to excrete nitrogenous waste products and to maintain fluid and electrolyte homeostasis.
Increase in serum creatinine level X 3. complete loss of kidney function >4 wk • End-stage kidney disease (E) . UO <0. or serum creatinine level > 4 mg/dL.5 mL/kg/h for 6 hours • Injury (I) .The RIFLE classification of ARF is as follows: • Risk (R) .Increase in serum creatinine level X 1.5 or decrease in GFR by 25%. or UO <0.Persistent ARF. decrease in GFR by 75%. or anuria for 12 hours • Loss (L) .0.3 mL/kg/h for 24 hours.5 mL/kg/h for 12 hours • Failure (F) .0 or decrease in GFR by 50%.Increase in serum creatinine level X 2. or UO <0.Loss of kidney function >3 months .
and heart failure are all common causes. diarrhea. • In the outpatient setting.or septic shock. fever. . prerenal azotemia is often due to cardiac failure. • Elderly patients are particularly susceptible to prerenal azotemia because of their predisposition to hypovolemia and high prevalence of renal-artery atherosclerotic disease. poor . liver dysfunction.Prerenal • Prerenal azotemia is rapidly reversible if the underlying cause is corrected. • Among hospitalized patients. use of diuretics.uid intake. vomiting.
hypovolemia. – Loss of water and electrolyte : acute gastroenteritis – Hypoalbuminemia – Heart failure: myocard infarct. – Neonatus septic shock or severe asphyxia . – Loss of plasma : combustio. hypotension and hypoperfusion kidney: – Severe blood loss: trauma.Etiology pre renal ARF. peritonitis. bleeding.
or retroperitoneal disorders and often presents in the outpatient setting.Post renal Causes • Acute renal failure occurs when both urinary outfow tracts are obstructed or when one tract is obstructed in a patient with a single functional kidney. such as bilateral renal calculi . • Obstruction is most commonly due to prostatic hypertrophy. • A neurogenic bladder can result in functional obstruction. cancer of the prostate or cervix. postrenal causes of acute failure can be intraluminal. • Other. less frequent.
ARF Post renal Obstruction cause by: – Congenital : valvula uretrovesical – Urolithiasis – Trombosis arteri/vena renalis – Tumor (prostate. pelvis) .
vessels.• • • • • Intrinsic Causes Intrinsic renal diseases that result in acute renal failure are categorized according to the primary site of injury: tubules. ischemic tubular necrosis represent when blood flow is suffciently the death of tubular cells. most cases are reversible if the underlying cause is corrected (Aminoglycoside antibiotics and radiocontrast agents. or glomerulus. snake bites . interstitium. chemotherapeutic agents / cisplatin) irreversible cortical necrosis can occur if the ischemia is severe. Injury to the tubules is most often ischemic or toxic in origin. especially if the disease process includes microvascular coagulation such as may occur with obstetrical complications.
intrinsic damage of tubule epithellial: acute tubular necrosis (ATN) • Iskemic type: prolong ARF • Nephrotoxic type: trombosis. hipertensi damage of glomerulus • Acute Glomerulonefritis • Hemolitic uremic syndrome Vascular disease: hypertension. thrombosis .
Conditions That Lead to Ischemic Acute Renal Failure. .
• Although studies that evaluated early and intensive dialysis suggested that such an approach improved survival and led to a more rapid recovery .ARF Therapy • There is no consensus among nephrologists as to when to begin dialysis or how frequently to perform dialysis.
Chronic kidney disease (CKD) • is a progressive loss of renal function over a period of months or years • Five stages Each stage is a progression through an abnormally low and deteriorating glomerular filtration rate. which is usually determined indirectly by the creatinine level in blood serum .
Signs and symptoms • can be detected as an increase in serum creatinine or protein in the urine. azotemia / uremia (symptoms ranging from lethargy to pericarditis and encephalopathy) • • • • Potassium accumulates in the blood hyperkalemia Erythropoietin synthesis is decreased anemia Fluid volume overload pulmonary edema Metabolic acidosis. decreased bicarbonate by the kidney . As the kidney function decreases: • Blood pressure is increased due to fluid overload and production of vasoactive hormones leading to hypertension and congestive heart failure • Urea accumulates.
• or permanent renal replacement therapy (RRT) .73 m2) Stage 5 CKD • Established kidney failure (GFR <15 mL/min/1.73 m2) Stage 4 CKD • Severe reduction in GFR (15-29 mL/min/1.73 m2). • Kidney damage is defined as pathologic abnormalities or markers of damage.73 m2.Stage 1 CKD • Slightly diminished function.73 m2) with kidney damage. including abnormalities in blood or urine test or imaging studies Stage 2 CKD • Mild reduction in GFR (60-89 mL/min/1. Kidney damage with normal or increased GFR (>90 mL/min/1. Stage 3 CKD • Moderate reduction in GFR (30-59 mL/min/1.
slowing progression.73m3) Action 1 Kidney damage with normal or GFR 90 Diagnosis & Treatment.Stages of Chronic Kidney Disease: A Clinical Action Plan Stage Description GFR (mL/min/1. Treat comorbid condition. CVD risk reduction Estimating Progression Evaluating & Treating complications Preparation for kidney replacement therapy Replacement (if uremia present) 2 3 4 5 Kidney damage with mild GFR Moderate GFR Severe GFR Kidney failure 60 – 89 30 – 59 15 – 29 < 15 or dialiysis .
• Control of blood pressure and treatment of the original disease. as they have been found to slow the progression of CKD to stage 5. are the broad principles of management. angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) are used.Treatment • The goal of therapy is to slow down or halt the otherwise relentless progression of CKD to stage 5. whenever feasible. . • Generally.
. a patient requires a form of renal replacement therapy to survive a renal transplant or dialysis. • A renal transplant is the surgical placement of a kidney from a kidney donor into a patient with kidney failure. and about 90% of renal function is lost.Renal Replacement Therapy • When renal failure is severe.
High-risk factor in transplantation • Age • Unfavorable psychological profile • Unfavorable medical status – – – – – – – – Pulmonary factors (smoking) Recurrent primary renal disease Diabetes Cardiovascular factors (unstable angina) Severe hypertension Neoplasia Chronic infection(s) Obesity .
• Dialysis hemodilysis peritoneal dialysis • is a process that cleans and filters the blood. removing harmful wastes and excess salt and fluids by passing blood across a semipermeable membrane. . including potassium. • Wastes from the blood diffuse across the membrane into a cleansing solution (dialysate) and bicarbonate diffuses into the blood to neutralize excess acid. and chloride. • Dialysis can control blood pressure and help maintain a balance of electrolytes. sodium.
Gambar skematis dializer Arah aliran darah Inlet darah (merah) Outlet darah (biru) Arah aliran dialisat Outlet cairan dialisat Inlet cairan dialisat .
Anatomy of a Hemofilter blood in dialysate out Cross Section hollow fiber membrane dialysate in Outside the Fiber (effluent) Inside the Fiber (blood) blood out 23 .
• Patients can read. sleep. or watch television during treatment. • Hemodialysis is usually performed 3 times weekly.Hemodialysis • can be performed at a dialysis center • hemodialysis treatment is provided by trained nurses and technicians. . write. talk. with each treatment lasting 2 to 4 hours.
wastes. to remove excess water. • No machine is necessary. • After 4 to 6 hours. The solution is usually changed 4 times a day. • Fluid. the lining of the abdomen. • A dialysate passes through the abdomen via a surgically placed catheter. and chemicals from the body. and chemicals pass from capillaries in the peritoneal membrane into the dialysate. . wastes.Peritoneal dialysis • uses the peritoneal membrane. the solution is drained back into the bag and replaced with fresh solution.
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