Renal Failure

Yuni Shahroh
ACKD
 Kidney Function

Acid base balance

Water balance

Electrolyte balance

Toxin removal

Blood pressure control

Making eritropoetin and renin

Vitamin D metabolism and

glukoneogenesis
 https://doi.org/
10.1038/ki.2013.153

INJURY pada ginjal ringan hingga berat  gangguan STRUKTUR dan FUNGSI ginjal  ditunjukkan dengan
perubahan parameter lab atau produksi urin  kerusakan berlangsung AKUT hingga KRONIS
Acute Kidney Injury
(AKI)
 Definition of AKI

•Increase in serum creatinine by 0.3 mg/dL or more (26.5

micromoles/L or more) within 48 hours
•Increase in serum creatinine to 1.5 times or more baseline within the
prior seven days
•Urine volume less than 0.5 mL/kg/h for at least 6 hours
 Classification of AKI

• AKI oliguria :
dinilai
berdasarkan
penurunan
jumlah urine
output

• AKI non-
oliguria :
dinilai
berdasarakan
peningkatan
serum
kreatinin
Makris K, Spanou L. Acute Kidney Injury: Definition, Pathophysiology and Clinical Phenotypes. Clin Biochem Rev. 2016
May;37(2):85-98. PMID: 28303073; PMCID: PMC5198510.
Outcome akan lebih baik
dengan deteksi dini dibanding
saai AKI sudah terjadi West Indian Med J 2019; 68 (1): 35 DOI: 10.7727/wimj.2018.154
 Cause of AKI

J. Clin. Med. 2020, 9(4), 1104; https://doi.org/10.3390/jcm9041104

 Evaluation to Determine the “Cause” of AKI

Historical clues
Physical
•Volume loss, decreased cardiac output,
suggest pre-renal causes of AKI. •Distended palpable
bladder suggests Labs
•Use of nephrotoxins, rhabdomyolysis, Imaging
post-renal causes. •Serum
pulmonary renal diseases are suggestive for
intrinsic renal disease. •Hypotension may creatinine (attempt to
suggest pre-renal ascertain a baseline) •Bedside ultrasound
•Alternating oliguria and polyuria is
failure. •Monitor urine  Urinary tract
suggestive for obstructive process.
output ideally with a  Hemodynamic
 Suspect postrenal AKI in men with •Hypertension
urethral catheter
prostatic disease or advanced (moderate-severe) is evaluation
age and patients with indwelling more suggestive of •Urinalysis
bladder catheters. •Non-contrast CT
intrinsic renal failure •Creatinine Kinase
 Anuria strongly suggests (rather than pre- (CK)
obstruction, although vascular renal etiologies). 
obstruction and fulminant renal •Electrolytes
disease are also possible.
Urinalysis Interpretation in the Context of AKI
 Classical Effects of AKI

Doyle, J.F., Forni, L.G. Acute kidney injury: short-term and long-term effects. Crit Care 20, 188
(2016). https://doi.org/10.1186/s13054-016-1353-y
 Prinsip Terapi AKI

1.Menentukan penyebab,
apakah pre renal, renal
atau post renal
2.Menentukan derajat AKI
berdasarkan kreatinin
serum dan produksi urin
3.Langkah berikutnya
tergantung dari kondisi
klinis pasien, lokasi dan
riwayat pasien
4.Tatalaksana disesuaikan
dengan derajat AKI
 Approach of AKI in ED

Indikasi Hemodialisis Cito

•A-asidosis berat (pH<7)
•I-intoksikasi (methanol,
lithium, salisilat)
•U-ureum > 200 mg/dL
•E-gangguan elektrolit :
hiperkalemia,
hiperkalsemia,
hipernatremia berat,
hiponatremia berat
•O-overload cairan, edema
paru
Chronic Kidney Disease
(CKD)
 Definition of CKD

Kerusakan ginjal secara struktural atau fungsional yang terjadi selama > 3
bulan yang berpengaruh pada kesehatan dengan memenuhi salah satu dari :
•Kerusakan ginjal yang ditandai dengan :
 Albuminuria
 Abnormalitas sedimen urin
 Kelainan elektrolit
 Kelainan histologis
 Kelainan struktural yang ditemukan pada pencitraan
 Riwayat transplantasi ginjal
•Penurunan laju filtrasi glomerulus (LFG) < 60 ml/menit/1,73 m2

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Managementof Chronic Kidney Disease, Kidney Int Suppl, 2013;3(1):5-111
 Acute vs Acute on Chronic

Chronic :
•Nilai Cr abnormal sebelumnya
•Faktor risiko : HTN, DM
•Hiperfosfatemia
•Anemia Normositik
•USG : ginjal mengecil
 Classification of CKD
CKD is classified based on Cause (C), GFR (G), Albuminuria (A)
 Management of CKD
Progresif cepat jika eGFR turun > 5
ml/1.73 m2/tahun
Kontrol TD
Kontrol glikemik
Gaya hidup sehat (olahraga, stop
merokok)
Terapi spesifik penyebab
Menghindari obat nefrotoksik
Mengatur dosis/interval pemberian obat
Diet rendah protein
Diet rendah garam
Complications
 Hiperkalemia

Batasi intake, 50-80 meq/hari Shifting kalium ke intrasel

Atasi konstipasi (glukosa-insulin, beta agonis,
Hindari obat-obatan yang dapat terapi alkali)
menyebabkan hiperkalemia Meningkatkan eksresi kalium
(NSAID, ACE-I, ARB, (diuretic, resin pengikat
Spironolakton) kalium, dialysis)
 Asidosis Metabolik

• Asimtomatik : ringan (Bic 12-20 meq/L, pH 7,2-

7,4)tidak perlu terapi
• Bic < 20 meq/L Nabic oral
Dosis terbagi, tidak boleh > 0,5 meq/kg/hr
Hati-hati overload Na
• Berat (Bic < 8 meq/L, pH < 7,2)Nabic IV, half
correction 0,3 x BB x delta Bic
Renal Anemia

• Erythtropoietin
• Iron therapy
• Nutritional support
• Adequate dialysis
 Hemodialisis

Goals :
•Mempertahankan keseimbangan cairan, elektrolit, asam basa
•Mencegah kerusakan ginjal lebih lanjut & pemulihan
•Mendukung terapi suportif

• Penurunan fungsi ginjal progresif (eGFR < 15)

• Penurunan fungsi ginjal progresif + komplikasi
metabolic yang refrakter terapi