Farmakoterapi Gagal Ginjal

Dr. Syamsudin
Department of Pharmacology
Faculty of Pharmacy
Pancasila University
• Fungsi ginjal
Regulasi volume cairan tubuh
Regulasi keseimbangan elektrolit
Regulasi keseimbangan asam basa
Regulasi tekanan darah (RAAS)
Ekskresi sampah metabolik
Regulasi erithropoesis
Metabolisme vit D
Sintesis prostaglandin
 Brain ADH

Renin

Angiotensin II
Kidney

Lung Na+ excretion

Ang II H2O excretion
Angiotensin I
Adrenal
Angiotensinogen Aldosteron

Hepar RAAS
 Diagnostic Tools for Assessing Renal
Failure
• Blood Tests
– BUN
– Creatinine
– K+
– PO4
– Ca
• Urinalysis
– Specific gravity
– Protein
– Creatinine clearance

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 BUN
• Normal 10-30 mg/dl
• Nitrogenous waste product of protein
metabolism
• Unreliable in measurement of renal function

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 Creatinine
• A waste product of muscle metabolism
• Normal value 0.5 - 1.5 mg/dl
• 2 times normal = 50% damage
• 8 times normal = 75% damage
• 10 times normal = 90% damage

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 Diagnostic Tools
• Biopsy
• Ultrasound
• X-Rays

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Gambaran Klinis GGA
• HB normal
• Oliguric type
• Non oliguric type (30-60%) – prognosis lebih
baik – causa AB / nephrotoxic agent
• Umumnya “reversible”
• Mortalitas tinggi: 40-60%
• Frekuensi : 5-15% pasien rawat
 Penyebab GGA
• Pre-renal : Hypovolemic, hypotensi, dehydrasi,
syok
• Renal (Intrinsic renal failure) – ATN (acute
tubular nephrosis) or VMN (vascular
membrane nephrosis)
• Post-renal : obstruksi, batu, prostat, trauma,
keganasan.
 Anamnesis
• Gastro Enteritis akut
• Riwayat tindakan / operasi
• Hipotensi  shock
• Hipertensi (accelerated / malignant)
• Drugs
• Renal disease
• Acute on chronic
 Clinical Course of ARF
• Onset Phase : oliguria, ureum creatinin
meningkat, gangguan elektrolit

• Oliguric Phase : “fluid overload”, edema

ankle/pulmo, hyperkalemia  cardiac,
arythmia, hyponatremia, acidosis, kussmaul
respiration.
 Acute uremic syndrome
• CVS : hipertensi, arythmia, CHF, pericarditis
• Gastroinstestinal : anorexia, nausea,
vomithing, diarhea, bleeding, pancreatitis
• CNS : cunfussion, twitching, asterixis,
soporosus  coma
• Hemopoetic system : bleeding, anemia
 Clinical Course of ARF (cont)

• Diuretic Phase : restorasi fungsi ginjal

– 1 hari s/d 2 minggu
– Keseimbangan cairan, dehydrasi, hypokalemia
– Gejala-gejala hilang, nafsu makan pulih
 Management of ARF
• Phase oliguri : cairan <500 cc/h, monitor
elektrolit : kalium, asupan kalori. Dialisis
• Phase diuretik : keseimbangan cairan dan
elektrolit
• Post diuretik : cairan / elektrolit
• Prognosis : tergantung penyebab, usia,
comorbid, infeksi, multi organ
 Chronic Renal Failure
• Slow progressive renal disorder related to
nephron loss, occurring over months to years

• Culminates in End Stage Renal Disease

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 Pe Reabs Na
Hipertrofi sel
renal Pe eksr sisa
metab
Ggn konstentrasi
urin Pe ekskr kalium

Penurunan GFR Ggn fs ekskresi Pe ekskr PO4

Pe ekskr ion H

CKD

Ggn Reproduksi

Ggn Imun
Ggn fs non
ekskresi  prod
eritropoetin

Pe abs Ca
 Causes of Chronic Renal Failure
• Diabetes
• Hypertension
• Glomerulonephritis
• Cystic disorders
• Developmental - Congenital
• Infectious Disease

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 Causes of Chronic Renal Failure

• Neoplasms
• Obstructive disorders
• Autoimmune diseases
• Hepatorenal failure
• Scleroderma
• Amyloidosis
• Drug toxicity
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 Glomerular Filtration Rate
GFR
• 24 hour urine for creatinine clearance
– Most accurate indicator of Renal Function
– Reflects GFR
– Formula:
• urine creatinine X urine volume
serum creatinine
• Can estimate creatinine clearance by:
Men: {140 – age} x IBW (kg)
72 x serum creatinine
Women: {140 – age} x IBW (kg)
85 x serum creatinine

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 Stages of Chronic Renal Failure
Old System
• Reduced Renal Reserve

• Renal Insufficiency

• End Stage Renal Disease (ESRD)

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 Stages of Chronic Renal Failure
NKF Classification System

Stage 1:
GFR >/= 90 ml/min despite kidney damage

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 Stages of Chronic Renal Failure
NKF Classification System

Stage 2: Mild reduction

(GFR 60 – 89 ml/min)
1. GFR of 60 may represent 50%
loss in function.
2. Parathyroid hormones starts to
increase.

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 During Stage 1 - 2
• No symptoms

• Serum creatinine doubles

• Up to 50% nephron loss

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 Stages of Chronic Renal Failure
NKF Classification System

Stage 3: Moderate reduction

(GFR 30 – 59 ml/min)
1. Calcium absorption decreases
2. Malnutrition onset
3. Anemia
4. Left ventricular hypertrophy

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 Stages of Chronic Renal Failure
NKF Classification System

Stage 4: Severe reduction

(GFR 15 – 29 ml/min)
1. Serum triglycerides increase
2. Hyperphosphatemia
3. Metabolic acidosis
4. Hyperkalemia

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 During Stage 3 - 4

• Signs and symptoms worsen if kidneys are

stressed
• Decreased ability to maintain homeostasis

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 During stages 3 - 4
• 75% nephron loss
• Decreased: glomerular filtration rate, solute
clearance, ability to concentrate urine and
hormone secretion
• Symptoms: elevated BUN & Creatinine, mild
azotemia, anemia

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 Stages of Chronic Renal Failure
NKF Classification System

Stage 5: Kidney failure (GFR < 15 ml/min)

1. Azotemia

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 During Stage 5
End Stage Renal Disease
• Residual function < 15% of normal
• Excretory, regulatory and hormonal functions
severely impaired.
• Metabolic acidosis
• Marked increase in: BUN, Creatinine,
Phosphorous
• Marked decrease in: Hemoglobin,
Hematocrit, Calcium
• Fluid overload

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 During Stage 5
• Uremic syndrome develops affecting all body
systems
– can be diminished with early diagnosis &
treatment

• Last stage of progressive CRF

• Fatal if no treatment

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Manifestations of Chronic Uremia

Fig. 47-5

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 Treatment Options
• Conservative Therapy
• Hemodialysis
• Peritoneal Dialysis
• Transplant
• Nothing

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 Conservative Treatment Goals
GOALS:
• Detect & treat potentially reversible causes of
renal failure
• Preserve existing renal function
• Treat manifestations
• Prevent complications
• Provide for comfort

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 Conservative Treatment
• Control
– Hyperkalemia
– Hypertension
– Hyperphosphatemia
– Hyperparthryoidism
– Hyperglycemia
– Anemia
– Dyslipidemia
– Hypothyroidism
– Nutrition

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 Penatalaksanaan CKD

Ditujukan untuk mengurangi gejala klinik , mencegah komplikasi ,

mencegah progresifitas CKD, mempersiapkan initiasi dialisis

Uremia : diit protein 0,6 – 0,8 gr / kg bb / hari

Hiperkalemia : diit rendah kalium ; 60 – 80 meq/hari
Asidosis metabolik : diit rendah protein / fosfat; HCO3

Stop rokok
Kontrol lipid ( preparat statin )
HbA1C < 7 %

Hipertensi
Anemia
Osteodistrofi renal
Komplikasi kardiovaskuler
 Pengobatan GGK
• Konservatif
– Diet : rendah protein: 0,6-08 g/KgBB
HBV kalori cukup

• Terapi Pengganti Ginjal (TPG)

 HD VS PD
Keunggulan Keunggulan
Dilakukan dalah waktu lebih singkat Kimia darah lebih stabil
Lebih efisien terhadap pengeluaran zat- Hematocrite lebih tinggi
zat BM rendah Pengendalian tekanan darah lebih
Terjadi sosialisasi di senter dialisis mudah
Cairan dialisat sebagai sumber nutrisi,
Kelemahan pada penderita DM, insulin bisa
Membutuhkan heparin diberikan intraperitoneal
Membutuhkan vascular access
Gangguan hemodinamik Kelemahan
Pengendalian tekanan darah yang lebih Peritonitis
sulit Obesitas
Dibutuhkan disiplin diet dan jadwal Hiperglikemi
pengobatan yang teratur Malnutrisi / protein loss
Hernia
Back pain