Patofisiologi Penyakit

Ginjal
Dr. Eka Roina Megawati
Departemen Fisiologi FK USU
 Penyakit Ginjal
Berdasarkan tempat kerusakan ; glomerulopathy
dan tubulointerstisial disease
Berdasarkan penyebab ; imunologik, metabolik,
infiltratif, infeksius, hemodinamik dan toksik
Berdasarkan gambaran klinis ; nephrotic
syndrome dan nephritic syndrome
 Gagal Ginjal
Kehilangan kemampuan mempertahankan
volume dan komposisi cairan tubuh
Gagal ginjal kronik : secara progresif & lambat
(beberapa tahun)
Gagal ginjal akut : beberapa hari - minggu
 Penyebab gagal ginjal
Prerenal ; akibat aliran darah ke ginjal yang
inadekuat
Intrarenal ; kerusakan pada nefron baik langsung
ataupun tidak
Postrenal ; akibat obstruksi saluran kemih baik
akibat batu ginjal, kelainan struktur maupun
fungsi
 MAJOR CAUSES OF KIDNEY DISEASE
PRERENAL DISEASE
True Volume depletion
Gastrointestinal, renal, or sweat losses or bleeding.
Heart failure.
Hepatic cirrhosis ( including the hepatorenal syndrome ).
Nephrotic syndrome ( particulary after diuretic therapy for edema )
Hypotension.
Nonsteroid anti inflamatory drugs.
Bilateral renal artery stenosis ( particulary after therapy with an
angiotensin converting inhibitor )
INTRARENAL DISEASE
Vascular disease
Acute : vasculitis
malignant hypertension
scleroderma
thromboembolic disease
Chronic : nephrosclerosis
Glomerular disease
Glomerulonephritis
Nephrotic syndrome
Tubular disease
Acute : acute tubular necrosis
multiple myeloma
hypercalcemia
uric acid nephropathy
Chronic : polycystic kidney disease
Medullary sponge kidney
INTERSTITIAL DISEASE
Acute : - pyelonephritis
- interstitial nephritis ( usually drug induced )
Chronic : - pyelonephritis ( due primarily to vesicoureteral reflex )
- analgesic abuse

POSTRENAL DISEASE
Obstructive uropathy
Prostatic disease
Malignancy
Calculi
Congenital abnormalities
 Initial clinical and laboratory data base for defining major
syndromes in nephrology
syndrome Important clues to
diagnosis
Acute or rapidly progressive renal Anuria
failure Oliguria
Documented recent decline in
GFR
Acute nephritis Hematuria, red cell casts
Azotemia, oliguria, edema
hypertension
Chronic renal failure Azotemia for > 3 months
Prolonged symptoms or signs of
uremia
Symptoms or signs of renal
osteodystropy
Kidneys reduced in size bilaterally
Broad casts in urinary sediment
Common findings not
Of diagnostic value
Hypertension
Hematuria, proteinuria,pyuria,
cast sedema
Proteinuria, pyuria, circulatory
congestion
Hematuria, proteinuria, casts
oliguria, polyuria, nocturia, edema,
hypertension
Electrolyte disorder
Nephrotic syndrome Proteinuria > 3,5 g/ 1,73 m per 24 Casts edema
hours
Hypoalbuminemia
Hyperlipidemia
lipiduria
Asymptomatic urinary Hematuria
abnormalities Proteinuria ( below nephrotic range )
Sterile pyuria, casts

Urinary tract infection Bacteriuria > 10 colonies/ ml Hematuria

Other infection agent document in Mild azotemia
urine Mild proteinuria
Pyuria, leukocyte casts fever
Frequency, urgency
Bladder tenderness
Flank tenderness
Renal tubular defects Electrolyte disordes Hematuria
Polyuria, nocturia Mild azotemia
Symptoms and signs of renal Mild proteinuria
osteodystrophy Fever
Large kidneys
Renal transport defects
hypertension Systolic / diastolic hypertension Proteinuria
Casts azotemia

Nephrolitiasis History of stone passage Hematuria

Or removal Pyuria
Stone seen by X ray Frequency, urgency
Renal colic

Urinary tract obstruction Azotemia , oliguria, anuria Hematuria

Polyuria, nocturia, urinary retention Pyuria
, slowing of urinary stream, large Enuresis
prostate, large kidneys, flank Dysuria
tenderness, full bladder after
voiding
 Gagal ginjal akut
Gambaran klinis ; peningkatan BUN dan serum
creatinin secara cepat dan dapat disertai dengan
oliguria
Penyebab :
 Major causes of acute renal failure

Hypovolemia Volume loss via the skin, gastrointestinal tract, or kidney.

Hemorhage. Sequestration of extracellular fluid
( burns, pancreatitis, peritonitis )

Cardiovascular failure Impaired cardiac output ( infarction, tamponade )

Vascular pooling ( anaphylaxis, sepsis, drugs )

Extra renal obstruction Urethral occlusion, vesical, pelvic, prostatic, or retroperitoneal

neoplasm, surgical accident
Medication, calculi. Plus blood clots

Intrarenal obstruction Crystal ( uric acid, oxalic acid, sulfonamides, methotrexate )

Bladder rupture Trauma

Vascular disease Vasculitis, malignant hypertension

Thrombotic thrombocytopenia purpura, scleroderma, arterial
or venous occlusion

glomerulonephritis Immune complex disease

Anti GBM disease.

Interstitial nephritis Drugs, hypercalsemia, infection idiopathic

postischemiic All condition listed above under hypovolemia and
cardiovascular failure

Pigment - induced Hemolysis ( transfusion reaction, malaria )

Rhabdomyolysis ( trauma, muscle disease, coma, heat stroke,
severe exercise, potassium or phosphate depletion)

Poison - induced Antibiotics. Contras material, anesthetic agent.

Heavy metals. Organic solvents.

Pregnancy - related Septic abortion, uterine hemorrhage, eclamsia

Pathophysiology of
ischemia induced 10
acute renal failure
 Gagal ginjal kronik
Stadium I : penurunan cadangan ginjal
Serum kreatinin dan BUN normal
Asimtomatik
Stadium II : insufisiensi ginjal
>75% nefron rusak
GFR 25% dari normal
Serum kreatinin dan BUN > normal
nokturia dan poliuria
Stadium III : Gagal ginjal stadium akhir = Uremia
>90% nefron rusak
GFR 10% dari normal
Creatinine clearance 5 10 ml/menit
Oligura
Sindroma uremik
 Patofisiologi Gagal Ginjal
Semua unit nefron telah terserang penyakit namun
dalam stadium yang berbeda-beda dan bagian tertentu
yang rusak
Hipotesis Bricker (Hipotesis nefron yang utuh) : bila
nefron terserang penyakit, maka seluruh unitnya akan
hancur, namun sisa nefron yang masih utuh tetap
bekerja normal pola adaptasi fungsional
homeostasis >75% nefron yang rusak
COMMON CAUSE OF CHRONIC RENAL FAILURE

1.DIABETES MELLITUS
2. HYPERTENSION COMMON
3. GLOMERULO NEPHRITIS

4. POLYCYSTIC KIDNEY DISEASE,

LESS COMMON
OBSTRUCTION & INFECTION
12
Pathogenesis of bone
diseases in chronic
renal failure
CLINICAL ABNORMALITIES IN UREMIA 13
14
Major causes of renal stones