ACUTE RENAL FAILURE (Kuliah)

GAGAL GINJAL AKUT
(PASIEN BEDAH)
A A Gde Oka
Seksi Urologi Lab/SMF Ilmu Bedah

14-Aug-17 1
FK UNUD/ RS Sanglah DENPASAR
PENDAHULUAN
Batasan
Pembahasan
1. Presentasi kasus
2. Sasaran dan Objektif
3. Diskusi
4. Etiologi
5. Diagnosis
6. Terapi
7. Pronosis
14-Aug-17 2
Batasan
Acute Renal Failure(ARF)
Gagal ginjal akut(GGA)
Penurunan fungsi ginjal akut
Akumulasi sisa metabolisme dlm. tubuh
Peningkatan BUN/SC
Peningkatan SC secara akut > 0,5 gr% (N)

14-Aug-17 3
Presentasi kasus
Seorang laki 20 tahun referal dari RS
Kabupaten setelah kecelakaan lalu-
lintas 72 jam yang lalu datang ke UGD
RS Sanglah dengan tanda vital Tensi
60/-mmHg,Nadi 120x/mnt, Pemeriksaan
fisis konjungtiva pucat, abdomen
distensi dan produksi urin pada DK 10
cc/jam
14-Aug-17 4
Sasaran dan Ojektif
MHS dan Residents
Dasar-dasar Fisis dan Diagnosis/Lab/RO
Etiologi
Prerenal
Renal/intrinsik
Postrenal/Obstruksi uropati
Terapi
Prognosis

14-Aug-17 5
Etiologi
Penurunan RBF(Prerenak)
Terjadinya perusakan
parenkhim(Renal/intrarenal/intrinsik)
Obstruksi aliran
urin(Postrenal/obstruksi uropati)

14-Aug-17 6
Etiologi
Prerenal :
Penurunan vol.Intravask.efektif
Kehilangan cairan(Luka bakar,Pedarahan)
Masuknya cairan ke-ruang III (Sepsis/Peritonitis)
Penurunan COP
Gagal jantung
Peny.katup
Perikarditis
Tamponade
Peny.ginjal vaskuler
14-Aug-17 7
Etiologi
Renal :
Glomerulus
Primer(Post-Streptokokus,Glomerulonefritis)
Sekunder(SLE)
Tubulointerstitial
Iskhemik(ATN)
Nefrotoksin(Aminoglikosida.Mediakontras)
Alergi(Drug-Induce)
Toksin metabolik(Asam Urat)
Logam berat(CIS-Platinum)
Vaskuler
Emboli
Small vessel(Sceroderma,HHD,DIC)
14-Aug-17 8
Etiologi
Postrenal :
BPH/ prostate cancer
Cervical cancer
Retroperitoneal disorders
Intratubular obstruction (crystals or myeloma
light chains)
Pelvic mass or invasive pelvic malignancy,
Intraluminal bladder mass (clot, tumor or
fungus ball)
Neurogenic bladder
Urethral strictures
14-Aug-17 9
Prerenal Causes of Acute Renal
Failure:

14-Aug-17 10
Intrinsic renal Causes of Acute
Renal Failure:

14-Aug-17 11
Diagnosis
Anamnesis(Symptoms)
Anoreksia
Lemah
Perubahan mental
Mual, muntah
Pruritus
Penurunan kesadaran
Nafas dangkal
14-Aug-17 12
Evaluation of the medical history
* has nausea, vomiting, and/or diarrhea been present ?
* Has bleeding occurred ?
* does the patient have a history of heart failure or recent
symptoms of dyspnea ?
* does the patient have a history of chronic liver disease,
hepatitis, or jaundice ?
* does the patient have a history of previous renal
insufficiency ?
* has edema, high blood pressure, or a change in urine
color occurred ?
14-Aug-17 13
Evaluation of the medical history
* has the patient had any unusual rashes develop
recently ?
* what medications has the patient been placed on, in
particular, are there any new medications ?
* has the patient been ill enough to have prolonged
episodes of hypotension ?
* has the patient received any contrast dyes ?
* does the patient have a history of renal stone disease
or evidence or lower urinary tract obstruction ?

14-Aug-17 14
Diagnosis
Pemeriksaan fisis(Signs)
Asterixis, mioclonus
Pericardial/pleural rub
Periperal edema
Pulmonary reles
Tekanan atrium kanan meningkat

14-Aug-17 15
Diagnosis
Pemeriksaan penunjang
Lab
Ro

14-Aug-17 16
The urine sediment findings are
summarized in the following table:

14-Aug-17 17
Urine and Serum Diagnostic
Indices:
FENa (%) = (Urine sodium / plasma sodium) x 100

(Urine creat. / plasma creat)
14-Aug-17 18
Laboratory Findings in the Differential
Diagnosis of Acute Renal Failure:

14-Aug-17 19
Classification of chronic
kidney disease
This classification is based on estimated GFR, and recognises
five stages of kidney disease, as follows:
Stage 1: Normal GFR; GFR >90 mL/min/1.73 m 2 with other
evidence of chronickidney damage*
Stage 2: Mild impairment; GFR 60-89 mL/min/1.73 m 2 with
other evidence of chronickidney damage*
Stage 3: Moderate impairment; GFR 30-59 mL/min/1.73 m 2
Stage 4: Severe impairment: GFR 15-29 mL/min/1.73 m 2
Stage 5: Established renal failure (ERF): GFR < mL/min/1.73
m 2 or on dialysis

14-Aug-17 20
The other evidence of chronic kidney
damage may be one of the following:
Persistent microalbuminuria
Persistent proteinuria
Persistent haematuria
(after exclusion of other causes, e.g.
urological disease)

14-Aug-17 21
Measurement of excretory kidney
function
Method for measurement of excretory kidney function
Kidney function in patients with CKD should be assessed by formula-based
estimation of
GFR, preferably using the 4-variable Modification of Diet in Renal Disease (MDRD) 26
equation a : Level of evidence 3 DA
GFR (mL/min/1.73m 2 ) = 186 x {[serum creatinine (mol/L)/88.4] -1.154 } x age (years)
-0.203
x 0.742 if female and x 1.21 if African American
All clinical biochemistry laboratories should report estimates of GFR alongside
measurements of serum creatinine.b When estimated GFR exceeds 90 mL/min/1.73 m
2 , it
should be reported as >90 mL/min/1.73 m 2
Laboratories should communicate to their users (possibly using the laboratory
report) the
following information:
a) that GFR estimates between 60 and 89 mL/min/1.73 m 2 do not indicate CKD
unless there is other laboratory/clinical evidence of disease
b) that the estimated GFR should be multiplied by 1.20 for African-Caribbean
patients, unless ethnic origin was available to the laboratory and this correction has
already been applied.
14-Aug-17 22
14-Aug-17 23
Key Symptoms Findings in Patients with
Acute Renal Failure and Uremia
1. Symptoms
Anorexia
Fatigue
Mental status changes
Nausea and vomiting
Pruritus
Seizures (if blood urea nitrogen level is very
high)
Shortness of breath (if volume overload is
present)
14-Aug-17 24
Key Physical Findings in Patients with
1. Symptoms
Anorexia
Fatigue
Nausea and vomiting
Pruritus
Seizures (if blood urea nitrogen level is very
high)
Shortness of breath (if volume overload is
present)
14-Aug-17 25
Key Symptoms in Patients with
1. Symptoms
Anorexia
Fatigue
Nausea and vomiting
Pruritus
Seizures (if blood urea nitrogen level is very high)
Shortness of breath (if volume overload is present)

14-Aug-17 26
Key Physical Findings in Patients with
1.Physical findings
Asterixis and myoclonus
Pericardial or pleural rub
Peripheral edema (if volume overload is
present)
Pulmonary rales (if volume overload is
present)
Elevated right atrial pressure (if volume
overload is present)
14-Aug-17 27
Probable Causes of Acute Renal Failure
Based on the Findings of the History
History Probable causes of

Review of systems acute renal failure
1. Pulmonary system Pulmonary-renal
Sinus, upper
respiratory or
syndrome or
pulmonary symptoms vasculitis
2. Cardiac system
Symptoms of heart
failure
Decreased renal
Intravenous drug perfusion
abuse, prosthetic valve Endocarditis
or valvular disease

14-Aug-17 28

1. Gastrointestinal system
Diarrhea, vomiting or
poor intake Hypovolemia
Colicky abdominal
pain radiating from Urolithiasis
flank to groin
2. Genitourinary system
Symptoms of benign Obstruction
prostatic hypertrophy

14-Aug-17 29

acute renal failure
Review of systems
1. Musculoskeletal Multiple myeloma or
prostate cancer
system Rhabdomyolysis
Bone pain in the (pigment nephropathy)
elderly
Trauma or prolonged Allergic interstitial
immobilization nephritis, vasculitis,
systemic lupus
2. Skin erythematosus,
atheroemboli or thrombotic
Rash thrombocytopenic purpura

14-Aug-17 30

1. Constitutional Malignancy or
symptoms
vasculitis
Fever, weight loss,
fatigue or anorexia
2. Past medical history Neurogenic
Multiple sclerosis,
diabetes mellitus or
bladder
stroke

14-Aug-17 31

1. Past surgical history Ischemia, atheroemboli,
Recent surgery or endocarditis or
procedure exposure to contrast
2. Medication history agent
Angiotensin- Ischemia, atheroemboli,
converting enzyme endocarditis or
inhibitors, exposure to contrast
nonsteroidal anti-
agent
inflammatory drugs,
antibiotics or
acyclovir (Zovirax)
14-Aug-17 32
Findings of Blood Tests for Specific
Types of Acute Renal Failure
Findings on blood tests Diagnoses to consider
Elevated creatine Rhabdomyolysis
kinase or
myoglobin levels Prostate cancer
Elevated prostate- Multiple myeloma
specific antigen Systemic lupus
Abnormal serum erythematosus,
protein postinfectious
electrophoresis glomerulonephritis,
Low complement subacute bacterial
levels endocarditis
14-Aug-17 33
Positive antineutrophilic Small-vessel vasculitis
cytoplasmic antibody (Wegener's
Positive antinuclear granulomatosis or
antibody or antibody to polyarteritis nodosa)
double-stranded DNA
Systemic lupus
Positive antibody to
erythematosus
glomerular basement
membrane Goodpasture's
Positive antibodies to syndrome
streptolysin O, Poststreptococcal
streptokinase or glomerulonephritis
hyaluronidase

14-Aug-17 34
Positive antibodies to Poststreptococcal
streptolysin O, glomerulonephritis
streptokinase or
hyaluronidase Hemolytic uremic
Schistocytes on syndrome or
peripheral smear, thrombotic
decreased haptoglobin thrombocytopenic
level, elevated lactate purpura
dehydrogenase level or
elevated serum Liver disease or
bilirubin level nephrotic
Low albumin level syndrome
14-Aug-17 35
Differential Diagnosis of
Acute Renal Failure
Types of acute renal Possible disorders
failure and underlying Sepsis, hemorrhage,
overdiuresis, poor fluid
problem intake, vomiting,
1. Prerenal diarrhea
True intravascular Congestive heart
depletion failure, cirrhosis or
Decreased effective hepatorenal syndrome,
circulating volume to nephrotic syndrome
the kidneys Angiotensin-converting
Impaired renal blood enzyme inhibitors,
flow because of nonsteroidal anti-
exogenous agents inflammatory drugs

14-Aug-17 36
Acute Renal Failure
Intrinsic Possible disorders
Ischemia
Acute tubular Toxins: drugs (e.g.,
aminoglycosides), contrast
necrosis agents, pigments (myoglobin
or hemoglobin)
Glomerular Rapidly progressive
disease glomerulonephritis: systemic
lupus erythematosus, small-
vessel vasculitis (Wegener's
granulomatosis or
polyarteritis nodosa),
Henoch-Schonlein purpura
(immunoglobulin A
nephropathy), Goodpasture's
syndrome

14-Aug-17 37
Acute Renal Failure
Intrinsic Possible disorders
Acute proliferative glomerulonephritis:
Vascular disease endocarditis, poststreptococcal
infection, postpneumococcal infection
Interstitial disease Microvascular disease: atheroembolic
disease (cholesterol-plaque
microembolism), thrombotic
thrombocytopenic purpura, hemolytic
uremic syndrome, HELLP syndrome or
postpartum acute renal failure
Macrovascular disease: renal artery
occlusion, severe abdominal aortic
disease (aneurysm)
Allergic reaction to drugs, autoimmune
disease: (systemic lupus
erythematosus or mixed connective
tissue disease), pyelonephritis,
infiltrative disease (lymphoma or
leukemia)

14-Aug-17 38
Acute Renal Failure
Postrenal Possible disorders
Benign prostatic
hypertrophy or prostate
cancer, cervical cancer,
retroperitoneal disorders,
intratubular obstruction
(crystals or myeloma light
chains), pelvic mass or
invasive pelvic
malignancy, intraluminal
bladder mass (clot, tumor
or fungus ball),
neurogenic bladder,
urethral strictures
14-Aug-17 39

ACUTE RENAL FAILURE (Kuliah)

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GAGAL GINJAL AKUT

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

FENa (%) = (Urine sodium / plasma sodium) x 100

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

History Probable causes of

Seksi Urologi Lab/SMF Ilmu Bedah

History Probable causes of

Seksi Urologi Lab/SMF Ilmu Bedah

History Probable causes of

Seksi Urologi Lab/SMF Ilmu Bedah

History Probable causes of

Seksi Urologi Lab/SMF Ilmu Bedah

History Probable causes of

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

Seksi Urologi Lab/SMF Ilmu Bedah

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