anatomi dan fisiologi perkemihan.ppt

7/24/2019 Anatomi dan fisiologi perkemihan.ppt

1/89

Anatomy and Physiology of UrinaryAnatomy and Physiology of Urinary

SystemSystem

WIDODOWIDODO

BAGIAN ANESTESIOLOGI,BAGIAN ANESTESIOLOGI,

PERAWATAN INTENSIF, DANPERAWATAN INTENSIF, DAN

PENANGANAN NYERIPENANGANAN NYERIRSUP WAHIDINRSUP WAHIDIN

SUDIROHUSODOSUDIROHUSODO

MAKASSARMAKASSAR


2/89

IntroductionIntroduction

Organ system that produces, stores, and carriesurineHumans produce about 1.5 liters of urine over 24hours, although this amount may vary according to

the circumstances.Increased fluid intake generally increases urineproduction.Increased perspiration and respiration maydecrease the amount of fluid ecreted through thekidneys.!ome medications interfere directly or indirectly"ith urine production, such as diuretics.
http://en.wikipedia.org/wiki/Organ_systemhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Literhttp://en.wikipedia.org/wiki/Perspirationhttp://en.wikipedia.org/wiki/Respiration_(physiology)http://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Diuretichttp://en.wikipedia.org/wiki/Diuretichttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Respiration_(physiology)http://en.wikipedia.org/wiki/Perspirationhttp://en.wikipedia.org/wiki/Literhttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Organ_system


3/89

KidneysKidneys

UretersUretersBladderBladder

UrethraUrethra

Components of systemComponents of system


4/89

Kidney Location and ExternalKidney Location and External

AnatomyAnatomy


5/89

unctions of the Kidney!unctions of the Kidney!

"aintaining #alance"aintaining #alance

$egulation of #ody %uid &olume and$egulation of #ody %uid &olume andosmolalityosmolality

$egulation of electrolyte #alance$egulation of electrolyte #alance

$egulation of acid'#ase #alance$egulation of acid'#ase #alance Excretion of (aste products )urea* ammonia*Excretion of (aste products )urea* ammonia*

drugs* toxins+drugs* toxins+ Production and secretion of hormonesProduction and secretion of hormones

$egulation of #lood pressure$egulation of #lood pressure


6/89

A. Renal Vein

B. Renal Artery

C. Ureter

D. Medulla

E. Renal Pelvis

F. Cortex

1. Ascending loop o !enle

". Descending loop o !enle

#. Peritu$ular capillaries

%. Proxi&al tu$ule

'. (lo&erulus

). Distal tu$ule

*+e ,idney and t+e -ep+ron


7/89

,he -ephron,he -ephron

unctional unit of the .idney )/*000*000+unctional unit of the .idney )/*000*000+

$esponsi#le for urine formation!$esponsi#le for urine formation!

iltrationiltration

SecretionSecretion

$ea#sorption$ea#sorption


8/89

(lo&erulus

Aerent and Eerent

arteriolesProxi&al *u$ule

/oop o !enle

Distal *u$ule

Collecting Duct

Co&ponents o t+e

nep+ron


9/89

Fro& +ttp0222.e&c.&aricopa.eduacultyara$eeB34B,BioBoo5E6CRE*.+t&l

4vervie2 o nep+ron unction

Fil i


10/89

Filtration


11/89

*!E (/4MERU/U7


12/89

Co&ponents o plas&a cross t+e t+ree layers o t+e glo&erular $arrier

during iltration

Capillary endot+eliu&

Base&ent &e&$rane 8net negative c+arge9

Epit+eliu& o Bo2&an:s Capsule 8Podocytes ;iltration slits allo2 si5D9

*+e a$ility o a &olecule to cross t+e &e&$rane depends on si


13/89

1lomerular iltration $ate1lomerular iltration $ate

)1$+)1$+

"easure of functional capacity of the"easure of functional capacity of the

.idney.idney

2ependent on di3erence in pressures2ependent on di3erence in pressures#et(een capillaries and Bo(man4s#et(een capillaries and Bo(man4s

spacespace

-ormal 5 /60 ml7min 5896 L7h5/:0-ormal 5 /60 ml7min 5896 L7h5/:0L7day;; )


14/89

,he $esponse to a $eduction in the 1$,he $esponse to a $eduction in the 1$

R $ ti


15/89

Rea$sorption

and secretion


16/89


Acti&e ,ransport re?uires A,PActi&e ,ransport re?uires A,P

-a@* K@ A,P pumps-a@* K@ A,P pumps

Passi&e ,ransport'Passi&e ,ransport'

-a@ symporters )glucose* a9a9*-a@ symporters )glucose* a9a9*

etc+etc+

-a@ antiporters )@+-a@ antiporters )@+

Ion channelsIon channels smosissmosis


17/89

actors in%uencingactors in%uencing


SaturationSaturation:: ,ransporters can get,ransporters can get saturatedsaturated#y high concentrations of a su#stance '#y high concentrations of a su#stance '

failure to resor# all of it results in its loss infailure to resor# all of it results in its loss in

the urine )eg* renal threshold for glucose isthe urine )eg* renal threshold for glucose isa#out /:0mg7dl+9a#out /:0mg7dl+9

Rate of owRate of owof the >ltrate! a3ects the timeof the >ltrate! a3ects the time

a&aila#le for the transporters to rea#sor#a&aila#le for the transporters to rea#sor#

molecules9molecules9


18/89

hat is $ea#sor#ed hereDhat is $ea#sor#ed hereD

Proximal tubule@ rea$sor$s )' o iltered Na+as 2ell as Cl-,Ca2+, PO4, HCO3-.'@> o H20. (lucose? car$o+ydrates? aminoacids, andsmall proteinsare also rea$sor$ed +ere.

Loop of Henle@ rea$sor$s "' o iltered Na+.

Distal tubule@ rea$sor$s o iltered Na+.Rea$sor$s HCO3-.

Collecting duct@ rea$sor$s t+e re&aining " o Na+only i t+e

+or&one aldosteroneis present. H20depending on +or&oneAD!.


19/89


20/89

SecretionSecretion

Proximal tubuleProximal tubule uric acid* #ile salts* uric acid* #ile salts*

meta#olites* some drugs* somemeta#olites* some drugs* some

creatininecreatinine

Distal tubuleDistal tubule "ost acti&e secretion "ost acti&e secretionta.es place here includingta.es place here including orga!"orga!"

a"!ds, K#, H#, drugs, Ta$$%a"!ds, K#, H#, drugs, Ta$$%

Hors&a'' (rote! )$a! "o$(oetHors&a'' (rote! )$a! "o$(oeto& *+a'!e "asts-o& *+a'!e "asts-


21/89

Countercurrent exchangeCountercurrent exchange

,he structure and transportproperties of the 'oo( o&He'ein the nephron createthe .outer"urret

$u't!('!ere/e"t9 A su#stance to #e exchanged

mo&es across a permea#le#arrier in the direction fromgreater to lesserconcentration9

3&age ro& +ttp0en.2i5ipedia.org2i5iCountercurrentGexc+ange


22/89

Loop of enleLoop of enle

1oal5 ma.e isotonic >ltrate1oal5 ma.e isotonic >ltrate

into hypertonic urine )don4tinto hypertonic urine )don4t

(aste (aste 660;;+0;;+

Counter'current multiplier!Counter'current multiplier!

2escending loop is permea#le to2escending loop is permea#le to-a@* Cl'* -a@* Cl'* 6600

Ascending loop is impermea#le toAscending loop is impermea#le to

660' acti&e -aCl transport0' acti&e -aCl transport

Creates concentration gradient inCreates concentration gradient in

interstitiuminterstitium

Urine actually lea&es hypotonicUrine actually lea&es hypotonic

#ut C2 ta.es ad& in ma.ing#ut C2 ta.es ad& in ma.ing

hypertonichypertonic

d d # h


23/89

ormones Produced #y theormones Produced #y the

KidneyKidney

$enin!$enin! $eleased from uxtaglomerular apparatus (hen lo( #lood$eleased from uxtaglomerular apparatus (hen lo( #lood

%o( or lo( -a@9 $enin leads to production of angiotensin II*%o( or lo( -a@9 $enin leads to production of angiotensin II*

(hich in turn ultimately leads to retention of salt and (ater9(hich in turn ultimately leads to retention of salt and (ater9

Erythropoietin!Erythropoietin! Stimulates red #lood cell de&elopment in #one marro(9 illStimulates red #lood cell de&elopment in #one marro(9 ill

increase (hen #lood oxygen lo( and anemia )lo(increase (hen #lood oxygen lo( and anemia )lo(hemoglo#in+9hemoglo#in+9

Fitamin 2G!Fitamin 2G!

EnHyme con&erts Fit 2 to acti&e form /*6)+EnHyme con&erts Fit 2 to acti&e form /*6)+66Fit29Fit29In&ol&ed in calcium homeostasis9In&ol&ed in calcium homeostasis9

Renin Angiotensin Aldosterone0


24/89

Renin? Angiotensin? Aldosterone0

Regulation o 7altHater Balance


25/89

AldosteroneAldosterone

Secreted #y the adrenal glands inSecreted #y the adrenal glands inresponse to angiotensin II or highresponse to angiotensin II or highpotassiumpotassium

Acts in distal nephron to increaseActs in distal nephron to increaseresorption of -a@ and Cl' and theresorption of -a@ and Cl' and thesecretion of K@ and @secretion of K@ and @

-aCl resorption causes passi&e-aCl resorption causes passi&e

retention of retention of 66


26/89

Anti'2iuretic ormone )A2+Anti'2iuretic ormone )A2+

smoreceptors in the #rain )hypothalamus+smoreceptors in the #rain )hypothalamus+

sense -a@ concentration of #lood9sense -a@ concentration of #lood9

igh -a@ )#lood is highly concentrated+igh -a@ )#lood is highly concentrated+

stimulates posterior pituitary to secrete A29stimulates posterior pituitary to secrete A29

A2 upregulates (ater channels on theA2 upregulates (ater channels on the

collecting ducts of the nephrons in the .idneys9collecting ducts of the nephrons in the .idneys9

,his leads to increased (ater resorption and,his leads to increased (ater resorption and

decrease in -a concentration #y dilutiondecrease in -a concentration #y dilution


27/89

UretersUreters

Slender tu#es that con&ey urine fromSlender tu#es that con&ey urine from

the .idneys to the #ladderthe .idneys to the #ladder

Ureters enter the #ase of the #ladderUreters enter the #ase of the #ladder

through the posterior (allthrough the posterior (all,his closes their distal ends as #ladder,his closes their distal ends as #ladder

pressure increases and pre&ents #ac.%o(pressure increases and pre&ents #ac.%o(

of urine into the uretersof urine into the ureters


28/89

UretersUreters

Ureters ha&e a trilayered (allUreters ha&e a trilayered (all

,ransitional epithelial mucosa,ransitional epithelial mucosa

Smooth muscle muscularisSmooth muscle muscularis

i#rous connecti&e tissue ad&entitiai#rous connecti&e tissue ad&entitia

Ureters acti&ely propel urine to theUreters acti&ely propel urine to the

#ladder &ia response to smooth muscle#ladder &ia response to smooth muscle

stretchstretch


29/89

C+apter "'0 Urinary 7yste& "

Urinary BladderUrinary Bladder

Smooth* collapsi#le* muscular sac thatSmooth* collapsi#le* muscular sac thattemporarily stores urinetemporarily stores urine

It lies retroperitoneally on the pel&ic %oorIt lies retroperitoneally on the pel&ic %oor

posterior to the pu#ic symphysisposterior to the pu#ic symphysis "ales prostate gland surrounds the nec."ales prostate gland surrounds the nec.inferiorlyinferiorly

emales anterior to the &agina and uterusemales anterior to the &agina and uterus,rigone triangular area outlined #y the,rigone triangular area outlined #y the

openings for the ureters and the urethraopenings for the ureters and the urethra Clinically important #ecause infections tendClinically important #ecause infections tend

to persist in this regionto persist in this region


30/89

C+apter "'0 Urinary 7yste& #>


,he #ladder (all has three layers,he #ladder (all has three layers

,ransitional epithelial mucosa,ransitional epithelial mucosa

A thic. muscular layerA thic. muscular layer

A >#rous ad&entitiaA >#rous ad&entitia,he #ladder is distensi#le and collapses,he #ladder is distensi#le and collapses

(hen empty(hen empty

As urine accumulates* the #ladderAs urine accumulates* the #ladderexpands (ithout signi>cant rise inexpands (ithout signi>cant rise in

internal pressureinternal pressure


31/89

C+apter "'0 Urinary 7yste& #1


Figure "'.1


32/89

UrethraUrethra

"uscular tu#e that!"uscular tu#e that!

2rains urine from the #ladder2rains urine from the #ladder

Con&eys it out of the #odyCon&eys it out of the #ody


33/89

UrethraUrethra

Sphincters .eep the urethra closedSphincters .eep the urethra closed(hen urine is not #eing passed(hen urine is not #eing passed Internal urethral sphincter in&oluntaryInternal urethral sphincter in&oluntary

sphincter at the #ladder'urethra unctionsphincter at the #ladder'urethra unction External urethral sphincter &oluntaryExternal urethral sphincter &oluntary

sphincter surrounding the urethra as itsphincter surrounding the urethra as itpasses through the urogenital diaphragmpasses through the urogenital diaphragm

Le&ator ani muscle &oluntary urethralLe&ator ani muscle &oluntary urethralsphinctersphincter


34/89

C+apter "'0 Urinary 7yste& #%

UrethraUrethra

,he female urethra is tightly #ound to the,he female urethra is tightly #ound to theanterior &aginal (allanterior &aginal (all

Its external opening lies anterior to theIts external opening lies anterior to the

&aginal opening and posterior to the clitoris&aginal opening and posterior to the clitoris

,he male urethra has three named regions,he male urethra has three named regions Prostatic urethra runs (ithin the prostate glandProstatic urethra runs (ithin the prostate gland

"em#ranous urethra runs through the"em#ranous urethra runs through theurogenital diaphragmurogenital diaphragm

Spongy )penile+ urethra passes through theSpongy )penile+ urethra passes through thepenis and opens &ia the external urethral ori>cepenis and opens &ia the external urethral ori>ce


35/89

C+apter "'0 Urinary 7yste& #'

UrethraUrethra

Figure "'.1

"icturition )Foiding or"icturition )Foiding or


36/89

"icturition )Foiding or"icturition )Foiding or

Urination+Urination+

,he act of emptying the #ladder,he act of emptying the #ladder 2istension of #ladder (alls initiates spinal2istension of #ladder (alls initiates spinal

re%exes that!re%exes that!

Stimulate contraction of the external urethralStimulate contraction of the external urethral

sphinctersphincter Inhi#it the detrusor muscle and internalInhi#it the detrusor muscle and internal

sphincter )temporarily+sphincter )temporarily+

Foiding re%exes!Foiding re%exes!

Stimulate the detrusor muscle to contractStimulate the detrusor muscle to contract Inhi#it the internal and external sphinctersInhi#it the internal and external sphincters

Chemical Composition ofChemical Composition of


37/89

Chemical Composition ofChemical Composition of

UrineUrine

Urine is


38/89

A.UTE KIDNEY IN0URY

WIDODO

RSUP WAHIDINsUDIROHUSODO

MAKASSAR

PendahuluanPendahuluan


39/89

PendahuluanPendahuluan

Salah satu kondisi yang paling sering terjadpada kasus-kasus trauma dan penyakit kritis

Gagal ginjal akut

(ARF)

7iste& scoring 5epara+an penya5it seperti

APAC!E 333dan 74FA? &e&$eri $o$ot yg cu5up $esar ter+adap disungsiginIal

Pendahuluan


40/89

Pendahuluan

D!s&ugs!

G!1a'

# Berat# "emerlu.an $$,# $ingan Peru#ahan .ecil nilai

.reatinin atau produ.si urin

"empengaruhi mor#iditasdan mortalitas pasien

A$ paling seringteradi ICU dan sering

merupa.an #agiandari disfungsi organ

lainnya

Pendahuluan


41/89

PendahuluanJaringan Kola#orasi #er#agai .elompo. !Jaringan Kola#orasi #er#agai .elompo. !

A2I5 the Acute 2ialysis uality Initiati&eA2I5 the Acute 2ialysis uality Initiati&e

AS- 5 American Society of -ephrologyAS- 5 American Society of -ephrology

-K 5 the -ational Kidney oundation-K 5 the -ational Kidney oundation

dan European Society of Intensi&e Care "edicinedan European Society of Intensi&e Care "edicine

AKI- the Acute Kidney Inury -et(or.

AKI

2EI-ISI


42/89

2EI-ISI

Belum ada konsensus terhadap berapa besar disfungsginjal yg dsb AKI.

Acute Kidney Injury

5lasii5asiRisk,Injuri, Failure,Loss andEnd Stage

Kidney

R!"#

ADJ3

2EI-ISI


43/89

S

mendefenisi.an G ting.atan

.eparahan

Ris. ) .elas $ +

Inuri ) Kelas I +

Failure ) Kelas +

Loss dan EndStage Kidney2isease

Risiko disfungsi ginjal

Sdh terjadi injuri pd ginjal

Gagal ginjal

kelas outcome

Kelas

Tingkatan


44/89

Gam$ar %. &'ema 'lasifi'asi () $erdasar'an 'riteria R!"#*di'utip elomo (, Ronco C,)ellum (,et al.(RCritical care 2004,R204-R2%2 /

DEFINISI


45/89

Pasien "asu. $SAsumsi 1$a(al normal

*ida5 ada data a2al

ungsi ginIal

1una.an -ilaiKreatinin Serum

UsulA2I

$umus "2$2 untu. perhitungan 1$Modifcation o Diet in enal Disease

8'/00 ml7menit per/*8Gm6

Ru&usan MDRD ini +anya dipa5ai untu5 &e&per5ira5an 5reatinin seru&

baseline

G!R per'iraan 1*mlmin per %.3 m2/

% 5 *&cr/ - %.14 5 *umur/ - 0.0203

5 *0.42 Perempuan /5*%.2%0 )ulit 6itam /

( * / lac' males Ot6er males lac' females Ot6er female


46/89

Ta2e' 3- Per4!raa 4reat!! seru$Ta2e' 3- Per4!raa 4reat!! seru$

baselinebaseline

(7e *8ears/ c es*m7dl 9:moll;/O e es

*m7dl 9:moll;/c e es

*m7dl 9:moll;/O e e e

*m7dl 9:mol

">;"% 1.' 81##9 1.# 811'9 1." 81>)9 1.> 89

"';" 1.' 81##9 1." 81>)9 1.1 89 1.> 89

#>;# 1.% 81"%9 1." 81>)9 1.1 89 >. 8>9

%>;'% 1.# 811'9 1.1 89 1.> 89 >. 8>9

'';)' 1.# 811'9 1.1 89 1.> 89 >. 819

K)' 1." 81>)9 1.> 89 >. 8>9 >. 819

DEFINISI


47/89

A2I AKI-

!erkurangnya ungsi ginjalsecara mendadak "dlm #$jam% yg dideenisikan se&agaipeningkatan kreatinin serumle&ih dari atau sama dengan

'()mg*dl "+,(# umol*l%(ataupeningkatan persentasekreatinin serum le&ih dari atausama dengan '/ "0( kali&ase line% atau &erkurangnya

urin output "oligurio kurangdari '( ml*kg per jam selamale&ih dari jam

DEFINISI


48/89

AKINAKIN "engusul.an penyempurnaan .riteria"engusul.an penyempurnaan .riteria $ILE$ILEPenelitian *er$aruPeru$a+an ,ecil ,reatinin 7eru& Ber+u$ungan

dengan 5 mortalitas

M: am ,ermasu. AKI

Kreatinin N6O*6umol7l

"emerlu.an$$,

,ermasu. AKI Stadium I

AKI Stadium III

DEFINISI


49/89

,a#el 6! Per#andingan 2e>nisi dan S.ema Klasi>.asi AKI #erdasar.an $ILE dan AKI-,a#el 6! Per#andingan 2e>nisi dan S.ema Klasi>.asi AKI #erdasar.an $ILE dan AKI-

R!s4

I1ur+

Fa!'ure

Pe!g4ata .r seru$63,78 2ase'!e atau (eurua GFR697:

Pe!g4ata .r seru$6 9 8 2ase'!e atau (eurua GFR67;:

Pe!g4ata .r seru$6 < 8 2ase'!e atau (eurua GFR6

=7:

atau .r 6 u$o'?L dega (e!g4ata a4ut se4urag+a

>>u$o'?L

@;,7 $L?4g?* 6

1a$

@;,7 $L?4g?*

6391a$

@;,7 $L?4g?*

69>1a$

atau aur!a 6 39

1a$-AKIN

Kr!ter!aKr!ter!a 4reat!! seru$ Kr!ter!a Ur! Out(u

Stage /

Stage 6

Stage G

Pening.atan Cr serum N 6O*6umol7L atau N/0'/


50/89

pasien yg memenuhi defenisi AKI memili.i G .ali .ecenderungan matiselama pera(atan di $S9 "ere.a secara #ermagna memerlu.an dialisis da

lama pera(atan l#h lama di#anding.an pasien tanpa AKI

Per#andingan KriteriaPer#andingan Kriteria AKINAKINQQ

RIFLERIFLE

penelitian &ultisenter ter+adap 1">.1"# pasien sa5it 5ritis ole+ Bangs+a2 d5

AKI- td. l#h sensitif dari pd $ILE dlm mendiagnosis AKI dlm 6M ampertama di ICU

penelitian secara 5o+or pd %1 pasien yd dira2at di 3CU sela&a 1 t+n ole+ Barrantes d5

EPIDEMIOLOGI


51/89

AKI #erat Qperlu $$,

= di ICU

A$ 60 tahuntera.hir

A$ yangmemerlu.an $$,

60 tahun tera.hir

O/ 6:: per /009000 populasi

M 68 per /009000 populasi

AKI di USAperiode penelitian/ tahun

M .ali lipat dari O/0 menadi6::0 pasien

AKI di Australia /:=AKI di AS /6*M= masu. .ategori $ILE $is.* 6O*8=

$ILE Inury dan 6:*/= $ILE ailure

ETIOLOGI


52/89

ETIOLOGI

Bersifat fungsional dan secara de>nisi tida.disertai peru#ahan histopatologi9

Ji.a sdh teradi .erusa.an pada stru.turnefron sprti! glomerulus*tu#ulus*pem#uluh

darah dan interstisial9

,eradi pd o#stru.si tra.tus urinarius

ETIOLOGI


53/89

,a#el G9 Penye#a# AKI,a#el G9 Penye#a# AKI

Pre Renal Volumeresponsive

ntrinsi' Post renal

!ipovole&ia

@Munta+ dan diare

@Perdara+an

Ber5urangnya volu&e

sir5ulasi ee5ti

@(agal Iantung

@7eptic s+oc5@7irosis

4$at

@ ACE in+i$itors

(lo&erular

@(lo&eruloneritis

(lo&erular endot+eliu&

@Vas5ulitis

@!U7

@!ipertensi &aligne

*u$ular@A*-

@ R+a$do&yolisis

@ Myelo&a

3ntersisial

@ -eritis intersisial

4$stru5si

@Batu ginIal

@Fi$rosis retroperitoneal

@!ypertrop+y prostat

@Carcino&a

@7tri5tur uretra

@-eoplas&a $ladder@-eoplas&a pelvis

@-eoplas&a retroperitoneal

OUT.OME


54/89

/< :G=9

Kematian diRS dgn RF!"

#Klas R:*:=*#Klas I//*M=*#Klas F6O*G=#Pasien tanpa AKI *=

!ama Perawatan#$ dan RS

Pasien dengan AKI memili.i lama pera(atan diICU dan rumah sa.it yang le#ih lama i.adi#anding.an dengan pasien tanpa AKI

%orbiditas"nd Stage

# Biaya yang mahal# "enurunnya .ualitas .esehatan seseorang*

# "ortalitas yang le#ih #esar dari populasisecara umum ) 6:*/=+# Pemulihan fungsi ginal menadi salah satu

outcome Rang penting untu. die&aluasi9

PE-A,ALAKSA-AA-


55/89

Konsensus "engenai ,erapi AKI Rang Efe.tifKonsensus "engenai ,erapi AKI Rang Efe.tif

Belum ada .arena!Belum ada .arena!

/9 Penye#a# AKI yang multifa.torial

69 Ber&ariasinya de>nisi AKI9

G9 Penilaian penurunan1$ yang tergantung pad

peru#ahan .reatinin serum9

M9 ,ingginya ang.a mortalitas AKI

9 ,ida. ada .onsensus .apan dan enis dialisis ap

yang tepat untu. penderita AKI9

PENATALAKSANAAN


56/89

PENATALAKSANAAN

Penelitian pd e(anPenelitian pd e(anagent yg ter#u.tiagent yg ter#u.ti

efe.tif ut. AKIefe.tif ut. AKI

Loop diureti.Loop diureti.

Lo('dose dopaminLo('dose dopamin A-PA-P

ormon tyroidormon tyroid

I1'/I1'/

Penelitian secara.linis tida. ada yg

ter#u.ti efe.tif

PE-A,ALAKSA-AA-


57/89

Renal Re&la'ment era&* (RR)Renal Re&la'ment era&* (RR)

Pengganti ginal ) enal eplacement+

Pendu.ung fungsi ginal7organ lainnya )enal*multi-organsupport

Berdasar.an me.anisme pengeluaran cairan7solud dan

Intermitten atau Kontinyu

Semua T kecuali 1D dicapai dengan Ultra>ltrasi

# 1radient te.anan a.an mendorong cairamele(ati mem#ran semipermia#el9

# Lau U dipegaruhi oleh! gradien te.anan trensmem#ran* permea#iltas air mem#ran* dan luas permu.aan mem#ran9

PE-A,ALAKSA-AA-


58/89


Berdaar.an me.anisme utama remo&al solute difusi dan.on&e.si

$emo&al solute yang Predominan pada masing'masing enis $$,

/9 Intermittent haemodialysisi ) I2+ difusi69 Continous &eno&enous haemo>ltration )CFF+

.on&e.siG9 Continous &eno&enous haemodialysis ) FF2+ difuM9 Continous &eno&enous haemodia>ltration )FF2+

difusi dan .on&e.si

PE-A,ALAKSA-AA-


59/89


nisiasi%. Oli7uria *am

2. (nuria * am/3.


60/89


1rade 2

1rade E

1rade C*etapi pada 5e$anya5an 5asus? RR* di&ulai se$elu& urea

&encapai ">@#> &&ol/9.

$$, harus dimulai #erdasar.an #alans cairan* umlah

urin* .adar .alium ataupun deraat asidosis tergantung.ondidi .linis pasien9

PE-A,ALAKSA-AA-Renal Re&la'ment era&* (RR)Renal Re&la'ment era&* (RR)


61/89

Renal Re&la'ment era&* (RR)Renal Re&la'ment era&* (RR)P!'!*a Metode RRT

HD CRRA &"#DEe'anism

remoBal cairan


62/89


)euntun7an dan pertim$an7an '6ususHD CRRA &"#D

RemoBal cairan 8an7 cepat

ersi6an solute cepat

Hiper'alemia $erat

Hempdinami' ta' sta$il

)ontrol cairan le$i6 $ai'

-Hi76 nutritional &upport-RemoBal solute EEI

J


63/89

.*ro!" K!de+ D!sease

Ch i Kid 2iCh i Kid 2i


64/89

In the United States* there is a rising incidence andIn the United States* there is a rising incidence andpre&alence of Kidney 2isease9pre&alence of Kidney 2isease9

-early G0*000 of these are on dialysis9-early G0*000 of these are on dialysis9

Also* there is an increasing pre&alence of earlier stagesAlso* there is an increasing pre&alence of earlier stagesof chronic .idney disease (hich unfortunately is under'of chronic .idney disease (hich unfortunately is under'

diagnosedT and under'treatedT in the United States9diagnosedT and under'treatedT in the United States9 In 6000* the -ational Kidney oundation )-K+ KidneyIn 6000* the -ational Kidney oundation )-K+ Kidney

2isease utcomes uality Initiati&e )K72I+ Ad&isory2isease utcomes uality Initiati&e )K72I+ Ad&isoryBoard appro&ed de&elopment of clinical practiceBoard appro&ed de&elopment of clinical practiceguidelines to de>ne chronic .idney disease and toguidelines to de>ne chronic .idney disease and toclassify stages in the progression of chronic .idneyclassify stages in the progression of chronic .idneydisease9disease9

Chronic Kidney 2iseaseChronic Kidney 2isease

Stages of Chronic Kidney 2iseaseStages of Chronic Kidney 2isease


65/89

Stages of Chronic Kidney 2iseaseStages of Chronic Kidney 2isease

Stage /Stage / Kidney damage (ithKidney damage (ithnormal ornormal or 1$ 1$

1$1$ N


66/89

Causes of End Stage $enal 2iseaseCauses of End Stage $enal 2isease

U7RD7 Annual Data Report

Ch i Kid 2iCh i Kid 2i


67/89

Chronic Kidney 2iseaseChronic Kidney 2isease

"any terms are used to descri#e states o"any terms are used to descri#e states o

reduced glomerular >ltration )1$+ not re?uirinreduced glomerular >ltration )1$+ not re?uirin

renal replacement therapyWrenal replacement therapyW

Chronic $enal InsuXciencyChronic $enal InsuXciency

Chronic $enal ailureChronic $enal ailure

$enal InsuXciency$enal InsuXciency

Pre dialysis renal diseasePre dialysis renal disease

Pre uremiaPre uremia

$enal dysfunction$enal dysfunction

,hey are imprecise Q poorly de>ned9,hey are imprecise Q poorly de>ned9

C+ronic ,idney DiseaseC+ronic ,idney Disease


68/89

"easurement of 1$"easurement of 1$ 1old standard is Inulin Iothalamate91old standard is Inulin Iothalamate9

Creatinine Clearance calculated #y timed )6Mh+ urinCreatinine Clearance calculated #y timed )6Mh+ urin

collection along (ith serum collection for Creatinine9collection along (ith serum collection for Creatinine9

&erestimate 1$ (hen CK2 is se&ere due to a&erestimate 1$ (hen CK2 is se&ere due to aincrease in tu#ular secretion of creatinine9increase in tu#ular secretion of creatinine9

,his factor can #e corrected #y cimetidine9,his factor can #e corrected #y cimetidine9

Estimation of 1$Estimation of 1$

"ore than /0 formulae for estimation of 1$9"ore than /0 formulae for estimation of 1$9

"2$2 most (idely accepted no(9"2$2 most (idely accepted no(9

C+ronic ,idney DiseaseC+ronic ,idney Disease

CK2 $is. actorsCK2 $is. actors


69/89

CK2 $is. actorsCK2 $is. actors

2ia#etes "ellitus2ia#etes "ellitus

ypertensionypertension

Cardio&ascular 2iseaseCardio&ascular 2isease

#esity#esity

"eta#olic Syndrome"eta#olic Syndrome

Age and $aceAge and $ace

Acute Kidney InuryAcute Kidney Inury

"alignancy"alignancy

amily history of CK2amily history of CK2

Kidney StonesKidney Stones

Infections li.e ep CInfections li.e ep C

and IFand IF

AutoimmuneAutoimmune

diseasesdiseases

-ephrotoxics li.e-ephrotoxics li.e

-SAI2S-SAI2S

CK2 CausesCK2 Causes


70/89

CK2 ' CausesCK2 ' Causes

2ia#etic2ia#etic -on 2ia#etic-on 2ia#etic

1lomerular1lomerular -ephritic! PI1-* IgA* "P1--ephritic! PI1-* IgA* "P1-

-ephrotic! S1S* "em#ranous* Amyloidosis-ephrotic! S1S* "em#ranous* Amyloidosis

,u#ulointerstitial! Analgesic* $e%ux* Ch9 #s,u#ulointerstitial! Analgesic* $e%ux* Ch9 #s

Fascular! Fasculitis* ,-* $ASFascular! Fasculitis* ,-* $AS

Cystic! A2PK2Cystic! A2PK2 CK2 in transplantationCK2 in transplantation

CK2 CausesCK2 Causes


71/89

CK2 ' CausesCK2 ' Causes

CAUSES 2EA, I- ES$2CAUSES 2EA, I- ES$2


72/89

CAUSES 2EA, I- ES$2CAUSES 2EA, I- ES$2

U9S9 $enal 2ata System! US$2S 6006U9S9 $enal 2ata System! US$2S 6006

CK2 "anifestationsCK2 "anifestations


73/89

A#normal Sodium'ater meta#olismA#normal Sodium'ater meta#olism

Edema* ypertensionEdema* ypertension

A#normal Acid'#ase a#normalitiesA#normal Acid'#ase a#normalities

"eta#olic Acidosis due to uremia or $,A"eta#olic Acidosis due to uremia or $,A

A#normal hematopoesisA#normal hematopoesis

Anemia of CK2Anemia of CK2 Cardio&ascular A#normalitiesCardio&ascular A#normalities

LF* CA2* 2iastolic 2ysfunctionLF* CA2* 2iastolic 2ysfunction

A#normal Calcium'Phosphorus meta#olismA#normal Calcium'Phosphorus meta#olism

yperphosphatemia* pruritus* arthralgiayperphosphatemia* pruritus* arthralgia

yperparathyroidismyperparathyroidism $enal steodystrophy$enal steodystrophy

CK2 ' "anifestationsCK2 ' "anifestations

CK2 "anagementCK2 "anagement


74/89

CK2 ' "anagementCK2 ' "anagement

2iagnostic (or. up to decide underlying etiology2iagnostic (or. up to decide underlying etiology ,reatment of ypertension and 2yslipidemia,reatment of ypertension and 2yslipidemia

,reatment of Anemia,reatment of Anemia

,reatment of yperphosphatemia,reatment of yperphosphatemia

A&oidance of 2ehydration Q -ephrotoxic agentsA&oidance of 2ehydration Q -ephrotoxic agents

Proper 2osing of 2rugsProper 2osing of 2rugs

Preparation for $enal $eplacement ,herapyPreparation for $enal $eplacement ,herapy

CK2 E&aluationCK2 E&aluation


75/89

CK2 ' E&aluationCK2 ' E&aluation

CK2 E&aluationCK2 ' E&aluation


76/89

Serum electrolytesSerum electrolytes Urine spot protein analysis )6M hour no longerUrine spot protein analysis )6M hour no longer

recommended+9recommended+9

A-A* CG* CMA-A* CG* CM

SPEP* UPEPSPEP* UPEP Kidney UltrasoundKidney Ultrasound

Urine sediment analysisUrine sediment analysis

BiopsyBiopsy

E&idence of glomerular disease (ithout dia#etesE&idence of glomerular disease (ithout dia#etes Sudden onset of nephrotic syndrome or glomerularSudden onset of nephrotic syndrome or glomerular

hematuriahematuria

CK2 ' E&aluationCK2 ' E&aluation

CK2 ' ypertensionCK2 ' ypertension


77/89

Anti'ypertensi&e AgentsAnti'ypertensi&e Agents

Single most important measure could #e ade?uate BPSingle most important measure could #e ade?uate BPcontrolcontrol

,arget BP /G07:0 (ith minimal proteinuria and,arget BP /G07:0 (ith minimal proteinuria and

BP/678 (ith signi>cant proteinuria )/g+9BP/678 (ith signi>cant proteinuria )/g+9

ACEIs and A$Bs ha&e #een demonstrated to slo( #otACEIs and A$Bs ha&e #een demonstrated to slo( #otdia#etic and non'dia#etic renal disease in #otdia#etic and non'dia#etic renal disease in #ot

experimental and human studies9experimental and human studies9

2ecrease the sodium inta.e to 69 g 7day2ecrease the sodium inta.e to 69 g 7day

Usually re?uires more than 6 medications9Usually re?uires more than 6 medications9

2iuretics enhance the antihypertensi&e and2iuretics enhance the antihypertensi&e and

antiproteinuric e3ects of other agents99antiproteinuric e3ects of other agents99

CK2 ' 2yslipidemiaCK2 ' 2yslipidemia


78/89

2yslipidemia and Cardio&ascular mor#idity2yslipidemia and Cardio&ascular mor#idity

Se&eral studies li.e the M2 study sho(ed noSe&eral studies li.e the M2 study sho(ed no#ene>t of statins in dialysis patients9#ene>t of statins in dialysis patients9

o(e&er* post hoc analysis of this data doeso(e&er* post hoc analysis of this data doessuggest that the management of dyslipidemiasuggest that the management of dyslipidemia

in CK2 6 M impro&es cardiac mortality andin CK2 6 M impro&es cardiac mortality andmor#idity9mor#idity9

2yslipidemia is fre?uently seen in glomerular2yslipidemia is fre?uently seen in glomerulardisease (ith proteinuria )nephrotic syndrome+disease (ith proteinuria )nephrotic syndrome+and its control reduces atherosclerosis relatedand its control reduces atherosclerosis relatedmor#idity and mortality9mor#idity and mortality9

CK2 ' AnemiaCK2 ' Anemia


79/89

2ecreased ?uality of2ecreased ?uality of

life (ith anemia9life (ith anemia9

2iagnosis of exclusion92iagnosis of exclusion9

"ostly apparent in the"ostly apparent in the

stage M and of CK29stage M and of CK29

2ue to decrease in EP2ue to decrease in EP

production in theproduction in the

.idney9.idney9

CK2 ' AnemiaCK2 ' Anemia


80/89

CK2 AnemiaCK2 Anemia

ErythropoietinErythropoietin Epoetin alfa !Procrit Y * EpogenYEpoetin alfa !Procrit Y * EpogenY

2ar#epoietin Alpha! A$A-ESP Y2ar#epoietin Alpha! A$A-ESP Y

,arget g le&els #et(een //g and /6g #ut,arget g le&els #et(een //g and /6g #ut

not exceeding /Gg9not exceeding /Gg9 1reater than /Gg sho(ed increased1reater than /Gg sho(ed increased

mortality as per the CI$ study9mortality as per the CI$ study9 SuXcient Iron should #e administered toSuXcient Iron should #e administered to

correct iron stores9correct iron stores9

CK2 ' yperphosphatemiaCK2 ' yperphosphatemia


81/89

Control of yperphosphatemiaControl of yperphosphatemia

2ue to decreased excretion in urine92ue to decreased excretion in urine9

Control of hyperphosphatemia #y dietary measures slo(Control of hyperphosphatemia #y dietary measures slo(

progression in experimental models of CK29progression in experimental models of CK29

yperphosphatemia leads to pruritus* calci>cation inyperphosphatemia leads to pruritus* calci>cation in

syno&ial mem#ranes* #lood &essels and e&en cardiacsyno&ial mem#ranes* #lood &essels and e&en cardiac&al&es9&al&es9

,herapy includes Phosphorus restriction to :00mg7day,herapy includes Phosphorus restriction to :00mg7day

and use of phosphrous #inders (ith food9and use of phosphrous #inders (ith food9 Calcium Car#onate ),U"S+* Ca'acetate )PSL+Calcium Car#onate ),U"S+* Ca'acetate )PSL+

LanthanumLanthanum $enagel$enagel

CK2 CK2 Bone and "ineralBone and "ineral

diseasedisease


82/89

diseasedisease

yperparathyroidism!yperparathyroidism! igh phosphorus and lo( Fitamin 2igh phosphorus and lo( Fitamin 2

causing lo( calcium9causing lo( calcium9

"onitor Intact P, le&els and .eep"onitor Intact P, le&els and .eep#et(een /00 and 009#et(een /00 and 009

"aintain Phosphorus and Calcium (ithin"aintain Phosphorus and Calcium (ithin

normal ranges9normal ranges9

Fitamin 2 analog paricalcitol9Fitamin 2 analog paricalcitol9 Calcimimetic agents li.e cinacalcet9Calcimimetic agents li.e cinacalcet9

CK2 ' -ephrotoxicsCK2 ' -ephrotoxics


83/89

CK2 -ephrotoxicsCK2 -ephrotoxics

A&oidance of 2ehydration7-ephrotoxic AgentsA&oidance of 2ehydration7-ephrotoxic Agents

2rugs such as Aminoglycosides* -SAI2s2rugs such as Aminoglycosides* -SAI2s

A&oiding exposure to $adio contrast agents9A&oiding exposure to $adio contrast agents9

In presence of dehydration* e&en in a#sence ofIn presence of dehydration* e&en in a#sence of

reno&ascular disease* ACEIs or A$Bs can aggra&atereno&ascular disease* ACEIs or A$Bs can aggra&aterenal dysfunctionrenal dysfunction

2ehydration is fre?uent in tu#ulo'interstitial disorders2ehydration is fre?uent in tu#ulo'interstitial disorders

(here urinary concentration is impaired9(here urinary concentration is impaired9

Proper 2osing of 2rugs eg9 AllopurinolProper 2osing of 2rugs eg9 Allopurinol

CK2 "edication 2osingCK2 "edication 2osing


84/89

CK2 "edication 2osingCK2 "edication 2osing

Proper 2osing of 2rugsProper 2osing of 2rugs Uremia a3ects 1I a#sorptionW eg Iron9Uremia a3ects 1I a#sorptionW eg Iron9

Impaired plasma protein #inding of drugsW eg 2ilantin9Impaired plasma protein #inding of drugsW eg 2ilantin9

Increased &olume of distri#utionWIncreased &olume of distri#utionW

Excretion of many drugs depends upon the .idneyWExcretion of many drugs depends upon the .idneyW Some drugs used in normal dose (ill lead to nephrotoxic e3ectSome drugs used in normal dose (ill lead to nephrotoxic e3ects

eg9 Allopurinoleg9 Allopurinol

ther drugs (hen used in normal dose (ill lead to other toxicther drugs (hen used in normal dose (ill lead to other toxic

e3ects eg9 Fancomycin9e3ects eg9 Fancomycin9

2ose $eduction or Inter&al Extension2ose $eduction or Inter&al Extension

CK2 ' $$,CK2 ' $$,


85/89

CK2 $$,CK2 $$,

Preparation for $enal $eplacement ,herapyPreparation for $enal $eplacement ,herapy Education for ptions of 2ialysis Q $enalEducation for ptions of 2ialysis Q $enal

,ransplantation for $enal $eplacement,ransplantation for $enal $eplacement

emodialysis Fs Peritoneal 2ialysisemodialysis Fs Peritoneal 2ialysis

A&oidance of Feni'puncture Q insertion ofA&oidance of Feni'puncture Q insertion of

catheters in peripheral &eins once 1$ O0mlscatheters in peripheral &eins once 1$ O0mls

,imely placement of &ascular access or P2,imely placement of &ascular access or P2

catheter9catheter9

CK2 ' $$,CK2 ' $$,


86/89

CK2 $$,

Indications )A#solute+!Indications )A#solute+! Uncontrolled hyper.alemia and acidosisUncontrolled hyper.alemia and acidosis Uncontrolla#le hyper&olemia )pulmonary edema+Uncontrolla#le hyper&olemia )pulmonary edema+

PericarditisPericarditis

A"S and somnolence )ad&anced encephalopathy+A"S and somnolence )ad&anced encephalopathy+

Bleeding diathesisBleeding diathesis Indications )$elati&e+!Indications )$elati&e+!

-ausea* &omiting and poor nutrition-ausea* &omiting and poor nutrition

"eta#olic acidosis"eta#olic acidosis

Lethargy and "alaiseLethargy and "alaise orsening .idney function /0 ml or / ml inorsening .idney function /0 ml or / ml india#eticsdia#etics

CK2 ' $$,CK2 ' $$,


87/89

,ransplantation!,ransplantation!

Preempti&e transplantPreempti&e transplant

carries #oth patient andcarries #oth patient and

graft sur&i&algraft sur&i&al

ad&antage9ad&antage9 1raft sur&i&al #etter1raft sur&i&al #etter

(ith li&ing donor(ith li&ing donor

.idneys9.idneys9

Immunosuppresion isImmunosuppresion is

almost al(ays a must9almost al(ays a must9

CK2 ' $$,CK2 ' $$,


88/89

,ransplantation!,ransplantation! 2iseases li.e S1S may reccur early in the2iseases li.e S1S may reccur early in the

transplanted .idney9transplanted .idney9

Increased ris. for infection* #one loss*Increased ris. for infection* #one loss*

cardio&ascular disease9cardio&ascular disease9

Contraindications!Contraindications! "alignancy )recent or metastatic+"alignancy )recent or metastatic+

Current infectionCurrent infection

Se&ere extra renal diseaseSe&ere extra renal disease

Acti&e use of illicit drugsActi&e use of illicit drugs


89/89

anatomi dan fisiologi perkemihan.ppt

Documents

anatomi fisiologi jantung

anatomi dan fisiologi

anatomi fisiologi muskulo

anatomi fisiologi sistem kardiovaskuler dan anatomi...

anatomi-fisiologi mata

anatomi fisiologi ginjal

anatomi fisiologi reproduksi

anatomi sistem perkemihan.ppt

anatomi fisiologi payudara

anatomi & fisiologi telinga

pengantar anatomi fisiologi

anatomi & fisiologi pernapasan

· anatomi, fisiologi dan biolooi sel anatomi, fisioiogi...

anatomi & fisiologi jantung

anatomi & fisiologi

anatomi fisiologi

anatomi fisiologi kulit

anatomi fisiologi manusia

anatomi fisiologi hidung

anatomi fisiologi sistem perkemihan.ppt