Aspek Klinis Hemodialisis - Campur

8/17/2019 Aspek Klinis Hemodialisis - Campur

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ASPEK KLINIS HEMODIALISISASPEK KLINIS HEMODIALISISDANDAN

CONTINOUS AMBULATORY PERITONEALCONTINOUS AMBULATORY PERITONEALDIALYSIS ( CAPD )DIALYSIS ( CAPD )

WACHID PUTRANTO


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BAB II

TINJAUAN PUSTAKA

DEFINISI CKD: National Kidney Foundation 2002 =1. Kerusaka !"#a$ se$a%a & ' ($)*! +",u#ukka +! a+a-

*a a(r%a$",as s,ruk,ur a,au /u!s" !"#a$) +! a,au

,aa eurua FR) *! %e%u*a" %a"/es,as" : a(r%a$",as k%s"s" +ara a,au ur") a,au

a(r%a$",as +a$a% imaging test .

2. FR 3 40 %$ 5 %e", se$a%a & ' (u$a


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TAHAPAN P6K INJA7 KRONIK:

1. Peurua 8a+a!a !"#a$ 9 /aa$ !"#a$ : 0 - ;< >.

2. Isu/"s"es" !"#a$ 9 /aa$ !"#a$ 20 - '. a!a$ !"#a$ 9 /aa$ !"#a$ < - 2< >.

. Ure%"a 9 /aa$ !"#a$ 3 10 >.

TAHAPAN BERDASAR FR ?ENURUT NKF 2002:

1. Kerusaka !"#a$ +! FR r%a$5%e"!ka,: & @0 %$5%,

2. Kerusaka !"#a$ +! eurua FR r"!a : 40 - @ .

'. Peurua FR se+a! : '0 -


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ETIO7OI Ber(e+a u,uk ,"a e!ara :

1. Here+",er.

2. Pe*ak", s"s,e%"k :

A. D?

B. Pe*ak", #ar"!a "ka,.

C. A%*$"+s"s)?*e$%a !"#a$) u,. D. H"er,es" eses"a$.

'. $%eru$e/r","s.

. Pe*ak", !"#a$ ,u(u$",ers,","a$.


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Gambaran klinis aal in!al kr"nis

1. Gejala subyektif (symptoms)

Umum : Lemah badan, cepat lelahSaluran cerna : nafsu makan turun, mual muntah, lidah hilan! rasa,

ce!ukan

"euromuskuer : tun!kai lemah, parestesi, kram otot#otot, daya konsentrasiturun, insomnia dan !elisah

$elamin : Libido menurun (hilan!), nokturia atau oli!uria

$ardio%askuler : Sesak nafas, sembab, batuk, nyeri perikardial

&. Gejala obyektif (si!ns)

Umum : "ampak sakit, men!urus

$ulit : 'iperpi!mentasi, kerin! (ekskoriasis)

$epala : Sembab (puffy), anemia, retinopati

$ardio%askuler : 'ipertensi, kardiome!ali, sembab

"euromukuler : "europati perifir, arteriksis, mioklonus

Laboratorium rutin

$enaikan U" kratinin serum, anemia normokrom normositer, lekopenia,trombopati, trombositopenia, hiperurikemia, hiperfosfatemia, hipokalsemia,


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PATOFISIO7OI P6K INJA7 KRONIK

Bricker : intact nephron hypotesis

INJUR6 KRONIK INJA7

KERUSAKAN NEFRON IREERSIBE7

PENURANAN ?ASA INJA7

KO?PENSASI:HIPERFI7TRASI ADAPTIF DARI

NEFRON 6AN ?ASIH BAIK.

FIBROSIS JAR.PARUT 9SK7EROSIS

7O?ERU7US>

DESTRUKSI HI7ANN6A NEFRON BERTA?BAH


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PERJA7ANAN PEN6AKIT INJA7

KRONIS


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Penyakit ginjal kronis

Meninggal Dialisis

HD di Rumah Sak

HD di RumahCAPD

Gagal

Transplantasiginjal Berhasil

Penyakit ginjal terminal

Terapi konservati

Algoritme program pengobatan gagal ginjal kronis (GGK)HD = Hemodialisis

CAPD = Continous Ambulatory Peritonial Dialysis


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#ak$"r %&mb'r'k la!' il$rasi l"m&r'l's (L#G)1. nfeksi : • ntrarenal (S$)

•*kstrarenal (penumonia, sindromsyok)

&. +bat "efrotosik : • mino!likosida• "S-s• emaktan

• /edia kontras

0. 'ipertensi berat (mali!nant)

. -epresi air dan "2 : • "atriuresis• Gastroentritis

3. +struksi : • Litiasis• 4rostat hipertrofi

5. 4embedahan atau trauma !anda6. Ga!al jantun! kon!estif

7. +bat antihipertensi yan! potent


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PENATA7AKSANAAN PK


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TERAPI KONSERATI#

*+ T'!'an ,

a+ M&n-amba$ m&mb'r'kn.a aal in!alb+ M&rinankan k&l'-an akiba$ ak'm'lasi$"ksin a/"$&mia

0+ M&m%&r$a-ankan m&$ab"lism& s&0ara"%$imal

1+ M&m&li-ara k&s&imbanan 0airan 1an&l&k$r"li$


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TERAPI KONSERATI#

2+ B&b&ra%a %rinsi% $&ra%i k"ns&r3a$i

• M&n0&a- ak$"r s'mba$an (ba$' 1ll)

• M&n-in1ari "ba$ n&r"$"ksik

• M&n0&a- 1an s&0&%a$n.a m&m%&rbaiki an'an

-im"1inamik

• M&n0&a- an'an &l&k$r"li$

• P&mba$asan %r"$&in (%r"%"rsi"nal)


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!! "endalikan hipertensi"endalikan hipertensi

!! Terapi #S" dan ineksi lainyaTerapi #S" dan ineksi lainya

!! "endalikan hiperosatemia$"endalikan hiperosatemia$

hiperuksemiahiperuksemia

!! "endalikan asidosis$"endalikan asidosis$

hiperglikemiahiperglikemia

!!

Terapi anemiaTerapi anemia


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4+ P&ranan Di&$

a+ T&ra%i r&n1a- %r"$&in

-ar's 1i-i$'n s&0ara %r"%"rsi"nal

K&'n$'nan ,

5 M&n0&a- ak'm'lasi $"ksin 'r&nia

5 M&n-amba$ m&mb'r'kn.a aal in!al


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(. Ke(u,ua #u%$a ka$r"(. Ke(u,ua #u%$a ka$r"

e%(er"a ka$r" arus 8uku ,eru,a%a +ar"e%(er"a ka$r" arus 8uku ,eru,a%a +ar"

(aa kar("+ra, #u%$a ka$r" *a! +"(er"ka $e("(aa kar("+ra, #u%$a ka$r" *a! +"(er"ka $e("

+ar" '< K8a$5K!BB5ar".+ar" '< K8a$5K!BB5ar".


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CKD STAE < TERAPI PENANTI INJA7 9 TP >

2 JENIS TERAPIPENANTI INJA7 :1. D"a$"s"s :

• He%+"a$"s"s

• Per",ea$ +"a$"s"s

2. Tras$a,as" !"#a$.


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TP TERUS ?ENERUS PERSIAPAN AAR

PASIEN ?EN6ESUAIKAN DIRI

EDUKASI PRE DIA7ISIS :

- Per#a$aa a$a%"a e*ak", !"#a$.

- Peru(aa +"",

- Pers"aa %e%asuk" ,aa !a!a$ !"#a$ ,er%"a$

Akses asku$er.


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INDIKASI HEMODIALISE

• KLINIS - Sesak (over hydrasi)- Nafas Kusmoul

- Hipertensi sulit terkontrol

- Prekoma

• KIMI!I - sidosis meta"olik

- Hiperkalemia- #reum $ %&& m'

- Kreatinin $ m'


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HE?ODIA7ISIS

Saa, %e%u$a" +"a$"s"s 9 I"s"as" > :

1. TKK 5 7F 3 10 %$ 5 %, +! !e#a$a ure%"a 5 %a$u,r"s".

2. TKK57F 3 < %$ 5 %, a$auu ,aa !e#a$a.

'. I+"kas" kusus :

- K%$"kas" aku, 9 e+e%a aru) "erka$e%") as"+s"s %e,a($"k

(eru$a! >

- D? : TKK 5 7F 3 1< %$ 5 %,

10 G u%ur 9,> BB 9 k! >

TKK = --------------------------------------------- Krea,"" seru% 9 %!5+$ > ;2

Wa",a 0)<


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K%$"kas" aku, e%+"a$"s"s :

1. H",es".

2. H"er,es".

'. ?ua$ %u,a.

. Sak", kea$a.


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KO?PONEN UTA?A :1. Ca"ra D"a$"sa, :

- Ase,a,.

- B"8ar(a,

2. D"a$"ser 5 "#a$ (ua,a:

- Te%a, ,#+*a 8u8" rses e8u8"a : e!e$uara sa%a5

,ks" as"$ %e,a($"s%e ,u(u.

- Je"s : a. Ka"$er 9$$ /"(er >.

(. Para$e$ $a,e. 8. C"$.

'. S"rku$as" +ara :

2 (a!"a (esar :

1. Sa$ura ar,er" 9 u,$e, > : sa$ura s($ +"a$"ser

%era. 2. Sa$ura ea 9 "$e, > : Sa$ura ss+ +"a$"ser

B"ru


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ASETAT

(mE67 L)

BICARBONAT

( mE67L)Na *48 5 *98 *48 : *98K ; : 9


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EA7UASI JANKA PANJAN PASIEN HD :

1. Pas"e (aru : - +ara $e!ka

- E$ek,r$", 9 Na) K) C$) Ca) P >

- HBsA!.

- A," HC. - F, +a+a.

- EK.

2. Sesua" #a+a$ : - Na)K)Ca) P) ureu% ,"a ' ($.

- SI) TIBC) Fer",".

- HBsA!) a," HC)AD)EK : 4 ($.

- Ekkar+"!ra/" : ' ,au.'. Pe%er"ksaa kusus:

- ?! 9 ar",%"a > PTH ,"a ,au.

Des",%e,r") ra+"$!"k) HI.


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CAPD

I+"kas" :

1. ?e+"k :- D?.

- P*k C : a!"a ) ka,u #a,u! (ua,a) ar",%"a.

- P*k kr"s : ae%"a kr"s.

HI s","/.

Ke$a"a er+araa.

Hea,","s.

2. Ps"kss"a$ :

- a*a "+u a$,"/.

- Taku, #aru%.

- Bu,u +"", *a! /$eks"(e$.


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KONTRA INDIKASI ABSO7UT :1. ?e+"s : Ra+a! usus *a! (era, - D"er,"ku$","s ak,"/ aku,.

- Iske%"k usus ak,"/.

- A(ses a(+%"a$"s.

2. Ps"kss"a$ : - Ps"ks"s ak,"/ 5 %a"k +eres"/.

- Ke,er(e$aka!a %e,a$ (era,


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KONTRA INDIKASI RE7ATIF :

-R"a*a, e%(e+aa eru,.

-ra/, ar,a.

-PPOK

-Ter+aa, k$sk".

-Ke!aasa s,a+"u% $a#u,.

-H"er,r"!$"ser"+e%"a (era,.


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Karak,er"s,"k Pas"e CAPD *a! "+ea$ :

1. ?,"as" (a!us.

2. Kea,ua (a"k.

'. I+ee+es".

. a*a "+u ak,"/.


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MN *N+ L,IH IK.


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ANTIKOAU7AN PADA HE?ODIA7ISIS

WACHID PUTRANTO


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TROMBOSIS+

-Pr"s&s %&mb&n$'kan $r"mb's a$a' a1an.a $r"mb's 1alam PD a$a'

r'an !an$'n+

-#ak$"r -&m"s$asis ,*+ Prim&r , @P&r$ama $&rliba$ bila a1a %&r1ara-an+

@Tr"mb"si$ 1an %&mb'l'- 1ara-+

@Dim'lai 1&nan 3as"k"ns$riksi PD 1an %&mb&n$'kan

%lak $r"mb"si$ 1 0ara,5 A1-&si , m&l&ka$ %1 11 PD+ 5 Ar&asi , salin m&l&ka$

2+ S&k'n1&r ,

@ #ak$"r %&mb&k'an 1an an$i%&mb&k'an+

@ Dim'lai 1&nan ak$i3asi k"a'lasi m&lal'i !al'r &ks$rinsik

1an in$rinsik+ Tr"mb's7 ibrin+

5 K&lainan -&m"s$asis P&r1ara-an a$a'%'n $r"mb"sis


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D&$&la- ibrin $&rb&n$'k an$ik"a'lan alamia- b&r%&ran

M&mba$asi $r"mb's+

An$ik"a'lan alamia- , 5 AT III+

5 Pr"$&in C+

5 Pr"$&in S +

5 H&%arin k"ak$"r II+

5 Ala * an$i$ri%sin+

5 Ala 2 makr"l"b'lin+


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TROMBOSIS PD ORGAN ITAL ,

5 OTAK+

5 an$'n+ B&rba-a.a+

5 Par'


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OBAT ANTITROMBOSIS

4 G"l"nan , *+ An$ik"a'lan+

2+ An$i%la$&l&$ ar&asi+ 4+ Tr"mb"li$ik 7 #ibrin"li$ik+

T'!'an %&mb&rian an$i$r"mb"sis ,

*+ M&n0&a- %&rl'asan $r"mb's+

2+ M&n'rani $&r!a1in.a r&k'r&nsi $r"mb's+

4+ M&n0&a- %&mb&n$'kan &mb"li+


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ANTIKOAGULAN ,

*+ Dir&k , 5 b&r'nsi lans'n sb An$i$r"mbin III+

5 H&%arin +

2+ In1ir&k , 5 m&m'$'skan -'b'nan an$ara ak$"r : ak$"r %&mb&k'an

.an 1ib&n$'k 1i -a$i ( # II


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9+ AP $i1ak s$abil+

8+ Tr"mb"sis b&r'lan+

+ Pr"ilaksis b&1a-+

DASAR PENUNAAN ANTIKOAU7AN PADA DIA7ISIS


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INTERAKSI P7AS?A ?E?BRAN DIA7ISIS

AKTIASI CASCADE PE?BEKUAN

-TRO?BOSIS PADA SIRKUIT EKSTRAKORPOREA7- DEPOSISI TRO?BIN PADA DIA7ISER

DISFUNSI DIA7ISER

DASAR PENUNAAN ANTIKOAU7AN PADA DIA7ISIS


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PENI7AIAN TERJADIN6A KOAU7ASI SE7A?A DIA7ISIS :

1. ISUA7 :

Dara ,er$"a, !e$a.Ba*a!a 5 e+aa ",a% +a$a% +"a$"ser.

Ter$"a, (ekua +ara

A$"ra +ara a+a eus $"e %e!a$"r $e(" $a%(a,

2. TES PE?BEKUAN DARAH 5 C7OTTIN TEST Jara! +"er"ksa

a+a +"a$"s"s ru,".

-PTT = Par,"a$ Tr%($as," T"%e .

-ACT = A8,"a,e+ C$,,"! T"%e


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OBAT G OBAT ANTITRO?BOTIK

ANTIP7ATE7ET ANTIKOAU7AN

ORA7 PARENTERA7 ORA7 PARENTERA7

-ASPIRIN-TIK7OPIDIN-C7OPIDORE7

P II (5 IIIa

a,a!"s

Ku%ar" HEPARIN7?WH

HIRUDINARATROBAN


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HEPARIN?EKANIS?E KERJA.

?e!ak,"/ka A,",r%(" III %e!a%(a, ,r%(" +a La

Hear" a8,"a,es

A,",r%(" III

LI LIa

IL ILa

III

PF' L La

PROTRO?BIN THRO?BIN

FIBRINOEN FIBRIN

ESSENTIA7 HE?ATO7O6


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HEPARIN : - ?ura.

- Cara e%aka"a %u+a.

- Ha$/ G $"/e e+ek.

Ds"s Cara e%(er"a : 1.


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KONTRAINDIKASI HEPARIN ,

Abs"l'$ , *+ P&r1ara-an ak$i+

2+ P&r1ara-an 0&r&br"s%inal+ 4+ Hi%&rs&nsi$i $-1 -&%arin+

9+ Ria.a$ HIT+

8+ Dia$&sis -&m"raik+

R&la$i , *+ Ul0's %&%$ik'm+

2+ Pas0a "%&rasi ma."r F 8 -ari+

4+ Tra'ma ma."r .an bar' sa!a $&r!a1i+

KO?P7IKASI :


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KO?P7IKASI :

1. Per+araa.

2. 7""+s : - ?e"!ka,ka Ka+ar Tr"!$"ser"+.

- ?euruka ka+ar HD7.'. Tr%(s",e"a : HIT

- T"e 1 : (eru(u!a +e!a +s"s +a $a%a*a e%(er"a

ear".

- T"e 2 : I%u!$(u$" .. Prur",us : a,a$ +a reaks" a$er!" saa, D"a$"s"s M


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CARA PEMBERIAN HEPARIN+

H&%arin , 5 BM b&sar< $1k bisa m&l&a$i m&mbran+

5 T1k 1is&ra% 's's+ 5 T1k m&l&a$i %las&n$a+

Han.a 1a%a$ i37s0


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DIA7ISIS TANPA HEPARIN. INDIKASI :

1. Pas"e +e!a er+araa ak,"/.2. K,ra"+"kas" Hear" : HIT

?e8e!a 8$,,"! a+a +"a$"ser : !u*ur +e!a sa$".


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Per"kar+","s

Pe%(e+aa : - Be+a #a,u!.

- Be+a %a,a 9 re,"a +a ka,arak >.

- Tras$a,as" !"#a$.

- Be+a ,ak.

Ka!u$a,".

Tr%(s",e"a.

Per+araa ",rasere(ra$.

Per+araa ak,"/.

INDIKASI DIA7ISIS TANPA HEPARIN


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PANDUAN HEPARIN PADA KASUS KO?ORBID

1. Per+araa R"s"k er+araa.

; ar" as8a eras" %a*r. Taa ear"

1 ar" as8a eras" ",ra8ra"a$ .

2. ;2 #a% as8a ("s" r!a "s8era Taa ear".

'. & ; ar" aska eras" %a*r a,au & ;2 #a% aska ("s" Hear".

. D"a$"s"s ;2 #a% s($ (e+a %"r Taa ear".


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7OW ?O7ECU7AR WEIHT HEPARIN 9 7?WH >

-R"s"k er+araa $e(" ke8"$.

- Jara! %e*e(a(ka ,r%(s",e"a.

- T"+ak er$u %",r"! ke,a, a+a as"e DT.


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Aspek Klinis Hemodialisis - Campur