Gagal ginjal

Dr Putra Hendra SpPD

khronik
UNIBA

Clarification of Terminology
Chronic Renal Failure
Damage to kidneys but treatment is not necessary
End Stage Renal Failure
Long term damage requiring renal replacement
therapy 90-95% nephrons not functioning
Acute Renal Failure
Sudden decline in renal function at least 50%
decrease in GFR
50% patients sembuh
Acute on Chronic Renal Failure

Acute episode which may require treatment & then revert back
to chronic, however the patient may then have reached end
stage

What is ESRD?
The deterioration of nephrons resulting in loss of ability to
excrete wastes, concentrate urine, and regulate
electrolytes.
Occurs as chronic or acute renal failure progressing to
the point where function kurang 90% dari normal.
Function is so low that without dialysis or kidney
transplantation, death will occur from accumulation of
fluids and waste products in the body.
ESRD almost always follows chronic kidney failure, which
may exist for 10 - 20 years or more before progression to
ESRD.

Incidence/Prevalence
- More than 20 million people in the US have chronic

kidney disease
- More than 345,000 people suffer from ESRD
- 31% of cases annually occurs in African Americans
- 2% of cases of ESRD each year occurs in native
Americans
- 31% of cases of ESRD each year occurs in
Caucasians in America
- 60,000 people die annually

Common causes of Chronic

Renal Failure
Glomerulonephritis
Diabetes

Mellitus
Hypertension
Chronic pylonephritis/reflux
Polycystic kidney disease
Interstitial nephritis
Obstruction
Unknown

25%
25%
10%
10%
10%
5%
3%
12%
J Winterbottom 2005

RF: Natural History

DD
ARF

CRF

ESRD

GFR

Rapid decline
Reversible

Slow,
progressive,
irreversible

Permanent no
function

Urine output

Anuria, oliguria on
non-oliguria

Polyuria

Polyuria or normal

Urine analysis

Sp.gr.:>1.020
May be active
sediment

Sp.gr.: 1.010
Bland sediment

1.010
Bland Sediment

Serum K+

Usually high
May be normal

Usually low
May be normal or
high

Usually low
May be normal or
high

Uremic bone
disease

Not present

Usually present

Always present

DM

Causes
Chronic Glomerulonephritis
Hypertension

Congestive Heart Failure

Diabetes (most common cause)

Causes
Systemic Lupus Erythrematosus
Polycystic Kidney Disease

Atherosclerosis
Amyloidosis

Causes
Aminoglycoside nephrotoxicity
(Gentamycin, Azithromycin)

IV contrast medium

Long term use of NSAIDS

Causes

Nephrolithiasis

Prostate Cancer

Lab Tests
Creatinine

and BUN levels

(chronically high)
Creatinine clearance (very low).
Electrolyte measurements (high K+,
low Na+)
Urinalysis

Creatinine

Creatinine is a breakdown
product of creatine, an
important part of muscle.
Creatinine is excreted entirely
by the kidneys.
With kidney failure, the serum
creatinine level is high.
Normal value: 0.8 to 1.4
mg/dl.

BUN
(Blood Urea Nitrogen)

Measures the amount of urea

nitrogen (a breakdown product
of protein metabolism) in the
blood.
Urea is formed in the liver as the
end product of protein
metabolism.
The urea makes its way into the
blood and it is ultimately
eliminated in the urine by the
kidneys.
With kidney failure BUN
levels are chronically high.
Normal Value: 7 to 20 mg/dl

Creatinine Clearance
Creatinine clearance
menggambarkan
glomerular filtration rate
(the volume of filtrate made
by the kidneys per minute).
Urine and serum creatinine
levels diukur dengan urine
volume in 24 hours.
Pada kidney failure
clearance is chronically
low.
Normal values:
Male: 97 to 137
ml/min. Female: 88 to
128 ml/min.

CRF: Monitoring Renal

Function
Cockroft

& Gault equation:

Cr Cl.= (140- age) wt /Cr P
Reliable in steady state

Clearance

of 125 I-isothalamate,
99Tc-DTPA: rapid and accurate

Stages of kidney disease

1.

Asymptomatic urinary abnormalities:

GFR > 90 ml/min (> 1,5
ml/s)

Mild CRF:

GFR 60-89 ml/min (1-1,5 ml/s)

Moderate CRF:
ml/s)

GFR 30-59 ml/min (0,5-1

Severe CRF:
ml/s)

GFR 15-29 ml/min (0,25-0,5

Approaching 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

Treatment
Diseases that cause or result from chronic renal
failure must be controlled.:
Hypertension, congestive heart failure, urinary
tract infections, kidney stones, obstructions of
the urinary tract, glomerulonephritis, and other
disorders should be treated appropriately

Dialysis or kidney transplantation are the only

treatments for ESRD
In the U.S., nearly 300,000 people are on
long-term dialysis and more than 20,000 have
a functioning transplanted kidney.

Treating ESRD
4 forms of treatment;
HAEMODIALYSIS
PERITONEAL

DIALYSIS (CAPD)
TRANSPLANTATION
CONSERVATIVE

J Winterbottom 2005

Dialysis

Method of removing toxic substances from the blood.

Blood is diverted from the access through a filter. The blood
flows counter-current to a special solution called the
dialysate. The electrolyte imbalances and toxins in the
blood are corrected and the is returned to the body.

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

Catheters
Catheters are a form of temporary
access. Large-bore catheters
placed in large veins
(Subclavian/femoral)
- support acceptable blood flows.
- Most catheters are used in
emergency situations, for short
periods of time.
- tunneled catheters can be used
for prolonged periods of time,
often weeks to months.
Femoral

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
Severe Metabolic Acidosis
Uremic Pericarditis
Uremic Enchephalopathy
Intoxication: Methanol, ethylene
glycol ASA, & Lithium