PHARMACEUTICAL CARE IN

RENAL DISEASE
DRA WIDYATI, MCLIN PHARM, APT
TREATMENT OUTCOME

 TREATING REVERSIBLE CAUSES

 SLOWING THE PROGRESSION OF RENAL
DISEASE
 PREVENT & MANAGE COMPLICATIONS
 COMMON PROBLEM
 PROBLEM MEDIK:
 Anemia, kelainan hematologi
 Hipertensi yang tidak terkontrol dg>3 AHT
 Uremia, acidosis
 Hiperuricemia, Hiperkalemia/Hipokalemia
 Gangguan GIT
 DRP:
 Over/low dose, cek apakah perlu penyesuaian
 Adrac
 Pemilihan obat yang kurang tepat
 IMPLIKASI FARMASI
KLINIK
 Estimasi fungsi ginjal: Cockroft-Gault, klirens
kreatinin
 Tinjau perlu-tidaknya penyesuaian dosis.
Sesuaikan dosis khususnya pada Renally
excreted drug/metabolit
 Ketahui metabolisme, aktivitas, DOA, dan
metode ekskresi.
 Pilih obat dg nefrotoksisitas minimal
 Lakukan TDM
 Hindari penggunaan lama
IMPLIKASI FARMASI
KLINIK
 Monitor efektifitas, ADR, toksisitas lebih ketat
 Gangguan GI:awasi peresepan antasid
 Plasma protein binding:awas obat highly protein
bound (ikatan protein>90%)
 Na & air retensi: cek Na-content
 Awasi tekanan darah & efektivitas antihipertensi
 Farmakodinamik: awasi obat yg  CNS
sensitivity
 Dialisis: sesuaikan dosis obat terdialisis
Estimate Renal Function
 Goal: to assess the need of dossage adjustment
 COCKROFT-GAULT
CrCl = 1.23(pria)or 1.04 (wanita) x(140-umur)x BB
Serum creatinine(mol/L)
BB: gunakan IBW kecuali BB<IBW
IBW : Pria 50+2.3/inch (TB>150 cm)
Wanita: 45.5 + 2.3/inch (TB>150 cm)
 Pengukuran CrCl melalui urin tampung 24 jam
CrCl= Uvol x [U Cr]
[Cr*] x t
* kadar pada midpoint pengumpulan urin
Populasi: Critically ill, trauma, post-op
Estimate Renal Function
 Modified Diet in Renal Disease
(MDRD)
 GFR (mL/min/1.73 m 2) = 186 x [Cr] –
1.154 x (Age) – 0.203 x (0.742 if
female) x (1.210 if African – American)
 SCr: serum creatinine in mg/dL; age in
years
Treating Reversible Causes
 Factors responsible for acute decrements in renal
function in CKD: volume depletion, CHF,
nephrotoxic drugs, radiocontrast
 Hypovolemia treatment: repletion, dose of
diuretic,↑ Na intake
 CKD + CHF treatment: Loop diuretic (maintaining
fluid balance)
 Use of Nephrotoxic drug: adjust dose, avoid
 Radiocontrast: use non-ionic contrast,hydration
12 hours before procedure
Slowing the Progression of RD
 Systemic HT
 Generates ↑intraglomerular pressures and
accelerate glomerular sclerosis and RD
Antihypertensive protect both renal &
cardiovascular
 Antihypertensive in non-proteinuric CKD unable to
slow the progression
 Agents: ACE,ARB, diuretic, Diltiazem, Verapamil, β-
blocker
 Dietary Protein intake
 Protein restriction to 0,6g/kg/day in pt not on
dialysis
 Glycemic control
 Strict glycemic control
Treating Complication
HIPERURICEMIA
 Krn kegagalan ginjal mengekskresi as urat.
 Terapi: Allopurinol atau dialisis.
ABNORMALITAS GI (lihat ARF)
Karakterisitik: anoreksia, gastrik/duodenal
ulcer
Penyebab: prod. amonia , siklus internal
amonia-urea
Terapi: Antasid, H2-bloker, sukralfat
DIABETIK NEFROPATI
 Terjadi hampir 1/3 DM
 Tk albuminuria berhubungan dg tk gagal
ginjal
 Faktor resiko perkembangan DN: Kontrol gula
yg buruk, HT, intake protein 
 Treatment: Insulin terapi, ACE inhibitor,
restriksi diet protein.
 Monitor: albuminuria, BP, komplikasi
 MONITORING
 BIOKIMIA:
 Cr, BUN, elektrolit (Na, K, Ca, PO4),
keseimbangan asam-basa, albumin, BSL,
Asam urat.
 Hematologi:
 Hb, platelet, hematokrit, white cell count, profil
koagulasi
 Karakteristik Pasien:
 BP, BB, temp.,KU, kulit.
 Terapi Obat: TDM, dosis, efek, adverse drug
reaction, nefrotoksisitas
 CASE1
 Ny MS, 60 th, BB 55kg
 RP:DM, ESRD (routine on Dialysis)
 RO: Dexacap 3x25mg, Diltiazem 3x30mg,
Glurenorm1-0-0.Neurovit E
1x1tab,Allopurinol2x1tab
 PC: Hyperglikemia, sesak napas, batuk
kering,febris, hypertension ( 200/120mmHg)
 Lab: Leukocyt 18000, Na 128 meq/dl,K 5,6 meq/dL,
BSL 200mg/dl, Urat5,6mg/dl Cr PHD 7,5 mg/dl,
BUN 89 mg/dl
 Dx: CRF + febris,encephalopathy
Case 2
 Ny H, 24th, BB 45kg TB 150cm
 PC: lemah, muntah, sesak napas
 RP: Hipertensi
 RO: Blopress 8mg
 Lab: Cr 14,7mg/dL, BUN 124 mg/dL, SGOT
(N), SGPT (N), Na 115meq/L, K 2,7 meq/L,
BSL 90 mg/dL.
 Dx: CRF, citto HD
 Apa rencana farmasis terhadap kasus ini?
 CASE 3
 Ny MS, 60 th, BB 55kg
 RP:DM, ESRD (routine on Dialysis)
 RO: Dexacap 3x25mg, Diltiazem 3x30mg,
Glurenorm1-0-0.Neurovit E
1x1tab,Allopurinol2x1tab
 PC: Hyperglikemia, sesak napas, batuk
kering,febris, hypertension ( 200/120mmHg)
 Lab: Leukocyt 18000, Na 128 meq/dl,K 5,6 meq/dL,
BSL 200mg/dl, Urat5,6mg/dl Cr PHD 7,5 mg/dl,
BUN 89 mg/dl
 Dx: CRF + febris,encephalopathy