KIDNEY EMERGENCY

M. SYAMSUL BAKHRI
Nama : MUHAMMAD SYAMSUL BAKHRI
Tempat/tanggal lahir : Banyuwangi, 10 September 1973
Alamat : Jl. Merpati Utara 27 A Malang – JATIM
081 130 3395 muhsyamsul@gmail.com
Pendidikan : SPK Malang 1993
POLTEKKES Malang 2002
S1 KEPERAWATAN Malang 2010
Kursus BASIC HEMODIALISIS Malang 2003
BASIC CAPD Jakarta 2009
INPLANT CAPD Malaysia 2010
overview

 The kidneys are a pair of small (

about the size of your fist-sized ),
bean shaped organs that lie on
either side of your spine, located
just below the lowest rib
 they filter by-products and toxins
from the blood and preserve the
balance of bodily fluids
and electrolytes
 Kidneys
• An adult kidney weighs 120 to
170 g (about 4.5 oz) and is 12
(about 4.5 inches) long, 6 cm
wide, and 2.5 cm thick.

•The kidneys are well protected

by the ribs, muscles, Gerota’s
fascia, perirenal fat, and the
renal capsule, which surround
each kidney.
FUNCTIONS OF KIDNEY
 Excretory function
 Homeostatic function
 Endocrine function
 Metabolic function
 EXCRETORY FUNCTION
 This include formation and excretion of
urine.
 The main step involved are
◦ Glomerular filtration
◦ Tubular reabsorption
◦ Tubular secretion
Homeostatic Functions of Urinary System
1. Regulate blood volume and blood pressure:
• by adjusting volume of water lost in urine
• releasing erythropoietin and renin
2. Regulate plasma ion concentrations:
– sodium, potassium, and chloride ions (by
controlling quantities lost in urine)
– calcium ion levels
3. Help stabilize blood pH:
– by controlling loss of hydrogen ions and bicarbonate
ions in urine
4. Conserve valuable nutrients:
– by preventing excretion while excreting organic
waste products
5. Assist liver to detoxify poisons
ENDOCRINE FUNCTIONS…
 Kidneys have primary endocrine function since they produce
hormones
 In addition, the kidneys are site of degradation for hormones
such as insulin and aldosterone.
 In their primary endocrine function, the kidneys produce
erythropoietin, renin and prostaglandin.
 Erythropoietin is secreted in response to a lowered oxygen
content in the blood. It acts on bone marrow, stimulating the
production of red blood cells.
 Renin -the primary stimuli for renin release include
reduction of renal perfusion pressure and
hyponatremia. Renin release is also influenced by
angiotension II and ADH.
 It is a key stimulus of aldosterone release. The effect of
aldosterone is predominantly on the distal tubular network,
effecting an increase in sodium reabsorption in exchange for
potassium.
 The kidneys are primarily responsible for producing vitamin D3
from dihydroxycholecalciferol
 METABOLIC FUNCTION

• Kidney perform gluconiogenesis during

periods of starvation.
 Fungsi Ginjal & Saluran Kemih
 Ekskresi
• pembuangan sisa metabolisme tubuh dan obat
• ekskresi & reabsorbsi selektif bahan-bahan hasil metabolisme tubuh

 Regulasi
• pengaturan volume cairan tubuh & komposisi ion
• peran utama homeostasis (pemeliharaaan lingkungan internal tubuh)
• pengaturan keseimbangan asam basa

 Endokrin
• sintesis renin, eritropoetin & prostaglandin

 Metabolisme
• metabolisme vitamin D & protein-protein dng berat molekul kecil
• tempat utama katabolisme hormon insulin, paratiroid & kalsitonin
Datta, Mirpuri, Patel, Renal & Urinary Systems 2nd ed, 2003
What’s an emergency Kidneys ?
When the kidneys
partly or completely
lose their ability to
filter water and waste
from the blood. This
condition also known
as Acute Kidney Failure
What cause Acute Kidney Failure?
Prerenal: Problems affecting the flow of blood
before it reaches the kidneys

Postrenal: Problems affecting the movement of

urine out of the kidneys

Renal: Problems with the kidney itself that prevent

proper filtration of blood or production of urine
INCIDENCE, DEFINITIONS,
AND CLASSIFICATION
 Incidence/Prevalence

 An incidence of 10-25%. Nearly 5% of people in hospital and as many as 15% of critically ill
people.
 Patients who are admitted with ARF on the ICU have an overall mortality of 23-80%.
 Patients with ARF not requiring RRT have a mortality of 10–53%.
 Patients who develop ARF that requires RRT have a higher mortality of 57–80%.
 Of those patients with ARF who receive RRT and survive, only 5–30% require long-term HD.
 The mortality of patients who are admitted to ICU with ARF, or who go on to develop ARF,
remains high.

Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med 1996;334:1448-60.
Albright RC Jr. Acute renal failure: a practical update. Mayo Clin Proc 2001;76:67-74.
Singri N, Ahya SN, Levin ML. Acute renal failure. JAMA 2003;289: 747-51.
Hou SH, Bushinsky DA, Wish JB, et al. Hospital-acquired renal insufficiency: a prospective study. Am J Med
1983;74:243–248.
Brivet FG, Kleinknecht DJ, Loirat P, et al. Acute renal failure in intensive care units — causes, outcomes and prognostic factors of
hospital mortality: a prospective multicenter study. Crit Care Med 1996;24:192–198.
Definition
 Rapid (hours to weeks) decline in GFR and retention of waste products
 “azotemia” (accumulation of nitrogenous wastes)
 elevated BUN and Creatinine levels
 decreased urine output (usually but not always)
 Lack a uniform definition  Classic laboratory definition
↑ of creatinine of >0.5 mg/dl in <72hrs
 ↑ in more than 50% over baseline Cr.
↓ in calculated Cr Cl by more than 50%.
 Any ↓ in renal function that requires dialysis
 Cr > 1.5 x, urine output <0.5ml/kg/hr
 Cr ↑ ≥ 1.0 mg/dl/2d
 Definition
 ADQI (the acute dialysis quality initiative)  RIFLE system  classifies
ARF into:
- 3 categories according to severity and
- 2 categories according to clinical outcomes
 ARF also classified based on UO:
- anuric: < 100 mL/d
- oliguric: 100 – 399 mL/d
- nonoliguric: > 400 mL/d
 Anuria usually reflects either complete urinary tract obstruction or a
vascular complicated by cortical necrosis
 Definition
Risk, Injury, Failure, Loss, & End-stage Kidney (RIFLE) classification

Class Glomerular filtration rate criteria Urine output criteria

Risk Serum creatinine × 1.5 or GFR decrease > 25% < 0.5 ml/kg/hour × 6 hours

< 0.5 ml/kg/hour × 12

Injury Serum creatinine × 2 or GFR decrease > 50%
hours
Serum creatinine × 3, or serum creatinine ≥ 4 mg/dl < 0.3 ml/kg/hour × 24 hrs,
Failure with an acute rise > 0.5 mg/dl or anuria × 12 hrs

Loss Persistent ARF = complete loss of kidney function > 4 weeks

End-stage kidney
End-stage kidney disease > 3 months
disease
• The RIFLE classification is a very sensitive definition of AKI: AKI defined by the RIFLE
classification occurred in 2/3 of general ICU patients.
• RIFLE classes injury and failure are independently associated with increased risk for in-hospital dead
• Patients who meet the very sensitive RIFLE "risk" criteria, are at significant risk for
progression to injury or failure, and therefore in-hospital dead
 Creatinine, a metabolic waste product which excreted by the
kidneys.
 Creatinine is filtered through the glomerulus into the tubules
& then excreted.

 Creatinine also is secreted by tubular cells.

 Medications can inhibit tubular secretion and falsely elevate the

serum creatinine level.
 Formulas to estimate the GFR in patients with acute renal failure
should not be used to adjust medication dosages.
Serum creatinine level is not in a steady state & continues to fluctuate.
Albright RC Jr. Acute renal failure: a practical update. Mayo Clin Proc 2001;76:67-74.
Singri N, Ahya SN, Levin ML. Acute renal failure. JAMA 2003;289: 747-51.
Renal Failure
Azotemia
Oliguria / Anuria

Pre-renal Renal Post-renal

Cause: Hypovolemia Nephritic syndrome Nephrotic syndrome Cause: Obstruction

• Sepsis • Azotemia • Massive proteinuria • BPH
• Shock • Hematuria • Severe edema • Cancer
• Heart Failure • Red cell cast • Hyperlipidemia • Stone
• hypertension • Hyperchlesterolemia
• Mild edema • No hematuria, azotemia
• Mild proteinuria or HTN at onset

MPGN MCD  Acute GN 5%

PIGN MGN • Interstitial nephritis 10%
RPGN FSGS • Tubular necrosis 85%
IgA nephropathy DN (Toxin 35%, Ischemia 50%)
Alport syndrome SLE
Amyloidosis

BUN < 20 May present as polyuria

BUN > 20 Urine is dilute
Urine is concentrated w/ high urine [Na+] &
Urine [Na +] high (> 20 mEq/L) Unconcenrated urine
Urine [Na +] low (< 10 mEq/L) ↑ FENa+
↓ FENa+ Cells/casts  tubular injury
Acute Kidney Failure Symptoms
Decreased
urine Body swelling
production
Abdo
Diarrhea Problems
fatigue minal
concentrating
pain
Nausea,
Confusion vomiting
 Become emergency….if….
 Change in level of consciousness (extreme sleepiness or difficulty
awakening)
 Fainting
 Chest pain
 Difficulty breathing
 Extremely high blood pressure ( hypertension ), greater than 180/100
 Severe nausea and vomiting
 Severe bleeding (from any source)
 Severe weakness
 Inability to urinate
 Diagnosis …..
• Levels of urea (blood urea nitrogen [BUN]) and creatinine are high in kidney failure. This is
called Azotemia.
• Electrolyte levels in the blood may be abnormally high or low because of improper
Blood test filtering.
laboratory • When the duration and severity of kidney failure is severe, the red blood cell count may
be low. This is called Anemia.

• When kidney tissue is injured, protein and desirable substances

Urine test may be inappropriately excreted in the urine.

• If the diagnosis is not certain after laboratory tests, an ultrasound

of the kidneys and bladder may be done to help reveal signs of
Ultrasound specific causes of kidney failure.
Treatment…

The first goal is to pinpoint the exact cause of

the kidney failure, as that will partly dictate the
treatment

Secondly, the degree to which accumulating

wastes and water are affecting the body will
impact treatment decisions about medications
and the need for dialysis.
Acute Kidney Failure Medical
Treatment
 Treatment is focused on removing
the cause of the kidney failure.
 Medications and other products the
patient ingests will be reviewed. Any
that might harm the kidneys will be
eliminated or the dose reduced.
 Other treatment…..
Correct dehydration: Intravenous fluids, with electrolyte
replacement if needed
Fluid restriction: For those types of kidney failure in which
excess fluid is not appropriately eliminated by the kidneys
Increase blood flow to the kidney: Usually related to
improving heart function or increasing blood pressure
Correct chemical (electrolyte) abnormalities: Keeps other
body systems working properly
If the treatment doesn’t respond…

They will need to undergo dialysis.

Dialysis is done by accessing the blood
vessels through the skin (hemodialysis)
or by accessing the abdominal cavity
through the lining that encases the
abdominal organs (peritoneal dialysis).
Prognosis..….

On long-term follow-up (1 to 10 years), approximately 12.5% of

survivors of acute renal failure require dialysis and 19% to 31% of
them have chronic kidney disease.

The in-hospital mortality (death) rate for

acute kidney failure is 40% to 50%.

The mortality rate in patients in intensive care

(ICU) settings with acute kidney failure that
requires dialysis is 70% to 80%
THANK YOU
TERIMA KASIH