Nephrology

Fungsi Ginjal
• Mengeluarkan sisa metabolisme :
ureum,kreatinin,uric acid,aliphatic amine,ß2
microglobulin,PTH,myoglobulin,dll
• Mengeluarkan kelebihan air dan elektrolit
(K,Na,Al,H,P)
• Produksi erythropoietin, renin-
angiotensin,vitamin D3 aktif
• Menjaga keseimbangan asam basa
• Membuang toksin dan obat
Apa yang terjadi bila fungsi ginjal rusak
berat ?
• Uremia (gejala akibat tertahannya zat-zat
toksik dalam tubuh): mual muntah, nafsu
makan turun, gatal, kesadaran turun
• Tertahannya garam(Na) dan air
:bengkak,sesak,hipertensi
• Keseimbangan asam basa terganggu: asidosis
• Fungsi hormonal terganggu :anemia, kalsium
menurun
 Penyebab Gagal Ginjal
Glomerulonephritis
Diabetic Nephropathy
Urinary Stones Disease
Hypertension
Analgesic nephropathy
Polycystic Kidney
 Laboratory
• Normal creatinine serum level
– Male : 0.7 -1.3 mg/dl
– Female : 0.6 -1.1 mg/dl
• Normal BUN level (7-18 mg/dl)
– ↑ in renal failure, pre renal azotemia, post renal
obstruction, GI bleeding and hypercatabolic states.
– ↓ in starvation, malnutrition, liver failure, pregnancy,
nephrotic syndrome, overhydration.
• BUN/Cr ratio
– > 20:1 in CHF, GI bleeding, high fever, dehydration,
infection, burns, drugs (tetracycline and steroid).
– < 10:1 in acute tubulr necrosis, malnutrition, liver disease,
SIADH, pregnancy.
1. CKD
 Definition of Chronic Kidney Disease
Criteria
1. Kidney damage for ≥ 3 months, as defined by structural or
functional abnormalities of the kidney, with or without
decreased GFR, manifest by either :
• Pathological abnormalities; or
• Markers of kidney damage, including
Abnormalities in the composition of the blood or
urine, or abnormalities in imaging tests

2. GFR < 60 mL/min/1.73 m2 for ≥ 3 mounths, with or without

kidney damage
 Assesed level of kidney function
Equation
Author, Year (No of Subjects) Equation

Cockcroft-Gault Equation
Cockcroft 1976 (N = 236) Ccr  ml/min  
140 - Age x Weight x  0.85 if famele
72 x Scr

“ Abbreviated” MDRD Study

Equation GFR (ml/min/1.73 m2 ) = 186 x (So)-1.154 x (Age)-0.203
Levey, 1999 (N = 1070 X (0.742 if femele) x (1.210 if African – American)
558 in Validation set)
Schwartz Formula Schwartz
1976 (N = 186) 0.55 x Length
Ccr (ml/min) 
S cr
Counahan-Barratt Equation
Counahan, 1976 (N = 108) 0.43 x Length
GFR (ml/min/1.73m 2 ) 
S cr
Attemps to prevent and correct acute
decline on chronic renal failure
• Volume depletion
• IV radiographic contrast
• Antimicrobial agent (aminoglycoside,amphotericine B)
• NSAID (including Cox2)
• ACE/ARB
• Obstruction of the urinary tract
• Infection of urinary tract
 Interventions that have been studied,
but the result of which are inconclusive

• Dietary protein restriction (0.6 – 0,8

gr/kgBB/day)
• Lipid lowering therapy (LDL<100 mg/dl)
• Partial correction anemia
 Apakah RRT ?
1. Transplantasi ginjal
2. Hemodialisis
3. Continuos Ambulatory Perito-
neal dialysis
 INDIKASI RENAL REPLACEMENT
THERAPY PADA
CHRONIC KIDNEY DISEASE

• Kliren kreatinin <10 ml/menit pada non

DM, atau <15 ml/menit apabila sudah
terdapat uremia

• Kliren kreatinin <15 ml/menit apabila

nefropati diabetik
 Definisi AKI
• Penurunan fungsi ginjal (GFR) secara
mendadak (dalam 1-7 hari) dan bertahan > 24
jam.Biasanya disertai penurunan produksi
urine.
2. AKI
Kriteria ARF
 20-30%
15%
50-60%
 Penyebab ARF
• Pre renal : volume depletion,inadequate
cardiac function, obstruksi arteri renalis
• Renal : glomerular, tubulointerstitial disesase,
obat, toksin
• Post renal : stones, tumor, strictur, kompresi
 Treatment of ARF
• Pharmacologic :
- Fluid
- Vasopressor
- Loop diuretic
- Avoid nephrotoxic drug
- treat infection
- Treat complication : overload,acidosis, electrolyte disturbance
- Atrial natriuretic

• Renal support :
- Continuous Renal Replacement Therapy
- Intermittent hemodialysis : SLED, SCUF, Daily
HD, Alternate-Day HD
- Acute Peritoneal Dialysis
 Indications for acute dialysis
1. Creatinine clearance < 25 ml/min :
a. Uremia
b. Progressive fluid overload
c. Uncontrolled hyperkalemia or me-
tabolic acidosis
2. Creatinine clearance <15 ml/min, BUN >100
mg/dl
3. Management of
Hypertension
 Target Organ Damage
• Heart :
- left venticular hypertrophy
- angina or prior myocardial infarction
- prior coronary revascularization
- heart failure
• Brain :
- stroke or transient ischemic attack
- HT encephalopathy
- seizure
• Chronic kidney disease, AKI  decrease of urine output
• Peripheral arterial disease
• Retinopathy  visual loss
• Nausea and vomiting
 JNC 7 blood pressure classification
in adults aged ≥18 years

BP SBP DBP
Classification (mm HG) (mm HG)
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1
140-159 or 90-99
hypertension
Stage 2
160 or 100
hypertension

National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on
the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2003.
 Patient evaluation : laboratory
• Electrocardiogram
• Urinalysis ; blood glucose and hematocrit
• Serum potassium, creatinine
• Calcium and a lipid profile .
• Optional tests : urinary albumin excretion or
albumin/creatinine ratio (ACR)
 Identifiable causes of hypertension
• Sleep apnea
• Drug-induced or related causes (estrogens, NSAID,
steroids, eritropoetin, efedrin, cocaine, amfetamin)
• Chronic kidney disease
• Primary aldoteronism
• Renovascular disease
• Chronic steroid therapy and cushing’s syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyiroid disease  hyperthyroid
systolic HT, hypothyroid diastolic HT.
 Secondary causes of hypertension
• The most common were renal disease
68%
• Endocrine 11%
• Renovascular diseases 10%
• Almost all children (98 percent) younger than 15
years of age had a secondary cause
• 75 percent of adolescents had essential
hypertension.
 Clinical features of secondary hypertension
Disorder Suggestive clinical features
General Severe or refractory hypertension
An acute rise in blood pressure over a previously stable
value
Proven age of onset before puberty
Age less than 30 years with no family history of
hypertension and no obesity

Renovascular An acute elevation in serum creatinine after administration

disease of ACE/ARB
Moderate to severe hypertension in a patient with diffuse
atherosclerosis or a unilateral small kidney
Repeated episodes of flash pulmonary edema
Systolic-diastolic bruit (not very sensitive)

Primary renal Anemia

disease Elevated serum creatinine concentration
Abnormal urinalysis
Oral contraceptives New elevation in blood pressure temporally related to use
 Screening tests for identifiable
hypertension
Diagnosis Diagnostic Test
Chronic kidney disease Estimated GFR
Coarctation of the aorta CT angiography

Cushing’s syndrome and other

glucocorticoid excess states including
chronic steroid therapy History; dexamethasone suppression test

Drug induced/related History; drug screening

24-hour urinary metanephrine and
Pheochromocytoma normetanephrine

24-hour urinary aldosterone level or excess

Primary aldosteronism and other states specific measurements of other
mineralocorticoid mineralocorticoids
Doppler flow study; magnetic resonance
Renovascular hypertension angiography
Sleep apnea Sleep study with O2 saturation

Thyroid/parathyroid disease TSH; serum PTH

CT, computed tomography; GFR, glomerular filtration rate; PTH, parathyroid hormone; TSH, thyroid-stimulating hormone
 Cardiovascular risk factors
• Hypertension
• Obesity
• Dyslipidemia
• Diabetes mellitus
• Cigarette smoking
• Physical inactivity
• Microalbuminuria or GFR < 60 ml/min
• Age (>55 for men, >65 for women)
• Familiy history of premature cardiovascular disease
 Goals of Therapy
• Treating SBP and DBP to targets that are
<140/90 mmHg is associated with a
decrease in CVD
• Diabetes or CKD, the BP goal is <130/80
mmHg
• DM or CKD with proteinuria, th BP is <125/75
mmHg
 JNC 7: Treatment Algorithm for Hypertension
Lifestyle modifications

Not at goal blood pressure (<140/90 mm Hg)

(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial drug choices

Without compelling indications With compelling indications

Stage 1 hypertension Stage 2 hypertension Drugs for compelling indications

(SBP 140–159 or DBP 90–99 mm Hg) (SBP 160 or DBP 100 mm Hg) Other antihypertensive drugs
Thiazide-type diuretic for most. Two-drug combination for most (diuretic, ACEI, ARB, BB, CCB) as
May consider ACEI, ARB, BB, CCB, (usually thiazide-type diuretic and needed.
or combination. ACEI or ARB or BB or CCB).

Not at goal blood pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.

SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin-

converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=-blocker;
CCB=calcium channel blocker
JNC 7. May 2003. NIH publication 03-5233.
Table 3. Lifestyle Modifications to Manage Hypertension*
 Compelling indications
Indications Antihypertensive

Diabetes mellitus no proteinuria Diuretic (ALLHATT), perhaps ACEI (HOPE)

Diabetes mellitus proteinuria ACEI/ARB
CKD ACEI/ARB
Post myocardial infarct ACEI, B blocker, aldosteron antagonist
Systolic heart failure ACEI/ARB, B blocker, diuretic,aldosteron antagonist
High coronary disease risk Diuretic (ALLHATT), perhaps ACEI (HOPE)
Angina pectoris B blocker, Ca antagonist
AF/Atrial flutter rate control B blocker, non dihydropyridine ca channel blocker
BPH Alpha blocker
Hyperthyroidism B blocker
Essential tremmor B blocker (non cardioselective)
Migraine B blocker, ca channel blocker
Perioperative hypertension B blocker
Raynaulds syndrome Dihydropyridine Ca channel blocker (CCB)
Pregnacy CCB,methyldopa,B blocker
ISH (elderly) CCB, diuretic
 Should not be used

Indications Antihypertensive avoided

Bronchospastic disease B blocker
Pregnant ACE/ARB
Depression Reserpine, central alpha blocker, B blocker
Angioedema ACEI
Gout Diuretic
Renovascular disease ACE/ARB
Hyponatremia Thiazide
Second/third degree AV- B blocker, non dihydropyridine ca channel
block blocker
Liver disease Methyldopa
Oral antihypertensive drugs*
 Follow-up and Monitoring
• Follow-up and adjustment of medications at monthly
intervals or until the BP goal is reached.
• More frequent visits hypertension stage 2 or with
complicating comorbid conditions
• After BP is at goal and stable, follow-up each at 3- to
6-month intervals
• Low-dose aspirin therapy should be considered only
when BP is controlled because of the increased risk
of hemorrhagic stroke
BGA
Metabolic acidosis:
• -If pCO2 is less than expected, a respiratory alkalosis
is also present
• -If pCO2 is greater than expected, a respiratory
acidosis is also present
• -If pCO2 equals the value, pure metabolic alkalosis is
present

Metabolic Alkalosis:
• -If pCO2 is less than expcted, a respiratory alkalosis
maybe present (<40 mmHG)
• -If pCO2 is much greater than expected, a respiratory
acidosis maybe present(>50 mmHG)
• -If pCO2 equals the valuer, a pure metabolic alkalosis
probably present
•
Respiratory Acidosis:
• -If pH or HCO3 is lower, metabolic acidosis is
present
• -If pH or HCO3 is higher, metabolic alkalosis is
present
• -If equal, pure respiratory acidosis is present

Respiratory alkalosis:
• -If pH or HCO3 is lower, metabolic acidosis is
present
• -If pH or HCO3 is higher, metabolic alkalosis is
present
• -If equal, pure metabolic alkalosis is present