5. patologi arf crf tp

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Pathogenesis and Management of

Renal Failure

and

Replacement Therapy forStage V Chronic Renal Disease

dr. Heru Prasanto, Bambang DjarwotoSub bagian Ginjal Hipertensi,

Bag Penyakit Dalam FK UGM / RSUP DR Sardjito, Yogyakarta



ACUTE RENAL FAILURE

• ACUTE renal failure is characterized by a

deterioration of renal function over a period

of hours to days, resulting in the failure of the

kidney to excrete nitrogenous waste products

and to maintain fluid and electrolyte

homeostasis.



The RIFLE classification of ARF is as follows:

• Risk (R) - Increase in serum creatinine level X 1.5 or

decrease in GFR by 25%, or UO <0.5 mL/kg/h for 6hours• Injury (I) - Increase in serum creatinine level X 2.0 or

decrease in GFR by 50%, or UO <0.5 mL/kg/h for 12hours

• Failure (F) - Increase in serum creatinine level X 3.0,decrease in GFR by 75%, or serum creatinine level > 4mg/dL; UO <0.3 mL/kg/h for 24 hours, or anuria for12 hours

• Loss (L) - Persistent ARF, complete loss of kidney

function >4 wk• End-stage kidney disease (E) - Loss of kidney function

>3 months



Prerenal

• Prerenal azotemia is rapidly reversible if the underlying

cause is corrected.

• In the outpatient setting, vomiting, diarrhea, poor .uid

intake, fever, use of diuretics, and heart failure are allcommon causes.

• Elderly patients are particularly susceptible to prerenal

azotemia because of their predisposition to hypovolemia

and high prevalence of renal-artery atheroscleroticdisease.

• Among hospitalized patients, prerenal azotemia is often

due to cardiac failure, liver dysfunction,or septic shock.



Etiology pre renal ARF,

hypovolemia, hypotension and hypoperfusionkidney:

– Severe blood loss: trauma, bleeding. – Loss of plasma : combustio, peritonitis.

– Loss of water and electrolyte : acutegastroenteritis

– Hypoalbuminemia

– Heart failure: myocard infarct.

– Neonatus septic shock or severe asphyxia



Post renal Causes

• Acute renal failure occurs when both urinary outfow

tracts are obstructed or when one tract is obstructed

in a patient with a single functional kidney.

• Obstruction is most commonly due to prostatichypertrophy, cancer of the prostate or cervix, or

retroperitoneal disorders and often presents in the

outpatient setting.

• A neurogenic bladder can result in functional

obstruction.

• Other, less frequent, postrenal causes of acute failure

can be intraluminal, such as bilateral renal calculi



ARF Post renal

Obstruction cause by:

– Congenital : valvula uretrovesical

– Urolithiasis

– Trombosis arteri/vena renalis

– Tumor (prostate, pelvis)



Intrinsic Causes

• Intrinsic renal diseases that result in acute renalfailure are categorized according to the primary siteof injury: tubules, interstitium, vessels, orglomerulus.

• Injury to the tubules is most often ischemic or toxicin origin.

• ischemic tubular necrosis represent when bloodflow is suffciently the death of tubular cells.

• most cases are reversible if the underlying cause iscorrected (Aminoglycoside antibiotics andradiocontrast agents, chemotherapeutic agents /cisplatin)

• irreversible cortical necrosis can occur if the ischemiais severe, especially if the disease process includesmicrovascular coagulation such as may occur withobstetrical complications, snake bites



intrinsic

damage of tubule epithellial: acute tubular

necrosis (ATN)

• Iskemic type: prolong ARF

• Nephrotoxic type: trombosis, hipertensi

damage of glomerulus

• Acute Glomerulonefritis

• Hemolitic uremic syndrome

Vascular disease: hypertension, thrombosis



Conditions That Lead to Ischemic Acute Renal Failure.



ARF Therapy

• There is no consensus among nephrologists as

to when to begin dialysis or how frequently to

perform dialysis.

• Although studies that evaluated early and

intensive dialysis suggested that such an

approach improved survival and led to a more

rapid recovery



Chronic kidney disease (CKD)

• is a progressive loss of renal function over a

period of months or years

• Five stages Each stage is a progression

through an abnormally low and deteriorating

glomerular filtration rate, which is usually

determined indirectly by the creatinine level

in blood serum



Signs and symptoms

• can be detected as an increase in serum creatinine or protein

in the urine.

As the kidney function decreases:

• Blood pressure is increased due to fluid overload and production of

vasoactive hormones leading to hypertension and congestive heart failure • Urea accumulates, azotemia / uremia

(symptoms ranging from lethargy to pericarditis and encephalopathy)

• Potassium accumulates in the blood hyperkalemia

•

Erythropoietin synthesis is decreased anemia • Fluid volume overload pulmonary edema

• Metabolic acidosis, decreased bicarbonate by thekidney

http://en.wikipedia.org/wiki/Creatinine

http://en.wikipedia.org/wiki/Blood_pressure

http://en.wikipedia.org/wiki/Hypertension

http://en.wikipedia.org/wiki/Congestive_heart_failure

http://en.wikipedia.org/wiki/Urea

http://en.wikipedia.org/wiki/Azotemia

http://en.wikipedia.org/wiki/Uremia

http://en.wikipedia.org/wiki/Pericarditis

http://en.wikipedia.org/wiki/Encephalopathy

http://en.wikipedia.org/wiki/Potassium

http://en.wikipedia.org/wiki/Hyperkalemia

http://en.wikipedia.org/wiki/Erythropoietin

http://en.wikipedia.org/wiki/Anemia

http://en.wikipedia.org/wiki/Fluid_balance

http://en.wikipedia.org/wiki/Pulmonary_edema

http://en.wikipedia.org/wiki/Metabolic_acidosis

http://en.wikipedia.org/wiki/Bicarbonate

http://en.wikipedia.org/wiki/Bicarbonate

http://en.wikipedia.org/wiki/Metabolic_acidosis

http://en.wikipedia.org/wiki/Pulmonary_edema

http://en.wikipedia.org/wiki/Fluid_balance

http://en.wikipedia.org/wiki/Anemia

http://en.wikipedia.org/wiki/Erythropoietin

http://en.wikipedia.org/wiki/Hyperkalemia

http://en.wikipedia.org/wiki/Potassium

http://en.wikipedia.org/wiki/Encephalopathy

http://en.wikipedia.org/wiki/Pericarditis

http://en.wikipedia.org/wiki/Uremia

http://en.wikipedia.org/wiki/Azotemia

http://en.wikipedia.org/wiki/Urea

http://en.wikipedia.org/wiki/Congestive_heart_failure

http://en.wikipedia.org/wiki/Hypertension


http://en.wikipedia.org/wiki/Creatinine



Stage 1 CKD• Slightly diminished function; Kidney damage with

normal or increased GFR (>90 mL/min/1.73 m2).•

Kidney damage is defined as pathologicabnormalities or markers of damage, includingabnormalities in blood or urine test or imagingstudies

Stage 2 CKD• Mild reduction in GFR (60-89 mL/min/1.73 m2) with

kidney damage.Stage 3 CKD• Moderate reduction in GFR (30-59 mL/min/1.73 m2) Stage 4 CKD•

Severe reduction in GFR (15-29 mL/min/1.73 m2) Stage 5 CKD• Established kidney failure (GFR <15 mL/min/1.73 m2,• or permanent renal replacement therapy (RRT)



Stages of Chronic Kidney Disease: A Clinical Action Plan

Stage Description GFR

(mL/min/1.73m3)

Action

1 Kidney damage with

normal or GFR

90 Diagnosis & Treatment, Treat

comorbid condition, slowing

progression, CVD riskreduction

2 Kidney damage with mild

GFR

60 – 89 Estimating Progression

3 Moderate GFR 30 – 59 Evaluating & Treating

complications

4 Severe GFR 15 – 29 Preparation for kidney

replacement therapy

5 Kidney failure < 15 or dialiysis Replacement (if uremia

present)



Treatment

•

The goal of therapy is to slow down or halt theotherwise relentless progression of CKD to

stage 5.

• Control of blood pressure and treatment of

the original disease, whenever feasible, are

the broad principles of management.

• Generally, angiotensin converting enzyme

inhibitors (ACEIs) or angiotensin II receptor

antagonists (ARBs) are used, as they have

been found to slow the progression of CKD to

stage 5.


http://en.wikipedia.org/wiki/Angiotensin_converting_enzyme_inhibitor


http://en.wikipedia.org/wiki/Angiotensin_II_receptor_antagonists









Renal Replacement Therapy

• When renal failure is severe, and about 90% of renal function is lost, a patient requires a formof renal replacement therapy to survive

a renal transplant or dialysis.

•

A renal transplant is the surgical placement of a kidney from a kidney donor into a patientwith kidney failure.



High-risk factor in transplantation

• Age

• Unfavorable psychological profile

• Unfavorable medical status – Pulmonary factors (smoking)

– Recurrent primary renal disease

– Diabetes

– Cardiovascular factors (unstable angina)

– Severe hypertension

– Neoplasia – Chronic infection(s)

– Obesity



• Dialysis hemodilysis

peritoneal dialysis

• is a process that cleans and filters the blood,removing harmful wastes and excess salt and fluidsby passing blood across a semipermeablemembrane.

• Wastes from the blood diffuse across the membraneinto a cleansing solution (dialysate) and bicarbonatediffuses into the blood to neutralize excess acid.

• Dialysis can control blood pressure and help maintaina balance of electrolytes, including potassium,sodium, and chloride.



Arah aliran darah

Arah aliran dialisat

Inlet darah

(merah) Outlet darah

(biru)

Inlet cairan dialisat Outlet cairan dialisat

Gambar skematis dializer



Anatomy of a Hemofilter

23

blood in

blood out

dialysate

in

dialysate

out

Outside the Fiber (effluent) Inside the Fiber (blood)

Cross Sectionhollow fiber membrane



Hemodialysis

• can be performed at a dialysis center

• hemodialysis treatment is provided by trainednurses and technicians.

• Hemodialysis is usually performed 3 timesweekly, with each treatment lasting 2 to 4hours.

• Patients can read, write, sleep, talk, or watchtelevision during treatment.



Peritoneal dialysis

• uses the peritoneal membrane, the lining of the

abdomen, to remove excess water, wastes, and

chemicals from the body.

• A dialysate passes through the abdomen via a

surgically placed catheter.• Fluid, wastes, and chemicals pass from capillaries in

the peritoneal membrane into the dialysate.

• No machine is necessary.

• After 4 to 6 hours, the solution is drained back into

the bag and replaced with fresh solution. The

solution is usually changed 4 times a day.

5. patologi arf crf tp

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