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8/17/2019 NUTRISI PASIEN HEMODIALISIS
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PRINSIP NUTRISIPASIEN HEMODIALISIS
dr. Agung Susanto,SpPD
Divisi Ginja Hip!rt!nsi
RSUD Dr.Mo!"ardi Sura#arta
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Pendahulua
n• GG$ % – P!nurunan &ungsi
– $roni# progr!si&
– 'ungsi nor(a !nd stag!
• )$D %
– $!ainan &* + anato(is -uan
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CKD dibagi 5 stadium :
I. Kidney DamageG'R nor(a + / 01 22+(!nitA-u(inuria, prot!inuria, 3!(aturia
II. Kidney DamageG'R (!nurun s!di#it 451670 22+(!nit8
A-u(inuria, prot!inuria, 3!(aturia
III. Penurunan GFR SedangG'R 1690 22+(nt
R!na “insufciency”
IV. Penurunan GFR BeratG'R :96;0 22+(ntR!na “insufciency”
V. Renal Failure (CRFG'R
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• Stadium I!IV – )$D -!u( diaisis 4pr!diaisis8
– T!rapi #ons!rvati& %• Diet
• "bat
• #u$uan nutrisi GGK
– M!n2!ga3 (anutrisi
– P!ning#atan =uait> o& Li&!
– P!nurunan (or-iditas + (ortaitas
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GG$ GG$
Gangguan :
-Absorbsi
-Ekskresi
-Metabolisme
• Metabolisme Lemak :
- Kolesterol LDL, VLDL
- Kolesterol HDL↓
• Metabolisme Protein
• Asidosis katabolisme protein
imbunan sisa metab! "itrogen #remik
Kelu$ kesa$ uremi
• Gangguan sintesis protein % asam amino
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GG$
R!t!nsi(!ta-ois(!%
6Prot!in6P!ptid!6Nu2!i2 a2id6Asa( a(ino6$ar-o3idrat
P!nurunan!#s#r!si %6Urin! +air6Gara(6$aiu(6Magn!siu(
6'os&at
P!nurunana-sor-si
6$asiu(6?!si6Ri-o@avin6'oat6it D
P!ning#atana#u(uasi
6AL
-Advancedglycosilationend product
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Akumulasi ToksinUreum
Metabolisme Abnormal
Protein & Asam Amino
Metabolisme
Abnormal
Hormon & Vitamin
Peningkatan Katabolisme
Protein
Gangguan
Keseimbangan Elektrolit
GGGG$ $
M A
L
N
UT
R
IS
I
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Penyebab %alnutrisi :
• Masu#an & 4naus!a + vo(itus8
• Asidosis (!ta-oi#
• R!spon ana-oi# 3or(on &
• In@a(asi #roni#
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DUKUNGAN
NUTRISI
MENEGAH
MA!NUTRISI
MENGURANGI E"EK SAMPING
AKI#AT #ERKURANGN$A "UNGSI
EKSKRESI
%UT%ME
GAGA! GINA!
GGGG
$ $
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MA!NUTRISI
TERGANGGUN$A
SISTEM IMUN
PEN$EM#UHAN
!UKA
TERGANGGU
M%R#IDITAS
&M%RTA!ITAS
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• Pasi!n )$D % – Pasi!n pr! HD
– Pasi!n HD rutin
– Pasi!n )APD.
Sama dalam'enatalasanaan
'embatasan)balans
*airan
Berbeda dalam dietnutrisi+ terutama
'r,tein.
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-. Pembatasan)BalansCairan
• P!rta(a daa( Di!t Ginja
• Pasi!n pr! HD, )$D stag! III6 (uta#(!(!ru#an -aans 2airan.
• Pasi!n gaga ginja t!r(ina HD rutinp!nurunan RR' diur!sis -!r#urang
-aans 2airan 3arus #!tat.
• P!(!i3araan RR' pada pasi!n HD rutindip!ru#an diur!sis r!ati& 2u#up(!(-!ri#an #!onggaran daa( inta#!2airan.
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• P!(-atasan 2airan -!r-!da antara satupasi!n dan ainn>a.
• $ondisi ov!r3idrasi -aans 2airan3arus n!gati&.
• Saat d!3idrasi -aans 2airan 3aruspositi& sa(pai r!3idrasi.
• P!ni(-angan pra dan pas2a HD 3arusdia#u#an s!tiap #ai s!si HD.
• P!rta(-a3an ?? antara pas2a HD dan
pra HD -!ri#ut p!rti(-anganp!nari#an 2airan >ang dia#u#an.
• Ma#si(a daa( : s!si L
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• Pada pasi!n )APD, -ia s!(ua
-!r&ungsi -ai# 2airan diaisat >angdi#!uar#an s!au !-i3 -an>a#.
• Pasi!n )APD (asi3 dapat (inu(
2u#up onggar, (!s#ipun t!tapdi-atasi.
• Daa( #!adaan !d!(a, -aans
2airan t!tap 3arus n!gati&.
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• Pada )APD, RR' !-i3 a"!t di-anding
HD.
• )APD d!ngan !*23ang! id!a B #aip!r3ari, a#an (!(-!ri#an @u#tuasi
ur!u(, #r!atinin, dan to#sin >ang!-i3 #!2i dan -!rada daa( #adarr!ati& r!nda3 di-anding#an HD.
• ?!-an to#sin ur!(ia pasi!n HD !-i3-!rat C-rosis !-i3 2!pat RR'!-i3 2!pat turun
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• $o(pi#asi pasi!n )$D d!ngan
ov!r3idrasi % – Ed!(a paru 2ito HD
– Ed!(a #a#i (!ngganggu pasi!n
– Asit!s, t!ruta(a -isa juga dia#i-at#an
3ipoa-u(in!(ia
• D!ngan HD rutin, di3arap#anp!r-ai#an #ondisi ov!r3idrasi.
• Ed!(a paru dan !d!(a #a#i !-i3(uda3 t!ratasi.
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• Asit!s 2!nd!rung suit diatasi d!ngan HD.
• Daa( indi#asi t!rt!ntu dia#u#anparas!nt!sis
• U(u(n>a paras!nt!sis dia#u#an d!ngan-atasan a-u(in (g+d, dan indi#asi
j!as.• S!tiap #ai paras!nt!sis, di#!uar#an 6B L
2airan.
• Paras!nt!sis -isa dia#u#an s!ang ; 3ari.
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.Kal,ri• $aori pasi!n )$D (!ngi#uti ?? id!a.
• M!nurut Nationa $idn!> 'oundationFs, #!-utu3an #aori padapasi!n 3!(odiaisis daa( #ondisi (!ta-oi# s!i(-ang adaa3169 #aori+$g.
• Rata6rata dip!ru#an :116:011 #aori+3ari.
• $aori s!-agian -!sar ditutup dari (asu#an #ar-o3idrat.
• Tida# -an>a# p!(-atasan.
• u(a3 #ar-o3idrat (!!ng#api tota #aori >ang 3arus dip!nu3i
p!r3ari, s!t!a3 di#urangi p!(-!rian #aori daa( -!ntu#prot!in.
/.Karb,hid
rat
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• Aturan dasar adaa3 p!(-atasan prot!in.
• Pasi!n )$D -!u( HD di!t r!nda3prot!in 1,961,5 g+#g??+3ari, d!ngan prot!in
>ang (!(ii#i niai -ioogis tinggi.• Pasi!n )$D >ang HD rutin, (asu#an
prot!in s!p!rti orang u(u(, -!r#isar 91 grprot!in p!r3ari untu# rata6rata ?? 91 #g.
• Pasi!n )$D d!ngan )APD di!t prot!in!-i3 tinggi, #ar!na #!3iangan prot!in !-i3-!sar.
0.'r,tein
5 1l t li
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• Natriu( dan #aiu( di-atasi.• 'os&at tida# -o!3 ada, o!3 #ar!na
suda3 t!rjadi 3ip!r&os&at!(ia.
• Au(iniu( tida# di-!ri#an #ar!narisi#o into#si#asi.
• Magn!siu( 3arus sangat 3ati63ati,
-!r3u-ungan d!ngan ost!odistroC.• ?!si, 3arus 2u#up, #ar!na
-!r3u-ungan d!ngan #!-!r3asian
p!(-!rian t!rapi !ritropo!tin.
5.1letr,lit
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2. Pemberian Su'lemen3sam Ket,
• Sup!(!n asa( #!to u(u( di-!ri#an padapasi!n )$D pr! HD.
• P!(-!rian sup!(!n asa( #!to padapasi!n d!ngan HD rutin dapat
dirasionaisasi untu# (!(p!rta3an#an RR'>ang (asi3 ada.
• Titi# #!rja asa( #!to adaa3 sup!(!nasa( a(ino !s!nsia >ang dip!ru#an
-adan, d!ngan tanpa (!(-!ntu# ur!anitrog!n.
4 K b h
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4.KebutuhanVitamin
• Pasi!n gaga ginja sangat ris#anuntu# d!Csi!nsi -!-!rapa(i#ronutri!nt.
• Pasi!n d!ngan diaisis dapat#!3iangan vita(in arut air.
• ita(in D (!rupa#an vita(in >ang
(!ngaa(i d!Csi!nsi #ar!na saa3satu &ungsi ginja adaa3 untu# a#tivasivita(in D.
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Chronic renal failurea,b,c Maintenance hemodialysis
!"#eContinous ambulatory or cyclic
$eritoneal dialysis CA%" or CC%"#d
Minerals ran&e of inta'e#
Sodium m&(day#
%otassium me)(day# %hos$horus m&('&(day#
Calcium m&(day#
Ma&nesium m&(day#
Iron m&(day#
*inc m&(day#
+ater ml(day#
itamins
Thiamin m&(day#
Ribofla-in m&(day# %antothenic acid m&(day#
Niacin m&(day#
%yrido.ine !CL m&(day#
itamin /01 µ&(day#
itamin C m&(day#
2olic Acid
itamin A
itamin " itamin 3 IU(day#
itamin 4
0555 to 6555h
75 to 857 to 05
0755 to 0955
155 to 655
≥ 05 to 0:m
0;
U$ to 6555 as tolerated
0
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KE#HA" "#'()( PADA PE"DE'(A GGK
Tabel< >umlah Nutrisi yan& dian?ur'an $ada $enderita @a&al @in?al 4roni', !emodialisis dan %eritoneal dialisis
Chronic renal failurea,b,c Maintenance hemodialysis
!"#eContinous ambulatory or cyclic
$eritoneal dialysis CA%" or CC%"#d
%rotein
Lo= $rotein diet
ery lo= $rotein diet
3ner&y 'cal('&(day
2at $ercent of total
ener&y inta'e#e,f
%olyunsaturatedsaturated
fatty acid ratiof
Carbohydrate f,&
Total fiber inta'e &m(day#f
5 015
$ercent or the $atient &ains or is afraid of
&ainin& un=anted =ei&ht
65 75
0
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