Anatomi dan fungsi saluran kemih

Urinary system function

• Regulating blood volume and blood pressure
• Regulating plasma concentration of Na, K, Cl,
other ion
• Helping to stabilize blood pH
• Conserving valuable nutrients
• Assisting the liver in detoxifying poison
Anatomi ginjal
Nefron
Ringkasan Struktur dan Fungsi Ginjal
Regulasi asam basa pada tubulus ginjal
Renin angiotensin aldosteron system
 Definition
An abrupt decrease ? How much?
• Acute kidney injury (AKI) is characterized
• Regulate fluid
clinically by an abrupt decrease in renalMarker?
• Regulate electrolyte
in renal function • Regulate acid-base Scr?
function over a period of hours to days,
• Nitrogen balance GFR?
overresulting inhours
a period of the accumulation
to days of nitrogenous
waste products (azotemia) andHow thelong?inability to
maintain and regulate fluid, electrolyte, and
Classification
acid–base balance.
RIFFLE & AKIN
Klasifikasi RIFLE

Bellomo et al, 2004

Klasifikasi AKIN

Mehta et al, 2007

Bellomo et al, 2004
Bellomo et al, 2004
 Risk Factor
• Older age
• Higher baseline serum creatinine (SCr)
• Chronic Kidney Disease (CKD)
• Diabetes
• Chronic Respiratory Ilness
• Underlying Cardiovascular Disease
• Prior Heart Surgery
• Dehydration resulting in Oliguria
• Acute Infection
• Exposure to nephrotoxins
 Conceptual model for development and clinical course of acute kidney injury.

Himmelfarb J et al. CJASN 2008;3:962-967

©2008 by American Society of Nephrology

Pre-Renal
Intra Renal
Post-Renal
Drug Induced
Marker
PENATALAKSANAAN
AKI
Hemodynamic Management

Rekomendasi Kelas

In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather 2b

than colloids (albumin or starches) as initial management for expansion of
intravascular volume in patients at risk for AKI or with AKI

We recommend the use of vasopressors in conjunction with fluids in patients with 1C

vasomotor shock with, or at risk for, AKI

We suggest using protocol-based management of hemodynamic and oxygenation 2C

parameters to prevent development or worsening of AKI in high-risk patients in the
perioperative setting or in patients with septic shock
Glycemic control and nutritional support

Rekomendasi Kelas

In critically ill patients, we suggest insulin therapy targeting plasma glucose 110–149 mg/dl (6.1– 2C
8.3 mmol/l)

We suggest achieving a total energy intake of 20–30 kcal/kg/d in patients with any stage of AKI 2C

We suggest to avoid restriction of protein intake with the aim of preventing or delaying initiation of 2D
RRT

We suggest administering 0.8–1.0 g/kg/d of protein in noncatabolic AKI patients without need for 2D
dialysis (2D), 1.0–1.5 g/kg/d in patients with AKI on RRT (2D), and up to a maximum of 1.7 g/kg/d
in patients on continuous renal replacement therapy (CRRT) and in hypercatabolic patients

We suggest providing nutrition preferentially via the enteral route in patients with AKI 2C
The use of diuretics in AKI

Rekomendasi Kelas

We recommend not using diuretics to prevent AKI 1b

We recommend not using diuretics to prevent AKI 2C

We suggest using protocol-based management of hemodynamic and oxygenation parameters to 2C

prevent development or worsening of AKI in high-risk patients in the perioperative setting or in
patients with septic shock

Vasodilator therapy: dopamine, fenoldopam, and natriuretic peptides

Rekomendasi Kelas

We recommend not using low-dose dopamine to prevent or treat AKI 1A

We suggest not using fenoldopam to prevent or treat AKI 2C

We suggest not using atrial natriuretic peptide (ANP) to prevent (2C) or treat (2B) AKI
 TERAPI FARMAKOLOGI
• Loop Diuretik

Menurunkan konsumsi oksigen pada loop of henle dengan menginhibisi

transport sodium, sehingga dapat mengurangi kerusakan akibat iskemia.

• Dopamin

Menstimulasi dopamin-1 reseptor, menyebabkan vasodilatasi vaskular

renal dan meningkatkan aliran darah renal.
• Fenoldopam
selektif dopamin-1 reseptor agonis yang menyebabkan
vasodilatasi di renal vaskular
 Loop Diuretics Furosemide, Bumetanide, Torsemide

Inhibition of the Na/K/2Cl transporter in the ascending limb of

Henle's loop
Furosemide
• Oral : 20, 40, 80 mg tablet; 8, 10 mg/mL oral solutions
• Parenteral : 10 mg/mL untuk injeksi IM atau IV

Bumetanide
• Oral : 0.5, 1, 2 mg tablet
• Parenteral : 0.5 mg/2 mL ampul untuk injeksi IV atau IM

Torsemide
• Oral : 5, 10, 20, 100 mg tablet
• Parenteral : 10 mg/mL untuk injeksi
 Thiazides
Hydrochlorothiazide

Inhibition of the Na/Cl transporter in the distal convoluted

tubule
Hydrochlorothiazide
• Oral : 12.5 mg kapsul;
25, 50, 100 mg tablet;
10, 100 mg/mL larutan

Metolazone: populer digunakan bersama dengan golongan

loop untuk efek sinergis
 Osmotics Diuretics
Mannitol
Physical osmotic effect on tissue water distribution because
it is retained in the vascular compartment

Mannitol
• Parenteral : 5, 10, 15, 20% larutan untuk injeksi
Efek samping : mual, muntah, sakit kepala
Growth factor intervention

Rekomendasi Kelas

We recommend not using recombinant human (rh)IGF-1 to prevent or treat AKI 1B

Adenosine receptor antagonists

Rekomendasi Kelas

We suggest that a single dose of theophylline may be given in neonates with severe perinatal 2b
asphyxia, who are at high risk of AKI
Prevention of aminoglycoside- and amphotericin-related AKI

Rekomendasi Kelas

We suggest not using aminoglycosides for the treatment of infections unless no suitable, less 2A
nephrotoxic, therapeutic alternatives are available

We suggest that, in patients with normal kidney function in steady state, aminoglycosides are 2B
administered as a single dose daily rather than multiple-dose daily treatment regimens.

We recommend monitoring aminoglycoside drug levels when treatment with multiple daily dosing 1A
is used for more than 24 hours
We suggest monitoring aminoglycoside drug levels when treatment with single-daily dosing is used 2C
for more than 48 hours

We suggest using topical or local applications of aminoglycosides (e.g., respiratory aerosols, instilled 2B
antibiotic beads), rather than i.v. application, when feasible and suitable

We suggest using lipid formulations of amphotericin B rather than conventional formulations of 2A

amphotericin B

We suggest using lipid formulations of amphotericin B rather than conventional formulations of 1A

amphotericin B
 INDIKASI AKUT HEMODIALISIS
• Pasien dengan severe acid base disorder
• Kelebihan cairan
• Hyperkalemia
• Symptomatic uremia
• Intoksikasi obat
Prinsip Penyesuaian Dosis
 Penyesuaian dosis berdasarkan klirens obat

• Pada pasien dengan gangguan ginjal, klirens tubuh

total akan berubah.

• Untuk mempertahankan konsentrasi obat dalam

plasma tunak rata-rata sama seperti yang diinginkan,
dosis atau interval pendosisan harus dirubah
 Penyesuaian dosis berdasarkan perubahan tetapan laju
eliminasi

• Tetapan laju eliminasi beberapa obat menurun pada pasien

dengan gangguan ginjal.

• Dapat dirancang dengan mengurangi dosis obat normal dan

menjaga frekuensi pendosisan atau dengan mengurangi
frekuensi pendosisan dan menjaga dosis tetap.
Chronic Kidney Disease
 Definition of CKD (KDIGO)
Table 2 | Criteria for CKD (either of the following present for >3 months)

Markers of kidney damage (one or more)
Albuminuria (AERZ30 mg/24 hours; ACRZ30 mg/g
[Z3 mg/mmol])
Urine sediment abnormalities
Electrolyte and other abnormalities due to tubular
disorders
Abnormalities detected by histology
Structural abnormalities detected by imaging
History of kidney transplantation

Decreased GFR GFR < 60 ml/min/1.73 m2

K/DOQI
 Simptom dan Gejala
Simptom :
Udem
Nafas Pendek
Palpitasi
Disfungsi Sexual
Tanda :
Cardiovascular-pulmonary
Gastrointestinal
Endocrine
Hematologic
Fluid/electrolytes
Risk Factor
 Gagal ginjal kronik
Tes laboratorium Hasil normal

Kreatinin clearance 90-130 ml/min

Hemoglobin Pria : 14-18 g/dl

Wanita : 12-16 g/dl

Iron stores Pria : 80-180 mcg/dl

Wanita : 60-160 mcg/dl

Albumin 3,3-4,8 g/dl

Ca 8-10,5 mg/dl

HDL <40 mg/d

 Gagal ginjal kronik
Tes laboratorium Hasil normal

Serum kreatinin 0,6 – 1,2 mg/dl

BUN 8 -20 mg/dl

K 3,5 – 5,0 mmol/l

LDL 70-160 mg/dl

TG >150 mg/dl

Tekanan darah <80 dan <120 mmHg

Gula darah tak terkontrol

 Berdasarkan Nilai GFR
– Rumus Cockrof-Gault

GFR = (140-umur) x BB (Kg)

72 x kreatinin serum (mg/dl)
Wanita = 0,85 x pria
– MDRD

GFR (mL/min./1.73m2) = 186 X (SCr)-1.154 X (Age)-0.203 X (0.742 if female) X

(1.210 if African-American)
 COCKROFT-GAULT

CrCl = 1.23(pria) atau 1.04 (wanita) x(140-umur)x BB

Serum creatinine(mol/L)

BB: gunakan IBW kecuali BB<IBW

IBW (male) = 0.9 H - 88
IBW (fem) = 0.9 H - 92
H = height in centimeters.
Cardiorenal Pathophysiology
 Anemia
• Suplemen Fe
– CKD defisiensi Fe Mekanisme kerja : membantu menghasilkan hemoglobin dan
meningkatkan transportasi O2 ke jaringan
– Efek samping : (oral) konstipasi, mual,abdominal cramping
– (IV)hipotensi, alergi, dizziness, dyspnea,pusing, nyeri tulang belakang.
• Eritropoitin
– Mekanisme kerja : merangsang diferensiasi sel-sel progenitor eritroid dan
menginduksi pelepasan retikulosid dari sumsum tulang menjadi eritrosit
– Efek samping : hipertensi
– Dosis : Sc atau iv 50-100 unit/kgBB 3x/minggu
 Hiperfosfat
(Calsium carbonat, calsium asetat)
• Mekanisme kerja : mengikat fosfat dalam
makanan di saluran pencernaan kemudiaan di
ekskresikan lewat feses
• Efek samping : diare, kram abdomen
• Dosis: 0,5-1 g (elemental kalsium) 3 X 1 saat
makan
 Vitamin D
• Berfungsi menekan sekresi PTH (paratiroid hormon)
dengan merangsang penyerapan serum kalsium oleh
sel intestinal dan secara langsung merangsang aktivitas
kelenjar paratiroid untuk menurunkan sintesis PTH.
• Efek samping : hiperkalsemi
• Sediaan : calcitriol 0,25 mcg
doxercalciferol 1 mcg
paricalcitol 1 mcg
 Asidosis Metabolik
Na- Bikarbonat
• Mekanisme kerja : meningkatkan pH darah
• Dosis : 2-5 mEq/kg I.V. infusion over 4-8 hours.
• Kontraindikasi : Alkalosis, hypernatremia,
severe pulmonary edema, hypocalcemia, nyeri
abdomen.
 Dislipidemi
Statin
Mekanisme kerja : menurunkan
kolesterol total dengan cara
menghambat pembentukan mevalonat
dengan menghambat enzim HMG coA
reduktase
Dosis simvastatin : 10 mg 1x sehari.

Fibrat
Mekanisme kerja : menurunkan sintesis
TG di hati dan menurunkan TG di VLDL.
Dosis : 600 mg 2 x sehari
Terapi Hemodialisis
Algoritme Terapi HT pada CKD
 Antihipertensi
ACE inhibitor
• (Captopril, Enalapril, Lisinopril,
ramipril)
• Mekanisme kerja:
menghambat perubahan
angiotensin I menjadi
angiotensin II, menurunkan
tekanan intraglomerular
• Dosis : captopril 25 -150 mg 2-
3 kali/hari
ARB
• (Irbesartan, losartan )
• Mekanisme kerja:
menghambat reseptor
angiotensin II, menurunkan
tekanan intraglomerular
• Dosis : irbesartan 150-300 mg
/ hari