Gagal ginjal khronik

Dr Putra Hendra SpPD

UNIBA
Fungsi ginjal
 Function of Kidney

1. Water balance
Osmoreceptor (hypothalamus)
ADH, Vasopressin (Pituitary)

Collecting duct

Absorption of H2O
2. Acid-base balance
Carbonic anhydrase (Distal tubules)

Carbonic acid-bicarbonate buffer system

H+ excretion
Na+ reabsorption
H2O excretion
3. Excretion sisa metabolisme
- Acid - base - H2O
- creatinine
- Metabolites
4. Blood pressure : Renin
5. Hematology - erythropoeitin
 Stadium gagal ginjal
1. Asymptomatic urinary abnormalities:
GFR > 90 ml/min (> 1,5 ml/s)

2 CRF ringan: GFR 60-89 ml/min (1-1,5 ml/s)

3 CRF Sedang: GFR 30-59 ml/min (0,5-1 ml/s)

4 CRF berat: GFR 15-29% (0,25-0,5 ml/s)

5 ESRD: GFR < 15 ml/min (< 0,25 ml/s)

 Terminology
 Chronic Renal Failure
Kerusakan ginjal  belum perlu obat
 End Stage Renal Failure
Kerusakan ginjal  90-95% nephrons tidak berfungsi
perlu dialisi/cangkok ginjal
 Acute Renal Failure
Penurunan mendadak fungsi ginjal minimal 50% GFR↓
50% patients sembuh
 Acute on Chronic Renal Failure
Penurunan akut fungsi ginjal pada CRF, bila diobati dapat
membaik. Seringkali dapat menjadi ESRD.
 Incidence ESRD
Di Amerika
- > 2 juta orang menderita CRF
- > 345000 menderita ESRD
- 60000 meninggal setiap tahun
Etiology of ARF
Perjalanan penyakit gagal ginjal
 DD
ARF CRF ESRD
GFR Cepat Lambat, Permanent no function
Reversible progressive,
irreversible

Urine output Anuria, Polyuria Polyuria or normal

oliguria

Urine analysis Berat jenis>1.020 Berat jenis.: 1.010 1.010

Serum K+ Usually high Usually low Usually low

May be normal May be normal or high May be normal or high

Uremic bone Not present Usually present Always present

disease
DM
 Causes
Aminoglycoside nephrotoxicity IV contrast medium Long term use of NSAIDS
(Gentamycin, Azithromycin)
 Lab Tests
 Ureum ↑ (Normal : 7 to 20 mg/dl )

 Creatinine ↑ (Normal : 0.8 to 1.4 mg/dl)

Creatinine clearance ↓ (Normal :Male: 97

to 137 ml/min. Female: 88 to 128
ml/min)

 Electrolyte ( K+ ↑, Na+ ↓)

 Urinalysis
 CRF: Monitoring Renal Function
 Rumus Cockroft & Gault :
 Cr Cl.= (140- umur) × BB /Cr P

Reliable in steady state

 Clearance of 125 I-isothalamate,

99Tc-DTPA: rapid and accurate
 Penyebab CRF
 Glomerulonephritis 25%
 Diabetes Mellitus 25%
 Hypertension 10%
 Chronic pylonephritis/reflux 10%
 Polycystic kidney disease 10%
 Interstitial nephritis 5%
 Obstruction 3%
 Tidak diketahui 12%

J Winterbottom 2005
 Stadium gagal ginjal
1. Asymptomatic urinary abnormalities:
GFR > 90 ml/min (> 1,5 ml/s)

2 CRF ringan: GFR 60-89 ml/min (1-1,5 ml/s)

3 CRF Sedang: GFR 30-59 ml/min (0,5-1 ml/s)

4 CRF berat: GFR 15-29% (0,25-0,5 ml/s)

5 ESRD: GFR < 15 ml/min (< 0,25 ml/s)

 Complications
 Pericarditis, cardiac tamponade, CHF, HTN, edema
 Platelet dysfunction, anemia
 Renal encephalopathy, dementia, seizures, peripheral
neuropathy
 Hyperparathyroidism, osteoporosis, osteomalacia
 Decreased immune response, increased incidence of
infection
 Hepatitis C, Hepatitis B, liver failure
 Electrolyte imbalances: hyperkalemia, hyponatremia,
hypocalcemia
 Treating ESRD
4 Bentuk pengobatan:
 HAEMODIALYSIS
 PERITONEAL DIALYSIS (CAPD)
 TRANSPLANTATION
 CONSERVATIVE :
 Perbaikikausa
 Diet uremi
 Pembatasan cairan
J Winterbottom 2005
 Dialysis

Peritoneal Hemodialysis

Hemodialysis
 Peritoneal

 Works by using the body's peritoneal

membrane, inside the abdomen, as a
semi-permeable membrane. Solutions that
help remove toxins are infused in, remain
in the abdomen for a certain time period,
and are eventually drained out. This can
be done at home on a continuous basis.
 Indicated in patients with acute renal
failure, require occasional dialysis, or those
who are young and have the capability of
doing this at home.
 Hemodialysis

 Works by circulating the blood, from an

access in the body, through a semi-
permeable filter in the dialysis machine
that helps remove toxins. The cleansed
blood is then returned to the body.
 Typically, most patients undergo
hemodialysis for three sessions every
week. Each session lasts 3-4 hours
 Patients on hemodialysis are always
heparinized to prevent clotting of the AV
access.
 Indicated in chronic tx and obese patients
 Arterio-Venous Connections
(Cimino)
 Permanent access is created by
surgically joining an artery to a
vein. This allows the vein to receive
blood at high pressure, leading to
thickening of the vein's wall. The
"arterialized vein" can sustain
repeated puncture and provides
excellent blood flow rates. The
connection between an artery and a
vein can be made using blood
vessels (an arteriovenous fistula, or
AVF) or a synthetic bridge
(arteriovenous graft, or AVG).
 RRT: Absolute Indications for
Dialysis
 Fluid Overload
 Hyperkalemia  kardiak arrest
 Severe Metabolic Acidosis
 Uremic Pericarditis
 Uremic Enchephalopathy
 Intoxication: Methanol, ethylene glycol
Lithium
 Obat Hyperkalemia

IV insulin and glucose

IV 10% calcium gluconate
Raises threshold for excitation
Sodium bicarbonate
Shift potassium into cells
Correct acidosis
Sodium polystyrene sulfonate
(Kayexalate)