4/8/2020
Overview
Acute Renal Failure (ARF)
Ns. YUNIE ARMIYATI, M.Kep, Sp.KMB
Incidence
• ARF affects approximately 1% of patients on
admission to the hospital, 2% to 5% during the
hospital stay, and 4% to 15% after
cardiopulmonary bypass surgery.
• Acute kidney injury (AKI), yang sebelumnya dikenal dengan gagal
ginjal akut (GGA, acute renal failure [ARF]) merupakan salah satu
sindrom dalam bidang nefrologi yang dalam 15 tahun terakhir
menunjukkan peningkatan insidennya (
• Acute renal failure (ARF) is the rapid breakdown of renal (kidney)
function that occurs when high levels of uremic toxins (waste products
of the body's metabolism) accumulate in the blood.
• ARF occurs when the kidneys are unable to excrete (discharge) the
daily load of toxins in the urine.
• GGA adalah penurunan tiba-tiba faal ginjal pada individu dengan
ginjal sehat sebelumnya, dengan atau tanpa oliguria dan berakibat
azotemia progresif disertai kenaikan ureum dan kreatinin darah (
Parsoedi & Soewito)
Klasifikasi AKI Kriteria RIFLE (2007)
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Based on the amount of urine that is excreted over

AKI Staging a 24-hour period, patients with ARF are separated
into two groups:

1. Oliguric: patients who excrete less than 500 milliliters

per day
2. Nonoliguric: patients who excrete more than 500
milliliters per day
 In nonoliguric patients, the urine is of poor quality (i.e.,
contains little waste) because the blood is not well
filtered, despite the fact that an adequate volume of
urine is excreted.
 Both kidneys are failing when ARF occurs. One
normally functioning kidney can maintain adequate
blood filtering.

Types
The three types of ARF are named for their
location within the renal (kidney) system:
1. Prerenal ARF
2. Postrenal ARF
3. Intrinsic renal ARF

Type AKI Etiologi GGA Pre renal

• Hipovolemik : postpartum hemorragic, luka bakar, diare
berat, panreatitis, pemakaian diuretik berlebih
• Terkumpulnya cairan intravaskular : pada syok septik,
anavilaktif, cedera jaringan
• Penurunan curah jantung : Gagal jantung, MCI,
tamponade jantung, emboli paru
• Peningkatan resistensi pembuluh darah ginjal :
pembedahan, anastesia, sindroma hepatorenal
• Obstruksi pembuluh darah ginjal bilateral : emboli,
trombosis

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Etiologi GGA Intra renal

AKI Pre Renal
(intrinsik)
• Nefrotoksin : Carbon tetraclorida, etilen glikol, metanol
• Logam berat : mercuri biklorida, arsen, timbal, uranium
• Antibiotik : metisilin, aminoglikosida, tetrasiklin, amfoterisin,
sefalosporin, sulfonamida, fenitoin, fenilbutazon
• Media kontras radiografik (khusus pasien DM)
• Pigmen : hemolisis intravaskular akibat tranfusi tidak cocok,
koagulopati intravaskular diseminata, mioglobinuria
• Penyakit glumerovaskular ginjal : Glumerulonefritis, Hipertensi
• Nefritis interstitial akut : infeksi berat, induksi obat

AKI Renal (Intrinsik) Etiologi GGA Post Renal

• Obstruksi muara vesika urinaria : hipertropi
prostat, karsinoma
• Obstruksi ductus collecting : asam urat, sulfa,
protein Bence Jones
• Obstruksi Ureter bilateral : kalkuli, bekuan
darah, tumor, fibrosis retroperitoneal, trauma
pembedahan

AKI Pascarenal Patofisiologi

Empat tahapan
1. Periode awal
 Awal kejadian GGA diakhiri oliguri
2. Periode oliguri
 Terjadi oliguri (jumlah urine < 400 cc/ hari) disertai
peningkatan ureum, kreatinin, asam urat dan Kalium
3. Periode diuresis
 Peningkatan urin bertahap disertai perbaikan glomerolus
 bisa terjadi dehidrasi
4. Periode penyembuhan
 Tanda perbaikan fungsi normal (berlangsung 3-12 bulan)
 nilai laborat kembali normal  penurunan GFR 1-3%

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Signs and Symptoms

• Acute renal failure does not produce a classic set
of symptoms. The most common symptom is
decreased urine output (oliguria), which occurs in
70% of patients.
• Diagnosis: ARF is most easily diagnosed by an
increase in blood levels of creatinin and blood
urea nitrogen (BUN). The blood level of creatinine
typically increases by 0.5 milligrams per tenth of
a liter (mg/dL) every day  Azotemia
• Hiperkalemia
• Metabolic ascidosis
• Anemia

Treatment
There are several modalities of renal replacement
therapy (RRT) for patients with acute renal failure:
• Intermittent hemodialysis
• Continuous hemodialysis (used in critically ill
patients)
• Peritoneal dialysis (rarely used)
• Sign and symptoms treatment  hypercalemi
management, metabolic ascidosis management,
uremia management  farmacology and diit
http://www.nephrologychannel.com/arf/

Prognosis Nursing Assestment (1)

• Before the development of renal replacement therapy (RRT), many
people with ARF died from severe electrolyte imbalance
(hyperkalemia, acidosis) or from the uremic toxins themselves.
• Patients with ARF are at risk for numerous complications that may
lead to death, such as seizures, bleeding, and coma.
• Since dialysis effectively treats the life-threatening complications of
ARF, advanced age and underlying diseases are more likely to
determine the risk for a patient's dying from ARF.
• Oliguric ARF patients continue to have a high mortality rate, despite
the availability of RRT.
• Almost uniformly, these patients have other acute and/or chronic
medical problems.
• Patients with nonoliguric ARF tend to have a more favorable
prognosis and are often easier to treat.
• Riwayat kesehatan dahulu  riwayat penyakit
berhubungan dengan etiologi (pre renal, intra
renal dan post renal)
• Sirkulasi: Hipotensi/hipertensi, disritmia jantung,
nadi lemah/halus, hipotensi orthostatik
(hipovolemia), hipervolemia (nadi kuat), oedema
pucat.
• Respiratory: Nafas pendek, tachipnea, dispnea,
peninggkatan frekuensi dan kedalaman
pernafasan (kussmaul), nafas amonia, batuk
produktif dengan sputum kental merah muda
(edema paru)

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Nursing Assestment (2) Nursing Assestment (3)

• Eliminasi: oliguri (kegagalan dini) atau poliuri (fase akhir), disuria,
ragu-ragu berkemih, dorongan kurang, kemih tidak lampias,
retensi (inflamasi/obstruksi, infeksi), abdomen kembung.
Perubahan warna urine menjadi lebih pekat/gelap, merah, coklat,
berawan, Oliguria (12-21 hari); poliuria (2-6 l/hari)
• Aktifitas dan istirahat: keletihan, kelemahan, malaise, kelemahan
otot, kehilanggan tonus
• Nutrisi, cairan dan metabolik: Peningkatan BB (edema),
penurunan berat badan (dehidrasi), mual, muntah, anoreksia,
nyeri ulu hati, riwayat penggunaan diuretik, perubahan turgor
kulit/kelembaban, edema
• Konsep diri & Persepsi: Kecemasan, ketakutan
• Neurosensorik: Sakit kepala, penglihatan kabur,
kram, gangguan status mental, penurunan
lapang perhatian, ketidakmampuan
berkonsentrasi, kehilangan memori, kacau,
penurunan tingkat kesadaran (azotemia,
ketidakseimbanggan elektrolit/asam/basa).
• Keamanan: Demam (sepsis, dehidrasi), ptechie,
echimosis kulit, pruritus, kulit kering

Nursing Assestment (4) Kelainan Analisis Urine AKI

• Pemeriksaan laboratorium urine: Volume < 400 ml/24 jam,
terjadi 24-48 jam setelah ginjal rusak, keruh, sedimen kecoklatan
menunjukkan adanya darah, Hb, Myoglobin. Porfirin. Berat jenis <
1,020 menunjukkan penyakit ginjal, BJ 1,020 menunjukkan
kerusakan ginjal berat. Osmolalitas kurang dari 350 mOsm/kg
menunjukkan kerusakan ginjal
• Pemeriksaan laboratorium darah: Hb menurun/tetap, SDM
sering menurun, pH kurang dari 7,2 (asidosis metabolik),
BUN/Kreatinin sering meningkat dengan proporsi 10 : 1. Kalium ,
magnesium, fosfat & Natrium meingkat . pH, Kalsium dan
bicarbonat menurun.

Nursing Assestment (5) Nursing Problem

Pemeriksaan diagnostik: • Fluid overload / hipervolumia
• Retrograde Pyelografi menunjukkan abnormalitas pelvis ginjal dan
ureter • Breathing patern dysfuction
• Arteriogram ginjal untuk mengkaji sirkulasi ginjal dan mengidentifikasi
ekstravaskularitas dan massa • Metabolic ascidosis
• Sistouretrogram berkemih : menunjukkan ukuran kandung kemih, • Elektrolit imbalance
refluks, retensi.
• USG Ginjal untuk menentukan ukuan ginjal dan massa kista, obstruksi • Risk for altered nutrition
sal kemih atas.
• MRI : memberikan informasi tentang jaringan lunak • Risk for cardiac perfusion decrease
• EKG : mungkin abnormal menunjukkan ketidakseimbangan elektrolit • Risk for infection
dan asam/basa
• Risk for volume deficit
• Fatigue
• Ansiety

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Nursing Management Tata Laksana Komplikasi

1. Monitoring fluid and electrolit imbalance
2. Reducing metabolic rate  to reduce catabolic rate
that release potassium and accumulation of
endogenous wasting product (urea & creatinine)
 Bed rest
 Prevent fever and infection
3. Promoting pulmonary function  deep breathing and
cough to prevent atelectasis
4. Preventing invection
5. Providing skin care
6. Providing support

Thank You Very Much