bsk lecture

7/28/2019 BSK Lecture

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FARMAKOTERAPI OBAT

PADA PENYAKIT

BATU SALURAN KEMIH


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Tx BG/SK

OT

Tempuyung

Obat

Pembedahan

Metode lain:Litotripsi aa

+_

Di Ind. dikenalsbg obat u/ BSKHeyne, 1987


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Why is it important? Prevalence

2% to 3%

Likelihood that a white man will develop stone

disease by age 70 1 in 8.

Recurrence rate without treatment for calcium

oxalate renal stones 10% at 1 year, 35% at 5 years, and 50% at 10

years(Uribarri et al, 1989).


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(Laerum & Murtagh, 2001)


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Epidemiology

Rare in Native Americans, blacks of

African or American decent, and native

born Isrealis

Bladder stones more common in

malnourished, kidney disease more

common in affluent


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Epidemiology

Genetic

Evidence not clear

Does appear in certain genetic disorders

Familial renal tubular acidosis

Cystenuria

Hereditary xanthinuria dehydroxyadeninuria


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Epidemiology

Age and sex

Peak occurrence in 20s to 40s

Males > females

Women are more likely to have infectious or

hereditary cause


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Ind. termasuk daerah sabuk batu (stone

belt) BSK (Subadi,1999)

Retensi urin; 28,58 % karena BKM & Ure-tra (Barus, 1999)

Wiranto, 1999 meneliti BSK di RSUP Dr.Sarjito dari Jan 93-Des 97 menemukan317kasus


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Batu saluran kemih dapat diderita siapa sajadari bayi sampai usia lanjut.

Gilsanz, dkk 1985 10 bayi prematur dg

Nefrolithiasis. Penderita BSK di RSUP

Dr.Sardjito termuda laki-laki usia 2,5 th. &

tertua 86 th. Pasien 79,6 %; 20,4 %

dan terbanyak ditemukan umur dekade

kelima yaitu 30 % (Wiranto, 1999).


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Patogenesis terjadinya BSK* Teori presipitasi kristalisasi

* Teori pembentukan inti matrik

* Teori ketiadaan inhibitor* Teori penghambatan sistem limfa

Teori yg konsisten pd bbrp pmbntk batu:

pengeluaran bhn/unsur pokok pmbtkbatu & pH. ( Teori presipitasi kristalisasi)


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Stones apparently form in an organized mannerinfluenced by:

-Composition of the environment-urinary solutes

-urinary particles, i.e. bacteria, sloughed

urothelium-uromucoidslarge arrays or protein formed in

the urinary tract

-glycoaminoglycansgroup of substances whichcoat the urinary tract


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-Nature of the bed of origin

-urothelium (transitional cell epithelium)

-Field characteristics

-magnetic

-gravitationalpossibly influence

of gravity on certain particles

-Nature of Nidal forcesit is assumedthat every stone starts as a central core


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Physical Chemistry

Supersaturation

Central event in stone formation

Dependant on concentration, temperature, pH,other chemicals

Urine

Contains inhibitors which allow supersaturation

metastable concentration


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Stone formationonce theprocess stone formation has

begun, we are no longer dealing

with a biological driven system,

it is all a chemical process from

that point on.


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Symptoms/signs

Moderate to severe colicky flank pain, may radiate

towards the testis, vulva or loin Radiation indicates that the stone has migrated

toward lower third of ureter

Some may even present with ureteral obstruction,unexplained persistent UTIs, or painless hematuria


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Full workup

Pt. have h/o diarrhea, UTIs, or gout?

FHx of stones?

Urine pH, culture if UA shows signs of infection Serum calcium, phosphorous, parathyroid hormone,

sodium, oxalate, citrate, uric acid, creatinine

24 hour urine collection for: calcium, sodium,

oxalate, citrate, urate, creatinine Further imaging


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Treatment

Percutaneous Ultrasound

Laser

Electrohydrolic

ESWL

the most frequent treatment modality forstones in the upper ureter and the kidneys

Endourolology

Laser

ultrasound

Extraction

Open lithotomy


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Treatment

Normal calcium intake (lowers stone events by 50%)

Low sodium diet

High fluid intake (UO should be >2L/day) Hypercalcuria worsened by: high sodium diet, loop

diuretics, high intake of animal protein

For recurrent stones: thiazide diuretic and/oramiloride


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What is amiloride?

Mild potassium-sparing diuretic

Unique class, acts on distal convoluted tubule

and collecting duct

Action is independent of aldosterone

Cannot use in patients with renal insufficiency

Can cause hyperkalemia

go
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Hyperoxaluria

Results from fat malabsorption (IBD, chronic

pancreatitis, jejunoileal bypass) excessivedietary consumption (leafy greens), or

recessive metabolic syndrome

Treatment: cholestyramine, low-fat, lowoxalate diet, calcium supplements given with

meals

go


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Hypocitrauria

Citric acid helps to prevent calcium stones by

complexing wth free urinary calcium

May be alone or found in combination with otherdisorders (RTA, chronic diarrheal illness

Treatment: alkali, usually complexed with

potassium instead of sodium Alkali increase urinary excretion of citrate

go other
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Hyperuricosuria

Can cause calcium oxalate stones

High urinary uric acid causes supersaturation

of calcium oxalate

Mainly from excessive dietary purine

consumption

Treatment: low dietary purine, allopurinol


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Uric acid stones

Urate stones are radiolucent

Hyperuricosuria AND low urinary pH (usually less

than 5.5) Assoc. conditions: myeloprolferative disorders (with

or without chemo), Lesch-Nyhan

Treatment: alkalinization of urine with bicarb or

citrate, hydration, allopurinol


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Struvite stones

From urease-producing organisms, most often

Proteus mirabilis

Infection can occur from chronic obstruction,

instrumentation, or chronic antibiotic therapy

Treatment: antibiotics, removal of staghorn

calculus, which is frequently infected


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Cystine Stones

Genetic defect in amino acid transport in the GI

brush border and renal tubules

Suspect when stones are formed at a young age

Stones are radioopaque

Treatment: hydration (UO>3L/day), alkalinization,

and D-penicillamine or alpha-mercaptoproprionylglycine


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Penanganan batu saluran kemih

Konservatif: Hidrasi, Diet.

Obat (Simptomatik: Analgesik, spasmolitik),

(kausatif).

Tindakan (Invasif, noninvasif)

Obat tradisional dari berbagai jenis tana-

man: daun (keji beling, gempur batu,

tempuyung, urat,wungu, kaki kuda); akar

(pohon enau, bt. Pepaya); rimpang(temulawak). Farmakologinya ???

other


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Tanaman Tempuyung (Sonchus arvensis L.

other


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Allopurinol - Zyloric

Cholestyramin - Questran


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other
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go

other
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Basitrasin

Vankomisin

AmfoterisinNistatinSulfonamid, Trimetoprim

Metronidazol, INH, Asam

Nalidiksat, vidarabin,

A l i

Linkomisin

Klindamisin

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