KEGAWATdarutan dibagian nefrologi yukk simakkk2025

pelajari dnean cermat tenang hal gal gawat darurat yangs ering terjadi di baian nefro

1. Kegawat daruratan Nefrologi Astried Indrasari

2. Hipertensi

3. PENAPISAN HIPERTENSI SEKUNDER Etiologi Manifestasi klinis Penunjang Gangguan parenkim renal Riwayat CKD Proteinuria, hematuria, pyuria. Penurunan LFG USG Hiperaldosteron primer Manifestasi hipokalemia Peningkatan plasma aldosterone-renin activity ratio, CT Stenosis arteri renalis Bruit abdominal, carotis , femoral. LFG menurun setelah konsumsi RAS Blocker >30% Ultrasound duplex, CT Abdomen, MRI Pheokromositoma Sefalgia , palpitasi Peningkatan metanephrines dan katekolamin . CT/MRI Cushing syndrome Obesitas sentral , striae, atrofi kulit , kelemahan otot Hipokalemia , peningkatan kortisol , DST, Imaging Coarctation aorta TD ekstremitas atas > bawah . Pulsasi femoral menurun atau hilang Echocardiografi , CT/MR Angiogram OSA Obesitas , snoring, gangguan tidur , nocturia polisomnografi Thyroid disease Hipertiroid , Hipotiroid FT4, TSHs

4. Classification of Blood Pressure for Adults

5. HIPERTENSI KRISIS

6. HIPERTENSI KRISIS

7. PEMERIKSAAN PADA HIPERTENSI KRISIS

8. PENATALAKSANAAN HIPERTENSI KRISIS

9. OBAT PILIHAN HIPERTENSI KRISIS

10. TATALAKSANA KHUSUS

11. Pengobatan Hipertensi urgensi : Dapat diberikan obat oral Observasi hasil pengobatan Target penurunan tensi : Bila kreatinin ↑  130/85 mmHg Bila protein urin > 1g/24 jam  125/75 mmHg

12. Obat-obat pada hipertensi urgensi Obat Mekanisme Dosis Onset Efek samping Kaptopril Penghambat ACE 6,25-50mg, Tiap 1-2 jam 15-30 menit Angiodema gagal ginjal akut Klonidin Agonis α 2-adreno reseptor 0,15-0,9mg tiap 1-2 jam 30-60 menit Hipotensi, sedasi, mulut kering Labetalol Penghambat reseptor α & β 100-200mg tiap 2-3 jam 30-120 menit Blokade jantung, bronkokostriksi, hipotensi ortostatik

13. 2. Hiperkalemi (dapat menyebabkan kematian mendadak) K+ >5,5 meq/L Gejala klinik : Kardiovaskular : aritmia, gelombang T ↑, kompleks QRS melebar Neuromoskular : parestesi, lemah, paralisis Ginjal : natriuresis, produksi amonia↓ Endokrin : sekresi aldosteron dan insulin ↑.

14. Abnormal serum K + levels can cause ECG abnormalities, which may lead to cardiac arrest and death ECG, electrocardiography; K + , potassium ion Lindner G, et al, European Journal of Emergency Medicine 2020, Vol 27 No 5 Typical ECG changes associated with hyperkalemia. It is important to note that ECG changes may not correlate closely with serum potassium concentration or be useful in predicting outcomes. As such, a normal ECG should not necessarily be regarded as reassuring if elevated potassium concentration has been definitively observed. Such patients may still experience sudden hyperkalemic cardiac arrest episodes.

15. Collecting duct lumen Aldosterone receptor Na–K ATPase Na + K + Ca 2+ Mg 2+ K + Na + K + e limination in urine Renal impairment, comorbidities and associated treatments can lead to impaired K+ excretion 1–3 Mild HK: 5.1–5.4 mmol /L; moderate-to-severe HK: ≥5.5 mmol /L ACE, angiotensin-converting enzyme; ACEi , angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blockers, ATPase, adenosine triphosphatase ; HK, hyperkalaemia; NSAID, nonsteroidal anti-inflammatory drug 1. Palmer BF. N Engl J Med 2004;351:585–592 ; 2. Palmer BF, Clegg DJ. Adv Physiol Educ 2016;40:480–490; 3. Noize P, et al. Pharmacoepidemiol Drug Saf 2011;20:747–753; 4. Eleftheriadis T, et al.  Hippokratia  2012;16:294–302 5 Na–K + pump inhibition: 4 β blockers and digoxin Angiotensinogen Angiotensin I Impaired renin release: NSAIDs, β blockers, cyclosporines Impaired aldosterone metabolism: Adrenal disease, heparin or ketoconazole Renin Angiotensin II Aldosterone KIDNEY Aldosterone receptor inhibition: Spironolactone and eplerenone Inhibition of Na + into cells: Na + channel blockers, such as amiloride , trimethoprim and pentamidine ACE Reduced tubular flow: Renal damage ACEi ARBs

16. A Systematic Approach is recommended when treating acute hyperkalemia K+, potassium ion References: Alfonzo et al . UK Renal Association. Clinical practice guidelines: Treatment of acute hyperkalaemia in adults 2023.

17. 5 Steps of Emergency Management of HK in Hospital Algorithm NICE: National institute of health and care excellence; K+: potassium ion; ECG: electrocardiography Alfonzo et al . UK Renal Association. Clinical practice guidelines: Treatment of acute hyperkalaemia in adults 2023.

18. 5 Steps of Emergency Management of HK in Hospital Algorithm (2) UKKA Guideline 2023 IV: intravenous Disclaimer: SZC should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action

19. Marshall WR, Curran GA, Traynor JP, Gillis KA, Mark PB, Lees JS. Sodium zirconium cyclosilicate treatment and rates of emergency interventions for hyperkalaemia: a propensity-score weighted case-control study. Clin Kidney J. 2024 Oct 21;17(11):sfae313. doi : 10.1093/ ckj /sfae313. PMID: 39669394; PMCID: PMC11635375. 19 SZC role on Emergency Settings Disclaimer: SZC should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action

20. Selected Characteristics of K+ Binders – Traditional vs Novel This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 of the SmPC for how to report adverse reactions. 8 ; a Dose differs for patients on haemodialysis- refer to SmPC for more information. 8 ; This is not Head to Head study result, the table is presented with intention to display of profile comparisons according to each product's product information. Novel Potassium Binder Traditional Potassium Binder LOKELMA - Sodium Zirconium Cyclosilicate Calcium polystyrene sulfonate (CPS) Mechanism Selective potassium binding in exchange for sodium and hydrogen 3 Nonspecific calcium cation-exchange resin; hypomagnesemia and/or hypercalcemia may occur 1 Onset 1 hour 3 Action may be delayed for 1 to 2 days 1 Dosing 10 g orally 3 times daily for a maximum of 72 hours (starting dose) 3 5 g orally once daily (recommended starting maintenance dose) 3 15 - 30 g orally divided 2 to 3 times daily 2   30 g given as retention enema once daily 2 Longest Duration Studied Prospectively 1 year 3 7 days 5 Site of K + Capture in Lumen of GI Tract Small and large intestine 3 Primarily Colon 1 Adverse events Hypokalaemia and oedema-related events 3 Cases of intestinal necrosis , which may be fatal, and other serious GI adverse events have been reported 2 Drug Interactions Administer at least 2 hours before or 2 hours after oral medications with clinically meaningful gastric pH–dependent bioavailability 3 Antacids, laxatives, digitalis, sorbitol, lithium, levothyroxine 2 Administer at least 3 hours before or 3 hours after other oral medications 2 1. Resonium calcium. Prescribing Information. Sanofi-Aventis Canada. ; 2 Calcium resonium . Summary of product characteristics. Sanofi.; 3. Lokelma. Product Information Indonesia BPOM Approved. 2025 LOKELMA is different from other K + Binders

21. Obat-obatan yang dapat menyebabkan hiponatremi Analog vasopresin Desmopresin (DDAVP) Oksitosin Potensial dengan vasopresin Klopropamid Siklofosfamid NSAID Asetaminofen (parasetamol) Meningkatkan pelepasan vasopresin Klorpropamid Klofibrat Karbamesepin Vinkristin Nikotin Narkotik Antipsikotik / antidepresi Mekanisme tidak diketahui Haloperidol Flufanesepin Ametriptilin Fluosetin Sertralin tioradasin 3. Hiponatremi (sering menyebabkan gangguan kesadaran)

22. Hiponatremi Bila kadar Na+ <125 meq/L Simtom Na+ 125-130 meq/L : Nausa Vomitus Na+ <125 meq/L : Sakit kepala Letargi Ataksia Kejang koma Bila terjadi edema serebral : Tekanan intra serebral ↑ Herniasi batang otak Depresi pernapasan kematian

23. Kejadian Hiponatremi Akut (kurang dari 48 jam) Kejadian selalu berat Kronik (lebih dari 48 jam) Peningkatan ADH berperan penting

24. Hiponatremia Koreksi Natrium Akut : naikkan 5 meq dalam 1 jam , lalu 1-2 meq perjam sampai Na+ 130 meq/L Kronik : maksimal naikkan 8 -12 meq/24 jam, kecepatan 0,5 meq/jam Asupan air dibatasi Albumin pada hipoalbuminemia Atasi gagal jantung Koreksi defisiensi hormon Antagonis vasopressin (aquaresis)

25. 4. Asidosis Metabolik Gangguan filtrasi anion organik Bikarbonat plasma ↓ pH darah ↓ Anion gap ↑

26. Klasifikasi Asidosis Metabolik Renal : Asidosis Uremik (LFG <20 mL/mnt) Asidosis Metabolik Dengan anion gap ↑ Ekstra renal : Asidosis laktat Ketoasidosis diabetik Ketoasidosis kelaparan Ketoasidosis alkoholik Keracunan Anion gap Ekstra renal : RTA RTA dengan insuf ginjal (LFG >20 mL/ mnt ) Ekstra renal : Diare Kehilangan melalui sekresi pankreas atau bilier Asidosis Metabolik Dengan anion gap N Hiperkloremik

27. Asidosis Metabolik Sistem pernapasan : stimulasi pernapasan , tidak vol. ↑ Pembuluh darah : vasodilatasi pembuluh perifer Jantung : supresi kontraktilitas jantung Sistem saraf : cepat capai , letargi , stupor, koma Ginjal : LFG ↓, ekskresi amonia urin ↑ Tulang : mobilisasi karbonat dan kalsium

28. Treatment

29. Acute Kidney Injury (AKI)

30. Major Disease Categories Causing AKI Disease Category Incidence Prerenal azotemia caused by acute renal hypoperfusion 55-60% Intrinsic renal azotemia caused by acute diseases of renal parenchyma: -Large renal vessels dis. -Small renal vessels and glomerular dis. -ATN (ischemic and toxic) -Tubulo-interestitial dis. -Intratubular obstruccttion 35-40% *>90%* Postrenal azotemia caused by acute obstruction of the urinary tract <5%

31. Treatments of AKI Roesli R. Pengelolaan Konservatif (Supportif) “Memilih pengobatan yang tepat di saat yang tepat”. Diagnosis & Pengelolaan Gangguan Ginjal Akut. Jakarta. 2011: 79-93. Basic Principles Diagnose AKI as early as possible  Assessing etiology/causes of AKI  Assessing complications of AKI Evaluate the stage of AKI  apply management based on stage of AKI Choosing the appropriate management  Conservative (Supportive) or Renal Replacement Therapy (RRT)

32. Treatments of AKI National Kidney Foundation. KDIGO. Acute Kidney Injury Guidelines. Kidney International Supplements (2012) 2, 19-36.

33. Bellomo R, Ronco C. Indications and Criteria For Initiating Renal Replacement Therapy in The Intensive Care Unit. Kidney Int 2006; 70: 963-968. Indication and Criteria for inisiate RRT in ICU setting 1 Oligouria (Urin Output <200/12 hours) 2 Severe Anuria/Oligouria (Urin Output <50cc/12 hours) 3 Hyperkalemia (K >6,5 mmol/L) 4 Severe Acidosis (Ph<7,1) 5 Azotemia (Urea >30 mmol/Liter) 6 Severe Clinical Manifestation (especially pulmonary edema) 7 Uremic Encephalopathy 8 Uremic Pericarditis 9 Uremic Neuropathy 10 Severe Dysnatremia(Na>160 or <115 mmol/L) 11 Hypertermia/Hypotermia 12 Drugs overdose that can be dialized 13 Bleeding diathesis 14 Refractory Hypertension Treatments of AKI

34. Terima Kasih