Diagnosis Dan Tatalaksana Terkini Acute Kidney Injury (AKI)

AKI (Akute Kidney Injury) adalah penurunan fungsi ginjal yang cepat dan ditandai dengan penurunan Laju filtrasi Glomerulus (LFG) dan berakibat penurunan pembuangan produk nitrogen, hilangnya regulari air,elektrolit dan asam basa. AKI mempunyai mortalitas yang tinggi 45-75%, angka survivalitas tergantung ketepatan diagnosis,terapi dan manajemen, Apapun penyebabnya, karena berbeda dengan Chronic Kidney Disease (CKD), pada AKI reversibilitas sangat tinggi. Secara garis besar penyebab AKI dalam tiga klasifikasi prerenal, intrinsik dan pasca renal. secara klinik sangat penting membedakan klasifikasi karena penting untuk pengelolaan. Urinalisis sangat penting dalam membedakan jenis AKI (Pre, intrinsik, atau pasca renal) Jenis AKI Prerenal Urinalisis Una EUN FENa (%) (mEq/L) (%) <1 35 Rasio BUN/Urea > 20: 1

Berat Jenis Tinggi Silinder normal atau < 20 Silinder hialin

Intrarenal Tubuler nekrosis berat jenis ygrendah Silindercoklat akut lumpur Sel epitel tubulus ginjal Kelainan Normal atau vaskular Hematuria Proteinuria,hematuri Glomerulonefritis a Silinder eritrosit Nefritis Protein uria ringan, interstitial hematuria,eritrosit, silinder eritrosit,eosinofil Normal atau Postrenal Hematuria leukosit,kadang dapat dijumpai silinder granuler

> 40

> 50

20:1

>20

Bervariasi

<20 >20

<1 1

< 20

Bervariasi

20:1

Diagnosis AKI menurut Acute Dialisis Quality Initiative (ADQI) berdasarkan kriteria RIFLE dan diperbaiki sebagai kriteria AKIN. RIFLE criteria for diagnosis of AKI based on Acute Dialisis Quality Initiative

Risk of renal injury Injury to the kidney Failure of kidney function

Increase in Scr Urine output 0,3 mg/dl increase <0,5ml/kg/hr for >6 hr 2x baseline <0,5ml/kg/hr for>12hr

3x baseline Anuria for >12 h >0,5 mg/dl increase if Scr 4 mg/dl Persisten renal Loss of kidney function failure End-stage disease for > 4 week persisten renal failure for > 3 month Definisi Acute Kidney Injury (AKI) berdasarkan Akut Kidney Injury Network Tahap Meningkatnya serum Kreatinin Produksi Urine 1 1.5-2 times baseline <0,5ml/kg/h for>6 h 0,3 mg/dl increase from baseline 2 2-3 times baseline <0,5ml/kg/h for>12h 3 3 times baseline <0,3ml/kg/h/for>24h 0,5 mg/dl increase if baseline OR Anuria for >12 h > 4 mg /dl Any RRT given

Acute Dialysis Quality Initiative

Acute renal failure (ARF) is commonly defined as an abrupt decline in renal function, manifested by acute elevation in plasma blood urea nitrogen (BUN) and serum creatinine, occurring in hours to days to weeks, and usually reversible. However, a consistent lack of consensus regarding the actual degree of elevation in serum creatinine that defines the syndrome has posed a major limitation to epidemiologic studies.[1, 2, 3, 4] For more information, see Acute Renal Failure and Acute Tubular Necrosis. In 2002, the Acute Dialysis Quality Initiative (ADQI) was created with the primary goal of developing consensus- and evidence-based guidelines for the treatment and prevention of ARF. The first order of business was to create a uniform, accepted definition of ARF; hence, the RIFLE criteria were born (see the table below). RIFLE is an acronym of Risk, Injury, and Failure; and Loss, and End-stage kidney disease.

Table 1. RIFLE Classification System for Acute Kidney Injury[5] (Open Table in a new window) Stage Risk GFR** Criteria SCr increased 1.5 or GFR decreased >25% SCr increased 2 or GFR decreased >50% SCr increased 3 or GFR decreased 75% or SCr 4 mg/dL; acute rise 0.5 mg/dL Urine Output Criteria UO < 0.5 mL/kg/h 6 h Probability High sensitivity (Risk >Injury >Failure)

Injury

UO < 0.5 mL/kg/h 12 h

Failur e

UO < 0.3 mL/kg/h 24 h (oliguria) or anuria 12 h

Loss

Persistent acute renal failure: complete loss of kidney function >4 wk Complete loss of kidney function >3 mo

High specificity

ESRD*

*ESRDend-stage renal disease; **GFRglomerular filtration rate; SCrserum creatinine; UOurine output Note: Patients can be classified either by GFR criteria or by UO criteria. The criteria that support the most severe classification should be used. The superimposition of acute on chronic failure is indicated with the designation RIFLE-FC; failure is present in such cases even if the increase in SCr is less than 3-fold, provided that the new SCr is greater than 4.0 mg/dL (350 mol/L) and results from an acute increase of at least 0.5 mg/dL (44 mol/L). When the failure classification is achieved by UO criteria, the designation of RIFLE-FO is used to denote oliguria. The initial stage, "risk," has high sensitivity; more patients will be classified in this mild category, including some who do not actually have renal failure. Progression through the increasingly severe stages of RIFLE is marked by decreasing sensitivity and increasing specificity.