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Dr.dr.Krisni Subandiyah, SpA(K)Curriculum Vitae
Anggota IDAI Cabang Jawa Timur, sejak tahun 1997Riwayat Pendidikan Tinggi1. Pendidikan Dokter (S1)–Universitas Airlangga, lulus tahun 19892. Pendidikan Spesialis Anak – Universitas Airlangga, lulus tahun 19973. Konsultan Nefrologi Anak - Universitas Airlangga, lulus tahun 20034. Program Doktor (S3) Ilmu Kedokteran – Universitas Brawijaya, lulus tahun 2008Pelatihan Profesional 2007 - Pediatric Neurologic Up date 2007 - Innovative Assesment in Pediatrics Training Program 2007 - Pelatihan Staf pengajar dalam OSCE dan Mini CEX 2007 - Pelatihan tata laksana edema pada anak 2007 - Manajemen Bayi Berat Lahir Rendah Level 3 (NICU) 2008 - Pelatihan dalam rangka Konika 14 2009 - Workshop Evidence Based Medicine (EBM) 2009 - Workshop Kegiatan PKB Anak XXXVIII 2009 - Workshop Penanganan Terpadu Infeksi HIV pada bayi & Anak 2009 - Workshop Penanganan Terpadu Infeksi HIV pada bayi & Anak 2010 - Pelatihan Resusitasi Neonatus 2010 - Pelatihan Motivasor Laktasi 2010 - Pelatihan UKK Infeksi dan Penyakigt Tropis 2011 - Workshop Antibiotic usage in Children Pengalaman JabatanSPS Ilmu Kesehatan Anak Fakultas Kedokteran Universitas Brawijaya, tahun 2005- 2012KPS Ilmu Kesehatan Anak Fakultas Kedokteran Universitas Brawijaya, tahun 2012 -sekarang
Nama : Dr. dr.Krisni Subandiyah,Sp.A(K)Agama : IslamStatus : Menikah Suami : Dr.dr.Edi Handoko,Sp.THT-KL Anak : dr.Rizki Ekaputra HandokoTTL : Surabaya, 19 Juli 1964NIP : 19640719 198910 2 001 Pangkat / Gol. : Pembina/ IV AAlamat Kantor : Jl. JA Soeprapto 2 , MalangTelp : (0341) 362101, 343343,Fax : (0341) 369393 Email : idaimlg @ yahoo.comAlmat Praktek : Jl. Bunga Cengkeh 63, MlgTelp : (0341) 486214 Alamat Rumah : Jl. Bunga Cengkeh 63, MlgTelp : (0341) 486214Email : krisdika2002 @ yahoo.comJabatan : Staf Pengajar Divisi Nefrologi
Anak Lab/SMF Ilmu Kesehatan Anak FK. UNIBRAW / RSU Dr. Saiful Anwar Malang
UKK NEFROLOGI IKATAN DOKTER ANAK INDONESIA
Krisni S Handoko
CONSERVATIVE THERAPY
OF ACUTE KIDNEY INJURY
ETIOLOGY OF AKI
Prerenal
Renal/ intrinsic
Postrenal
..................... Etiology
THE MAJOR CAUSES OF AKI IN CHILDREN
Indian J Pediatr. 2012;79(8):1069–1075
MANAGEMENT OF AKI
Therapy
Conservative therapy
Renal replacement therapy (RRT)
..................... Management
• Early goal – directed fluid therapy
• Fine control of acidosis & •Electrolyte balance
• Dietary
• Blood presure management
CONSERVATIVE THERAPY
Kidney International Supplements. 2012; 2(2)
Fluid Management
Volume status• Hypovolemia• Euvolemia• Fluid overload and pulmonary edema
Oliguria• Adults & older children : Urine output < 400 mL/day• Infant & younger children : Urine output
< 0,5-1.0 mL/kg/h
Anuria
• Complete absence of urine output
Indian J Pediatr. 2012;79(8):1069–1075
..................... Conservative Therapy
Textbook of Clinical Pediatrics. 2012
..................... Conservative Therapy
Fluid Management
Fluid Management
Fluid Management of Oliguric-Anuric Child
. ...................Conservative Therapy
Pedatr and Child Health, 2012; 22(8): 341-345.
Severe dehydration↓
Infusion 20–30 ml/kg (maximum 60– 80 ml/kg)
isotonic saline or Ringer’s lactate , boluses↓
Vital sign, CVP↓
If urine output increases andCVP is still low, infusion may be
continued↓
If fluid replacement is accomplished → furosemide
Pre-Renal Failure ..................... Conservative Therapy
Management of Acute Kidney Problems. 2010
Maintenance of Fluid Balance
• Modulate renal perfusion pressure
• Optimize the renal preload
To limit ischemic injury
• D5,D10 : 20-30 mL/100 kcal/day (about 25–30% of maintenance fluid requirements) or 500 mL/M 2 /day.
• D5½NS : depend results electrolyte
Insensible losses plus any ongoing losses
Clin J Am Soc Nephrol. 2011; 6: 966–973
..................... Conservative Therapy
................Conservative Therapy
FUROSEMIDE• Doses : (1-5 mg/kg/dose)• Force diuretic→ controversy
Contra indications :Dehidration Urinary tract obstruction (Postrenal AKI)
Side effects :• Promote excretion of sodium and
potassium• Ototoxicity
DIURETIC
May be used but ONLY after adequate volume
resuscitation
The Cochrane Library. 2011
................Conservative Therapy
MANNITOL• 0.5-1 g/kg delivered over
30 minutes• Increase intratubular urine flow →
limit tubular obstruction
Side effects :• Congestive heart failure• Hyperosmolarity.
DIURETIC
The Cochrane Library. 2011
DOPAMINE•Renal dose” dopamine(0.5-5μg/kg/min)• Improve renal perfusion after an ischemic insult
• Increases renal blood flow by promoting vasodilatation
• Improve urine output by promoting natriuresis
• Can induce tachy-arrhythmia’s, myocardial ischaemia, and extravasation out of the vein can cause severe necrosis
VASOACTIVE AGENTS..................... Conservative Theraphy
Pediatr Nephrol. 2013; 13: 2425-8
................Conservative Therapy
The Cochrane Library, 2011
Nabic = (desired-observed bicarbonate) x kg x 0,3 (mEq)
or2-3 mEq/kg/day every 12 hours
Hypocalcemia and tetanyKidney International Supplements. 2012; 2(2)
Metabolic Acidosis
ACID-BASE AND ELECTROLYTE BALANCE:
Hyponatremia
Due to : dehydration & fluid overload with dillutional hyponatremic
ACID-BASE AND ELECTROLYTE BALANCE:
Sodium < 130 mEq/L : fluid restriction Sodium < 120 mEq/L : NaCl 3% (0,5 mEq/ml)
- (125-serum Na ) x 0,6 X BW, slowly, 1-4 hours Corrected to at least 125 mEq/L
Kidney International Supplements. 2012; 2(2)
Hyponatremia
..................... Conservative Theraphy
With Seizures :
- NaCl 3% :10-12 mL/kg, iv, 1 hr
- NaCl 3% : (125- serumNa) x 0,6 + (0.513 mEq Na/mL NaCl 3%), rapidly
Kidney International Supplements. 2012; 2(2)
................Conservative Therapy
The Cochrane Library, 2011
Hyperkalemia
a. Decrease filtration
b. Impaired tubular secretion
c. Altered distribution of K+ by acidosis, which shifts potassium from the intracellular to the extracellular compartment
d. Release of intracellular K+ due to the associated catabolic state
Kidney International Supplements. 2012; 2(2)
................Conservative Therapy
The Cochrane Library, 2011
Hyperkalemia
Symptoms : Malaise, nausea Progressive muscle weakness.
Kidney International Supplements. 2012; 2(2)
................Conservative Therapy
The Cochrane Library, 2011
Mild – Moderate• K : 6.0 – 7.0 mEq/L (6.0 and 7.0 mmol/L)• Kation exchange resin (resonium A) :
- Kayexalat 1gm/kg/po or per rectal 4x /day Or
• Kalitake 3x2,5 gram
Hyperkalemia
Kidney International Supplements. 2012; 2(2)
................Conservative Therapy
The Cochrane Library, 2011
• K : > 7.0 mEq/L (7.0 mmol/L) + abnormal ECG or cardiac arrhythmias
• Ca glukonas 10% : 0,5-1 mL/kg, iv, 10-15 mnt
• Nabic 7,5% : 1-2 mEq/kg, iv, 30-60 minute
Severe Hyperkalemia
• Glucosa 0,5-1.0 g/kg + insulin 0,1unit/kg, iv, 30 minute or subcutan
• Insulin 0,2 unit/kg → dialysis should be initiated• Salbutamol 2,5 mg (BW< 25 kg), 5 mg (BW >
25 kg)
Not improvement
Kidney International Supplements. 2012; 2(2)
................Conservative Therapy
The Cochrane Library, 2011
Indian J Pediatr. 2012; 79(8): 1069-75
Hyperphosphatemia
- Skeletal resistance to
parathyroid hormone
- Overcorrecting the acidosis
- Dietary phosphorus restriction
- Calcium carbonate: 45-65 mg/kg/day,po
................Conservative Therapy
Hypocalcemia
☺ Hyperphosphatemia☺ Inadequate GI Ca absorption due to in adequate 1,25-dihydroxy vitamin D production by the kidney☺ Skeletal resistance to the action of PTH
☺ Calcium carbonate: 45-65mg/kg/day,po☺ Severe hypocalcemia : Calcium gluconate 10%, 0,5-1 mL/kg
(maximal : 10 mL), 30-60 min → ECG☺ 1,25-dihydroxyvitamin D3 (calcitriol), 0,01-0,05
mcg/kg/day, po (<3 tahun) or 0,25 mcg-0,75 mcg per day (>3 tahun)
................Conservative Therapy
The Cochrane Library, 2011
Volume overload → diuretic (furosemide) or dialysis
ACE inhibitor : captopril 0,3mg/kg/x, 2-3 x/day
Crisis hypertension → Calcium channel blocker (nifedipine) 0,25-1 mg/kg/dose, sublingual, maximal 10 mg/dose
Hypertension
Indian J Pediatr. 2012; 79(8): 1069-75
Hypertension
Pediatrics in Review . 2008. 29 (9 ) : 299-308
Nutritional Support
NDT Plus . 2010. 3: 1–7
................Conservative Therapy
Nutritional Support
• A diet of high biologic value protein
1
• Low phosphorus, low potassium food
2
• Maintaining appropriate fluid balance
3
................Conservative Therapy
The Cochrane Library . 2010
Calorie
kcal/kgBW
Protein kcal/kg
Conservative treatment 0 – 2 years
Child/teenager
95 - 100Minimal by age
1.0 - 1.81.0
Peritoneal Dyalisis 0 – 2 years
Child / teenager
95 - 100Minimal by age
2.0 - 2.51.0 - 2.5
Haemodialysis 0 – 2 years
Child / teenager
95 - 150
Minimal by body height
1.5 - 2.11.0 - 1.8
Nutritional Support................Conservative Therapy
The Cochrane Library . 2010
Risk of infection:
- Azotemia → depressed imunity
- Underlying nutritional status
Avoid :
Long term catheterization
Initial antibiotic ≈ level of renal
function
All procedures → aseptic techniques
Infections
................Conservative Therapy
Indian J Pediatr. 2012; 79(8): 1069-75
Withdrawal or replacement of offending medication (e.g., aminoglycosides, non-
steroidal anti-inflammatory drugs)
Anti microbial therapy ( e.g., malaria, leptospirosis, sepsis, urinary tract infection)
Surgical intervention for obstruction (e.g., removal of stones)
Diuretics and alkalinization of urine in crush injury/myoglobinuria/hemoglobinuria
Plasmapheresis in non diarrheal hemolytic uremic syndrome, rapidly progressive
glomerulonephritis, vasculitis
Pulse steroids in rapidly progressive glomerulonephritis, vasculitis, drug induced
acute interstitial nephritis
Treatment for Underlying Cause of AKI
Indian J Pediatr. 2012; 79(8): 1069-75
Prevention of AKI
Indian J Pediatr. 2012; 79(8): 1069-75
Indic
ati
on
When conservative
medical management is unsuccessful
in restoring renal function
Mod
aliti
es o
f R
RT - Hemodialysis
Peritoneal Dialysis
Renal Replacement Therapy