ACUTE RENAL FAILURE

Reinildis Hildegardis Uruk Hane

Acute Renal Failure(1951)

gagal ginjal yang timbul mendadak akibat trauma fisik, infeksi, peradangan, atau toksisitas; gejala mencakup uremia dan biasanya oliguria/anuria,disertai hiperkalemia & edema paru. Prarenal,intrarenal,pascarenal
Kamus Dorland(2010)

Acute Kidney Injury/Gangguan Ginjal Akut (2001)

Kemampuan 2: mendiagnosis dan merujuk

Tingkat

Penurunan mendadak faal ginjal dalam 48 jam yaitu berupa kenaikan kadar kreatinin serum>0,3 mg/dl (26,4mol/l),presentasi kenaikan kreatinin serum >50% (1,5x kenaikan dari nilai dasar), atau pengurangan produksi urin (oliguria yang tercatat <0,5 ml/kg/jam dalam waktu lebih dari 6 jam)
Buku Ajar IPD hal.1042

Etiologi

(http://emedicine.medscape.com/article/243492-overview#aw2aab6b2b4)

Prerenal AKI
Volume depletion Decreased cardiac output Systemic vasodilation Afferent arteriolar vasoconstriction Diseases that decrease effective arterial blood volume

Intrinsic AKI
Vascular (largeand small-vessel) causes Glomerular causes Tubular etiologies (ischemia or cytotoxicity) Interstitial causes

Postrenal AKI
Obstruction Intra-abdominal hypertension Renal vein thrombosis Diseases causing urinary obstruction from the level of the renal tubules to the urethra

Faktor Risiko

http://www.mayoclinic.com/health/kidney-failure/DS00280/DSECTION=risk-factors)

Dirawat di rumah sakit, terutama untuk kondisi

serius yang memerlukan perawatan intensif

Lanjut usia Penyumbatan pada pembuluh darah di lengan atau

kaki (penyakit arteri perifer)

Diabetes Tekanan darah tinggi Gagal jantung Penyakit ginjal Penyakit hati

Manifestasi Klinik
OLIGURIA ANURIA
Pre renal Renal Post renal

Buku saku IPD

ACUTE RENAL FAILURE

PRERENAL

Absolute decrease in effective blood volume Haemorrhage Volume depletion Relative decrease in blood volume (ineffective arterial volume) Congestive heart failure Decompensated liver cirrhosis Arterial occlusion or stenosis of renal artery Haemodynamic form NSAIDs ACE-inhibitors or angiotensin-II receptor antagonists in renal-artery stenosis or congestive heart failure

Hypovolemia

Baroreceptor activation

Reduced affective circulation volume

Respons neurohormonal

Axis renin-angiotensin aldosterone

Vasopressin

Sympathetic nervous system

Vasoconstriction contraction of mesangial cells Reabsorpsi natrium and water

Reduced renal blood flow and glomerular filtration rate

Acute renal failure pre-renal

ACUTE RENAL FAILURE

INTRINSIC RENAL

Glomerulonephritis Acute interstitial nephritis Vascular Drugs Vasculitis, Allergy Malignant HT

Acute tubular necrosis

Ischaemic (50%)

Nephrotoxic (35%)

Exogenous Antibiotics (gentamicin) Radiocontrast agents Cisplatin

Endogenous Intratubular pigments (haemoglobinuria, myoglobinuria) Intratubular proteins (myeloma) Intratubular crystals (uric acid, oxalate)

ACUTE RENAL FAILURE

POSTRENAL

Obstruction of collecting system or extrarenal drainage

Bladder-outlet obstruction Bilateral ureteral obstruction or unilateral in one functioning kidney

KDIGO 2012Clinical Practice Guideline for Acute Kidney Injury

Langkah Penegakan Diagnosis

Prioritas tatalaksana pasien dengan GGA

Cari dan evaluasi faktor pre dan pasca renal Evaluasi obat-obatan yang telah diberikan Optimalkan curah jantung dan aliran darah ke ginjal Perbaiki dan atau tingkatkan aliran urin Monitor asupan cairan dan pengeluaran cairan, timbang badan

tiap hari
Cari dan obati komplikasi akut (hiperkalemia, hipernatremia,

asidosis, hiperfosfatemia, edema paru)

Asupan nutrisi adekuat sejak dini Cari fokus infeksi dan atasi infeksi secara agresif Perawatan menyeluruh yang baik (kateter, kulit, psikologis) Segera memulai terapi dialisis sebelum timbul komplikasi Berikan obat dengan tepat sesuai kapasitas bersihan ginjal

Indications for dialysis in acute renal failure

Indications Uremia Characteristics Asterixis, seizures, nausea & vomiting, pericarditis

Hyperkalemia K+ >6.5 mmol/L; K+ 5.5-6.5 mmol/L if ECG changes Fluid overload Fluid overload resistant to diuretics, especially pulmonary edema pH < 7.2 despite sodium bicarbonate therapy; sodium bicarbonate not tolerated because of fluid overload

Metabolic acidosis

Proposed criteria for the initiation of renal replacement therapy in adult critically ill patients
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Oliguria (urine output < 200 ml/12 hr) Anuria/extreme oliguria (urine output < 50 ml/12 hr) Hyperkalemia ([K+] > 6.5 mmol/liter) Severe acidemia (pH < 7.1) Azotemia ([urea] > 30 mmol/liter) Clinically significant organ (especially lung) edema Uremic enchepalopathy Uremic pericarditis Uremic neuropathy/myopathy Severe dysnatremia ([Na] > 160 or < 15 mmol/liter) Hyperthermia/Hypothermia Drug overdose with dialysable toxin

WHEN ?

indications

The presence of : - one of the above criteria is sufficient to initiate renal replacement therapy in a critically ill patients - two of these criteria makes renal replacement urgent and mandatory. - combined derangements suggest initiation of renal replacement therapy even before the above mentioned limits have been reached.

Kesehatan Masyarakat
Pencegahan
pencegahan nefropati zat kontras waspadai pemakaian furosemid dan kemoterapi

Kesehatan lingkungan Keselamatan Kerja Gizi-nutrisi (utk GGA)

kurangi garam, cairan, potasssium, phosphorus

THAnk YOUUUU