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8/15/2019 PresKas (Chronic Kidney Disease) FIX
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PRESENTASI KASUS
Pembimbing :
dr.ANGGRAINI PERMATA SARI,Sp.PD
FAKHRI MUHAMMAD
1112100000!"
FE#$ %U&ANDARI
111110000010
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Iden'i'() p()ien *
• N(m( : N+. TA
• N. RM : 01-10!
• U)i( : / '(n
• Ag(m(: I)(m
• S3 : Snd(
• S'(') : Sd( Meni3(
• Pendidi3(n : T(m(' S&TA
• A(m(' : 4. Perm Reni 4(+( #3 0560
• Diperi3)( di pi pen+(3i' d((m p(d( (ri Senin '(ngg( - Apri 201/ p305.00
• M()3 in)'(()i r(7(' in(p Gedng Ter('(i (n'(i / U'(r( Rm( S(3i' Umm
P)(' F('m(7('i p(d( (ri Senin '(ngg( - Apri 201/ p3 20.00
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ANAMNESIS
Anamnesis dilakukan secara autoanamnepada hari Selasa pada tanggal 5 April 2016
08.00, di bangsal IRA !eratai, ruang 605
Ke(n '(m(:
&em() +(ng member(' )e8(3 1 (ri SMRS
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RI%A$AT PEN$AKIT SEKARANG
P()ien )er(ng 7(ni'(, / '(n, d('(ng 3e(n 3e pi pen+(3i' d(
deng(n keluhan lemas yang semakin memberat sejak 1 hari SMRS .Lemas dirasakan di seluruh tubuh. Keluhan baru dirasakan pertamakali. Keem((n )i)i )ebe( 'b +(ng 'ib(9'ib(, penrn(n 3e)(d(rbi(r( pe, )er'( 3ering(' dingin di)(ng3(. Ke(n m( d(n mn'(
di)(ng3(. Ri7(+(' )e)(3 n(;() d(n b('3 (m( 8g( di)(ng3(. Pasien juga merasa nafsu makan berkurang. Minum dibatasi 600 ml per hasejak didiagnosa mengalami gagal ginjal bulan SMRS. !"K sedikit#paling banyak $% kali dalam sehari dan &olume nya dalam sekali !tidak men'apai 1 gelas belimbing. Tid(3 (d( 3e(n n+eri ('(pnberd(r( 3e'i3( #AK. #A# Tid(3 (d( 3e(n. Ri7(+(' minm b('9
b('(n (n'i n+eri )ebemn+( di)(ng3(.
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• P()ien 'erdi(gn)i) meng((mi gagal ginjal sejak bulan yanglalu d(n )d( di)(r(n3(n n'3 di(33(n emdi(i)( 'e'(pip()ien menolak dilakukan hemodialisa. P()ien r'in 3n'r 3epi pen+(3i' d((m )e'i(p 1 b(n )e3(i. Pasien terdiagnosis (dan hipertensi sejak 10 tahun yang lalu dengan pengobatan
yang tidak teratur. S((' ini p()ien r'in menggn(3(n e
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Ri7(+(' Pen+(3i' D(
• Ri7(+(' A)m( di)(ng3(
• Aergi b(' di)(ng3(
• S(3i' 3ning di)(ng3(
• S(3i' 8(n'ng di)(ng3(
• Keg(n()(n di)(ng3(
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Ri7(+(' Pen+(3i' Ke(rg(
• )bu pasien mengalami ri*ayat ken'ing manis
• "dik pasien memiliki ri*ayat hipertensi dan ken'ing manis
• Ri7(+(' ()m(, (ergi, )(3i' 3ning, )(3i' 8(n'ng, d(n 3eg(n()(ndi)(ng3(
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Ri7(+(' S)i( E3nmi
• P()ien )er(ng ib rm( '(ngg(, )d( meni3( d(n memii3i r(ng (n(3. P()ien 'ingg( ber)(m( )(mi d(n (n(3 'er(3irn+(.Ri7(+(' mer33 d(n minm (3 di)(ng3(. 4(min(n 3e)e(berp( 4KN.
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• Pemeri3)((n Fi)i3 di(33(n )e(r( ('(n(mne)i) p(d( (ri Se
'(ngg( ! Apri 201/ p3 05.00, di b(ng)( IRNA Ter('(i, r(n
/0! E
Pemeri3)((n Fi)i3
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Pemeri3)((n Fi)i3
• Ke(d((n mm : T(mp(3 )(3i' )ed(ng
• Ke)(d(r(n : Kmp) Men'i)
• Si3(p : #erb(ring
• Kper()i : Kper('i;
• T# : 1!!m
• ## : !- 3g
• #MI : 22,-"
• Te3(n(n D(r( : 1+0,100 mm-g
• N(di : =6 meni', reg(r, i)i 3p, e>(
• Pern(;()(n : 1 =6 meni', reg(r, 3ed((m(n 3p
• S : /," ?@
8/15/2019 PresKas (Chronic Kidney Disease) FIX
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Kepala Nrm)e;(i, r(mb' i'(m 'er)eb(r mer('(,
'id(3 md( di(b', 7(8( )ime'ri)
Mata Konjungti&a pu'at /,/# )3er( i3'eri3 969, re;e3)
((+( (ng)ng '(3 (ng)ng B6B, ppi b('
i)3r, 3e3er(n en)( C969
elinga Nrm'i(, n+eri 'e3(n 'r(g) 969, )ermen 969,
i(ng 'eing( (p(ng, membr(n 'imp(ni in'(3
-idung Sep'm de
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antung In)pe3)i : I3') 3rdi) 'id(3 'eri('
P(p()i : Pulsasi i'tus di )2S 3 'm lateral dari linea midkla&ikula sinistra
Per3)i : #('() 8(n'ng 3(n(n : I@S I ine( p(r()'ern(i) de='r(
!atas jantung kiri )2S 3 'm lateral dari linea midkla&ikula sinistra
Pingg(ng 8(n'ng : I@S II ine( p(r()'ern(i) )ini)'r(
A)3'()i : #4 I, II reg(r, mrmr C9, G(p C9Paru In)pe3)i : #en'3 d(d( nrm(, ime'ri) )((' )'('i) d(n din(mi), pengb(n' n(;()C9 re'r(3)i )e( ig( C9
P(p()i : F3( ;remi') nrm( di 3ed( (p(ng p(r
Per3)i : Snr di 3ed( (p(ng p(r
A)3'()i : S(r( n(;()
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Abdmen :
In)pe3)i : D('(r, Di('()i
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• Pemeri3)((n &(br('rim di(33(n p(d( '(ngg(
2606201/, 1 mingg )ebem p()ien memeri3)(3(n diri
3e pi
Pemeri3)((n &(br('rim
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Pemeri3)((n &(br('rim
Pemeriksaan 4ilai Rujukan $5,0,$016
Hemoglobin 11,7 – 15,5 gr/dl 8,7
Hematokrit 33 – 45 % 25
Leukosit 5 – 10 rb/ul 8,1
Trombosit 150 – 440 rb/ul 478
Eritrosit 3,8 – 5,2 t/ul 2!"4
VER 80,0-100,0 fl 84,3
HER 26,0-34,0 pg 2,5
!HER 32,0-36,0 g/"l 34,
R#$ 11,5-14,5 % 14,5
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Pemeriksaan 4ilai Rujukan $5%0%$016
Hitung #enis
&'sofil 0-1 % 0
Eosino$il 13 % 7
(etrofil 50-)0 % 51
Li*fosit 20-40 % 33
+oosit 2-8 % )
Lu . 4,5 2
&ungsi 'inal
(sam urat dara) * 7 mg/dl ",4
+reum dara) 2040 mg/dl 13"
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Pemeri3)((n Ni(i R83(n 2909201/
reatinin dara) 0,-1,5 mg/dl 7,1
.iabetes
'. 70140 mg/dl 148
'.2 80145 mg/dl 30"
emak
Trigliserida *150 mg/dl 407
olesterol total *200 mg/dl 28"
!olesterol H#L 28-63 *g/"l 41
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Pemeri3)((n Ni(i R83(n 2909201/
olesterol . *130 mg/dl 202
Elektrolit
atrium 135147 mmol/l 132
alium 3,105,10 mmol/l 5,82
lorida "5108 mmol/l 112
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• Pemeri3)((n U'r()ngr(p+ di(33(n p(d( '(ngg(
1606201/, 2 Mingg )ebem p()ien memeri3)(3(n diri
3e pi
Pemeri3)((n U'r()ngrp(+
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) t t i
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)nterpretasi
% Hep(r : U3r(n d(n ben'3 nrm(. Perm3((n reger, 'epi '(8(m
E)'r3'r p(ren3im mgen nrm(
Si)'im biier '(3 meeb(r. pr'( d(n ep('i3( b(i3
T(3 (d( S&
9 K.E :U3r(n d(n ben'3 nrm(. Dinding '(3 meneb(
T(3 (d( )dge6b('
9P(n3re():#e)(r d(n ben'3 nrm(. E)'r3'r mgen
D3') p(n3re('i3) 'id(3 meeb(r. Tid(3 (d( S63()i;i3()i
9 &en : U3r(n d(n ben'3 nrm(. P(ren3im mgen nrm(.
9 Gin8( 3(n(n :U3r(n d(n ben'3 nrm(. Dinding meneb(
Si)'em pe
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9 Gin8( Kiri : U3r(n d(n ben'3 nrm(. Dinding meneb(.
Si)'em pe
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Re)me
• P()ien 7(ni'( )i( / '(n deng(n 3e pi pen+(3i' d((m R
S(3i' F('m(7('i deng(n 3e(n em() +(ng )em(3in member('
1 (ri SMRS. &em() dir()(3(n di )er 'b. Ke(n b(r dir()
per'(m( 3(i
• P()ien 8g( menge3(n n(;) m(3(nn+( ber3r(ng
• P()ien dib('()i n'3 minm )eb(n+(3 /00 m per (ri )e8(3 didi(g
meng((mi g(g( gin8( b(n SMR. P()ien )d( di)(r(n3(n
emdi(i)( 'e'(pi p()ien men(3. P()ien r'in 3n'r 3e
pen+(3i' d((m )e'i(p 1 b(n )e3(i.
• #AK )edi3i', p(ing b(n+(3 29 3(i d((m )e(ri d(n
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• 10 '(n SMRS p()ien 'erdi(gn)i) DM d(n iper'en)i. S((' i' Gd(n TD p()ien men(p(i 200 mg6d d(n 1/06100. b(' +(ngdi3n)m)i p()ien )((' i' me';rmin !00 mg d(n (p'pri 12,!mg. Pengb('(n DM d(n iper'en)i 'id(3 'er('r.
• S((' ini n'3 pengb('(n DM p()ien menggn(3(n e
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• P(d( pemeri3)((n ;i)i3 did(p('3(n TD 1-06100 mmHg, 3n8ng'i<p(', 'erd(p(' peeb(r(n p(d( b('() 8(n'ng 3iri, edem( pi''ingminim( p(d( 3ed( 'ng3(i, d(n p()ien '(mp(3 p('.
• P(d( pemeri3)((n (br('rim did(p('3(n (nemi( nrm)i'i3nrm3rm, 'rmb)i')i), pening3('(n e)in;i, pening3('(n 3(
()(m r(' d(r(, rem d(n 3re('inin d(r(, pening3('(n 3(d(r Gd(n GD2PP, di)ipidemi(, ipn('remi, iper3(im, iper3rid(
• P(d( pemeri3)((n 'r()ngr(p+ did(p('3(n 3e)(n rni ren(di)e()e bi('er(
• P()ien diin)'r3)i3(n n'3 dir(7(' e dr. 4. S(r7n, SpPD, KGd(n p()ien )e'8 n'3 di(33(n emdi(i)(
8/15/2019 PresKas (Chronic Kidney Disease) FIX
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D(;'(r M()((
• @KD )'(ge pr HD
• Anemi( nrm)i'i3 nrm3rm
• DM 'ipe 2, nrm7eig', GD bem 'er3n'r, n reg()i in)i
• Hiper'en)i gr(de II bem 'er3n'r
• Di)ipidemi(• Hiper3(emi(
• Trmb)i')i)
• E)in;ii(
• S)pe3 3(rdimeg(i
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Ren(n( T('((3)(n( n'3 Ed3()i
• Ed3()i p()ien mengen(i pen+(3i' )((' ini d(n ren(n( 'ind(3(ndep(n.
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Ren(n( T('((3)(n( n'3 Di(gn)i)
• Ee3'r3(rdigr(;i
• R. Tr(=
• Pemeri3)((n ee3'ri', CN('rim, K(im, @rid(, M(gne)im,F);r, (bmin, rin(i)(, (n(i)i) g() d(r(, )reening HD CAnH@, H#)Ag.
8/15/2019 PresKas (Chronic Kidney Disease) FIX
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Ren(n( T('((3)(n( n'3 Ter(pi
• Die' DM 1!00 33(6(ri, pr'ein 0, gr63g bb, rend( g(r(m
• IFD en;n
• &e
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@KDS'
gmeng((mi g(g(
gin8( , di)(r(n3(nHD b(n SMRS
Ri7(+(' memii3iDM d(n Hiper'en)
10 ' +
PF: TD1-06100,
pening3('(GDS: 1+5
7($PP 0
Ib d(n (di3 p()iememii3i ri7(+('
Hiper'en)i m(pDM
&(b: (). Ur(': 5,-
Ur6@r: 15, ",1
eGFR: !,/
R.d6:
(bmin,rin(i)(,
(n(i)i) g()d(r(
Hipn('remi(,iprid(,iper3(emi(
R.D6:
Pemeri3)((nee3'ri' Cn(,
3, , mg, P
USG (bd: Gin8(3(63i 3()i;i3()i,3r(n mengei
C5,0/65,0Ke)(n:@rni
Kidne+ Di)e()e
R.,
Pemasangan 2(Lu,-(
2a2o# !i'nat# 3it!1$# "s. 8olat# diet
rendah protein
R.(,
S'reening -(
An(i)( K())
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@KD S'(ge
• Ker)(3(n gin8( )e(m( b(n +(i' bi( di8mp(i 3e(in(n
)'r3'r ('( ;ng)i gin8( deng(n ('( '(np( penrn(n GFR
deng(n )(( )(' m(ni;e)'()i :
• 3e(in(n p('gi
• pe'(nd( 3er)(3(n gin8( 'erm()3 3e(in(n 3mp)i)i d(r( ('( rin (
r(digi
• GFR /0 m6meni'61," m2 b(n deng(n ('( '(np(
3er)(3(n gin8(
Sd+, Ar %, d33. Buku Ajar Ilmu Penyakit Dalam jilid 1 edisi IV . 4(3(r'(
Penerbi'(n Im Pen+(3i' D((
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• N('in( Kidne+ Fnd('in: Kidne+ Di)e()e 'me) J(i'+ Ini'i('i
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Rm)@3r;'9G('6
MDRD #tudy %uations
♂LFG (ml/menit/1,73m2) = (140 umur) x
beratbadan72 x kreatinin plasma (mg/dL)
♀LFG (ml/menit/1,73m2) = 0,! x (140 umur) xberatbadan
72 x kreatinin plasma (mg/dL)
LFG (mL/min per 1"73 m2) = 1# x (kreatininplasma)$1"1!4 x (umur)$0"203
♀dikali 0,742 % keturunan &'rika &merika dikali 1,21
• 9 N('in( Kidne+ Fnd('in: Kidne+ Di)e()e 'me) J(i'+ Ini'i('i
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K()i;i3()i E'igi
A
E'igi d(n Epidemigi
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E'igi d(n Epidemigi
"merika Serikat
4o. Penyebab )nsiden
1 (iabetes mellitusipe1ipe$
++# 93, 41,0
$ -ipertensi danpenyakit pembuluh
darah besar
$:#$ 9
7lomerulonefritis 5#$9
+ 4efritis interstitial 3,#
; Kista# penyakitba*aan #1 9
6 Penyakit sistemik
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↓
Massa ginjal
Molekul &asoaktif gro*th fa'tor=
-ipertrofi struktural > fungsional nefron yang masih tersisa aliran darah glomerulus
Sklerosis nefron
↓
8ungsi nefron yg progresif Abminri(, iper'en)i,
ipergi3emi(, di)ipidemi(
↑ Urem 3re('inin d(r( "ksis R"" intrarenal
growth factor i'7 Patofisiologi7 E"isi 67 Volu*e 17 E?< ;'k'rt'7 20067
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Kmpi3()i Umm @KD
• "nemia
• -ipertensi • Sindrom ?remikum
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Hemdi(i)i) menr' KDJI 201!
• Ini)i()i HD : @KD )'(ge - CGFR 0• Fre3en)i d(n Dr()i : 9! 8(m, 9- 3(i per mingg
• Indi3()i HD @i' : A)id)i) CpH",1, in'3)i3()i,remi3m CremL200mg6D, g(ngg(n ee3'ri'C3(im )ermL/ mE>6&, (+, KDJI, 201! Upd('e.
T('( &(3)(n( Umm F(rm(3 @KD
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T('( &(3)(n( Umm F(rm(3 @KD
• "sam 8olat !910mg6(ri
• !1$ !0mg = )e(ri
• 4atrium !ikarbonat !00mg = )e(ri
• 2a2@ !00mg = )e(ri
Mengb(
m)i)'ein men8(dime'inine +)'eine
Meindngi
pemb.d(r( d(ri3er)(3(n
m)i)'ein
Pengi3(' ;);('T(rge': ,!9
!,!mg6d
d(n @( = P
!!mg26d2
M(n(8emen Anemi( p(d( @KD menr'
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M(n(8emen Anemi( p(d( @KD menr'Perne;ri
• Penyebab
De;i)ien)i eri'rpie'in merp(3(n pen+eb(b '(m(
• A&aluasi "nemia
(. Dim(i bi( Hb 10g6d&, H' 0O
b. Di(gn)i) (br('rim: Hb, H', mr;gi eri'r)i' CM@, M@H,
i'ng re'i3)i', )'(') be)i C)('r()i 'r(n);erin, ;eri'in )erm
. E
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Anemi( de;. #e)i
Fng)in(@3p
Peri3)( FS d(n ST
erapi !esi 8ase Koreksi
Irn )r)e6Irn De='r(n 100mg
)e'i(p HD 10=
"nemia def. !esi8ungsional
FS 100
ST 20O
2ukupFS 100
ST 20O
S'(') #e)i
"nemia def. !esi"bsolut
FS 100
ST 20O
Anemi( de;. #e)i
Ab)'
arget ResponH' 29-O d((m 29- mingg
Hb 192g6d& d((m - mingg
erapi AP@ fase koreksi
2.0009-.000 IU6 = HD?langi terapi besi fase koreksi
sampai status besi 'ukup
erku*pul' (efrologi "oesi' ER(ER7 "oesi'
Re'l Registr RR7 2011
arget Respon
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H' 29-O d((m 29- mingg
Hb 192g6d& d((m - mingg
@(ri pen+eb(b EP
re)i)'en
D)i) EP ;()e
pemei(r((n
idak er'apai
Per'((n3(n d)i) EP )(mp(i'(rge' Hb6H' 'er(p(i
Melebihi argetCH' L O 6 - mingg
D)i)
2!O
!elum er'apaiD)i) !0O 6 - mingg
er'apai
er'apai
erku*pul' (efrologi "oesi' ER(ER7 "oesi'
Re'l Registr RR7 2011
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• erapi anemia defisiensi besi
a. )ndikasi terapi besi: Anemi( de;i)ien)i (b)' d(n;ng)in(
b. Kontraindikasi terapi besi: Hiper)en)i'i
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"R7A
K(d(r -b B 10 g,dL dan -t B 09 b(i3 deng(npenge((n 3n)er
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Ter(pi
pen+.d()(r
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M(n(8emen Hiper'en)i p(d( @KD' 4N@ III
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menr' 4N@ III
• arget tekanan darah sistolik C1+0# diastolik C0.
• @bat yang direkomendasikan
- "ngiotensin%2on&erting AnDyme
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M(n(8emen DM p(d( @KDmenr' KDJI
• )nsulin D(p(' diberi3(n.
• Sulfonilurea H(n+( Gi3idn, Gimepiride,Gi(ide +(ng d(p(' diberi3(n.
• !iguanid Me';rmin 'id(3 be diberi3(n p(d( Sr 1,! mg6d& ('( GFR 20m&6min
• iaDolidinedion Pigi'(n d(p(' diberi3(n.
• Penghambat AnDim "lfa%7lukosidase A(rb)e 'id(3be diberi3(n p(d( GFR 0m&6min
• Penghambat (PP%+ Si'(gip'in: GFR L!0, 100mg6d,GFR 09!0, !0mg6d, GFR 0, 2!mg6d
@ini( Pr('i
Di(be'e) (nd
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M(n(8emen Di)ipidemi( p(d( DM d(n@KD menr' KDJI
• b(' gng(n S'('in
• Tid(3 dire3mend()i3(n 'er(pi S'('in n'3 p()iendi(be'e) +(ng men8((ni di(i)i)
@ini( Pr('ieDi(be'e) (nd @K
Die' in Ren( Di)e()e
8/15/2019 PresKas (Chronic Kidney Disease) FIX
52/54
@mNep
Prognosis
8/15/2019 PresKas (Chronic Kidney Disease) FIX
53/54
PrgIn'e
Nep
8/15/2019 PresKas (Chronic Kidney Disease) FIX
54/54