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Problem batu ginjalProblem batu ginjalPenyebab utama batu ginjal belum diketahuiPenyebab utama batu ginjal belum diketahui

Bentuk utama batu :Bentuk utama batu :

Calcium,Calcium,

struvite,struvite,

asam urat,asam urat,

cystinecystine

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The prevalence of kidney stones isThe prevalence of kidney stones is three times higherthree times higherin men than women, and is higher amongin men than women, and is higher among

Caucasians than Asians or African Americans, forCaucasians than Asians or African Americans, forreasons that are not clearreasons that are not clear.. They are especially likely to strike between the ages ofThey are especially likely to strike between the ages of

40 and 60.40 and 60. Nutritional steps are important inNutritional steps are important in preventing stonespreventing stones

and can also helpprevent recurrencesand can also helpprevent recurrences, which is, which isimportant given that 30important given that 30--50 percent of people diagnosed50 percent of people diagnosedwith a renal stone have a recurrence within five years.with a renal stone have a recurrence within five years.

Preventing stones is like keeping a salt crystalPreventing stones is like keeping a salt crystalfrom forming in a glass of salty water. You canfrom forming in a glass of salty water. You caneither reduce the concentration of salt or addeither reduce the concentration of salt or add

more water.more water. Epidemiologic studies have shown that certain parts ofEpidemiologic studies have shown that certain parts of

the diet help reduce the amount of calcium that filtersthe diet help reduce the amount of calcium that filtersinto the urine. It is a simple matter to put these factorsinto the urine. It is a simple matter to put these factorsto work clinically.to work clinically.

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Batu calciumBatu calcium

70%70%--80% tersusun dari calcium oksalat80% tersusun dari calcium oksalatdengan atau tanpa fosfatdengan atau tanpa fosfat

Kelebihan calcium dalam urine dapatKelebihan calcium dalam urine dapatdisebabkan oleh :disebabkan oleh : 1. intake berlebihan makanan yang1. intake berlebihan makanan yang

mengandung calcium tinggimengandung calcium tinggi

2.kelebihan vitamin D,2

.kelebihan vitamin D,

absorbsi calciumabsorbsi calcium

3. imobilisasi lama3. imobilisasi lama

4. hiperparatiroidism4. hiperparatiroidism ekskresi calciumekskresi calcium

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Batu struviteBatu struvite

Terdiri dari MgNHTerdiri dari MgNH44POPO44 Sering disebut batu infeksiSering disebut batu infeksi

Tidak berhubungan dengan makananTidak berhubungan dengan makananspesifikspesifik

Tidak ada terapi diet spesifikTidak ada terapi diet spesifik

Biasanya berukuran besarBiasanya berukuran besar perlu operasiperlu operasiAngka kejadiannya : seringAngka kejadiannya : sering

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Batu asam uratBatu asam urat

Kelebihan ekskresi asam urat, gangguanKelebihan ekskresi asam urat, gangguanmetabolisme purin.metabolisme purin.

Terjadi pada penyakit gout, atau karenaTerjadi pada penyakit gout, atau karenapemecahan jaringan yang cepat selamapemecahan jaringan yang cepat selama

kelaparankelaparan

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Batu cystineBatu cystine

Angka kejadiannya jarangAngka kejadiannya jarang

Terjadi karena defect genetik padaTerjadi karena defect genetik pada

metabolisme asam amino cystine, akanmetabolisme asam amino cystine, akanterjadi gangguan reabsorbsi asam aminoterjadi gangguan reabsorbsi asam aminocystinecystine cystinuriacystinuria

Terjadi pada anak dengan riwayatTerjadi pada anak dengan riwayatpenyakit genetikpenyakit genetik

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TandaTanda--tanda klinistanda klinis

Tanda utama batu ginjal :Nyeri hebat,Tanda utama batu ginjal :Nyeri hebat, generalgeneralweakness,weakness, kadang ada panaskadang ada panas

Pengelolaan :Pengelolaan :

Intake cairan : banyak minumIntake cairan : banyak minum

urine encerurine encer

mencegah akumulasi material pembentuk batumencegah akumulasi material pembentuk batu Membatasi diet sesuai dengan komposisiMembatasi diet sesuai dengan komposisi

batubatumenghambat kekambuhanmenghambat kekambuhan Mengatur pH urineMengatur pH urine

Binding agents : mis, sodium phytate untuk mengikatBinding agents : mis, sodium phytate untuk mengikatcalcium, dan aluminium gel untuk mengikat fosfat,calcium, dan aluminium gel untuk mengikat fosfat,glisin untuk mengikat oksalat dalam ususglisin untuk mengikat oksalat dalam usus menghambat absorbsi, dan mengeluarkan dari tubuh.menghambat absorbsi, dan mengeluarkan dari tubuh.

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Diit pada batu ginjalDiit pada batu ginjal

Memperlambat pertumbuhan batu ginjalMemperlambat pertumbuhan batu ginjalatau membantu mencegah pembentukanatau membantu mencegah pembentukan

batu ginjalbatu ginjal Perencanaan nutrisi dihubungkan denganPerencanaan nutrisi dihubungkan denganjenis batu.jenis batu.

Mengurangi jenis makanan yang berperanMengurangi jenis makanan yang berperandalam pembentukan batu.dalam pembentukan batu.

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Macam diit dan indikasi pemberianMacam diit dan indikasi pemberian

Diit rendah calcium tinggi sisa asamDiit rendah calcium tinggi sisa asam Diberikan pada penderita dengan batu Kalsium : CaDiberikan pada penderita dengan batu Kalsium : Ca

Fosfat, Ca carbonat, dan Ca oksalat.Fosfat, Ca carbonat, dan Ca oksalat.

Makanan ini cukup kalori, protein, besi, vitaminA,Makanan ini cukup kalori, protein, besi, vitaminA,thiamin dan vitamin Cthiamin dan vitamin C

Syarat : banyak cairan ; 2500 ml/hari,Syarat : banyak cairan ; 2500 ml/hari,rendah calsium : 400mg/harirendah calsium : 400mg/hari

Makanan yang boleh diberikan :Makanan yang boleh diberikan :

KH : beras, bulgur,roti,mie, makaroni, bihun, tepungKH : beras, bulgur,roti,mie, makaroni, bihun, tepung--

tepungantepunganProtein hewani : telur, daging, unggas, ikan tanpaProtein hewani : telur, daging, unggas, ikan tanpa

tulangtulang

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Makanan yang boleh diberikanMakanan yang boleh diberikan

Protein nabati : tahu/tempe maks 50Protein nabati : tahu/tempe maks 50 g/hari, kacangg/hari, kacang--kacangan kering maks: 25 g/harikacangan kering maks: 25 g/hari

Lemak : minyak,mentega, margarinLemak : minyak,mentega, margarin

Sayuran : semua kecuali yang dilarang maks : 200 g/Sayuran : semua kecuali yang dilarang maks : 200 g/

harihari Buah : semua buahBuah : semua buah-- buahan segar maks: 200 g/ haribuahan segar maks: 200 g/ hari

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Makanan yang tidak boleh diberikanMakanan yang tidak boleh diberikan

KH : kentang, ubi,singkong, biskuit dan kue yang dibuatKH : kentang, ubi,singkong, biskuit dan kue yang dibuat

dengan susudengan susu

Protein hewani : susu,keju, udang, kepiting, ikan teri,Protein hewani : susu,keju, udang, kepiting, ikan teri,ikan asin, sardin, otak, ginjal, hati,jantungikan asin, sardin, otak, ginjal, hati,jantung

Sayuran : bayam, daun mangkokan, daun melinjo, daunSayuran : bayam, daun mangkokan, daun melinjo, daun

pepaya, daun lamtoro, daun singkong, daun talas, daunpepaya, daun lamtoro, daun singkong, daun talas, daunkatuk, daun kelor, jantung pisang, buah melinjo, sawi,katuk, daun kelor, jantung pisang, buah melinjo, sawi,leunca.leunca.

BuahBuah--buahan : semua buahbuahan : semua buah--buahan yang dikeringkanbuahan yang dikeringkan

Minuman : yang mengandung soda, coklat, soda kue,Minuman : yang mengandung soda, coklat, soda kue,yeastyeast

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Diit tinggi sisa basaDiit tinggi sisa basa

Diberikan pada penderita dengan batu cystine dan asam urat,Diberikan pada penderita dengan batu cystine dan asam urat,

makanan ini cukup kalori, mineral, dan vitaminmakanan ini cukup kalori, mineral, dan vitamin Syarat : banyak cairan : 2500 ml/hari, rendah asam amino yangSyarat : banyak cairan : 2500 ml/hari, rendah asam amino yang

mengandung sulfurmengandung sulfur

Makanan yang bpleh diberikan :Makanan yang bpleh diberikan :

KHKH: nasi maks: gelas/ hari, roti 4 potong, kentang ubi,singkong,: nasi maks: gelas/ hari, roti 4 potong, kentang ubi,singkong,

kuekue--kue yang dibuat dari tepung maezena, hunkwee, tapioka, agarkue yang dibuat dari tepung maezena, hunkwee, tapioka, agar--agar, sirop.agar, sirop.

Protein hewaniProtein hewani: daging 50 g, atau telor: 1 bt/ hari, susu.: daging 50 g, atau telor: 1 bt/ hari, susu.

LemakLemak: minyak, mentega, margarin: minyak, mentega, margarin

Protein nabatiProtein nabati: kacang: kacang--kacangan kering :25g/hari atau tahu,kacangan kering :25g/hari atau tahu,tempe,oncom : 50 g/haritempe,oncom : 50 g/hari

sayuransayuran: semua sayuran paling sedikit 300 g/hari: semua sayuran paling sedikit 300 g/hari

buahbuah--buahanbuahan: semua buah: semua buah--buahan paling sedikit 300 g/haribuahan paling sedikit 300 g/hari

minumanminuman : sari buah, the kopi, coklat: sari buah, the kopi, coklat

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Diit rendah purinDiit rendah purin

Tujuan :

Tujuan : Mengurangi pembentukan asam uratMengurangi pembentukan asam urat

Menurunkan berat badan bila pasien gemuk, danMenurunkan berat badan bila pasien gemuk, danmempertahankan BB dalam batas normalmempertahankan BB dalam batas normal

Syarat :Syarat :

Rendah purin : 120Rendah purin : 120--150 mg/hari, normal : 600150 mg/hari, normal : 600--1000 mg/hari1000 mg/hariCukup kalori, protein, mineral, dan vitaminCukup kalori, protein, mineral, dan vitamin

Tinggi hidrat arang, untuk membantu pengeluaran asam uratTinggi hidrat arang, untuk membantu pengeluaran asam urat

Lemak sedang : cenderung menghambat pengeluaran asam uratLemak sedang : cenderung menghambat pengeluaran asam urat

Banyak cairan ; membantu mengeluarkan kelebihan asam uratBanyak cairan ; membantu mengeluarkan kelebihan asam urat

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Bahan makan yang boleh diberikanBahan makan yang boleh diberikan :: KH : semuaKH : semua

Protein hewani : daging, ayam, ikan tongkol, ikanProtein hewani : daging, ayam, ikan tongkol, ikantenggiri, bawal, bandeng: 50 g/hari, telor, susu, kejutenggiri, bawal, bandeng: 50 g/hari, telor, susu, keju

Sumber protein nabati : kacangSumber protein nabati : kacang--kacangan keringkacangan kering:25g/hari atau tahu, tempe, oncom : 50 g/hari:25g/hari atau tahu, tempe, oncom : 50 g/hari

Lemak : minyak dalam jumlah terbatasLemak : minyak dalam jumlah terbatas

Sayuran : semua sayuran, kecuali asparagus,Sayuran : semua sayuran, kecuali asparagus,kacang polong, kacang buncis, kembang kol, bayam,kacang polong, kacang buncis, kembang kol, bayam,

jamur maksimum : 50 g/ harijamur maksimum : 50 g/ hari

BuahBuah--buahan : semua macam buahbuahan : semua macam buah

Minuman : teh, kopi, minuman yang mengandungMinuman : teh, kopi, minuman yang mengandungsodasoda

Bumbu : semua macam bumbuBumbu : semua macam bumbu

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Makanan yang tidak boleh diberikanMakanan yang tidak boleh diberikan

Sumber protein hewani : sardin, kerang, jantung, hati,Sumber protein hewani : sardin, kerang, jantung, hati,usus,limpa,paru,paru,otak, ekstraks daging/kaldu,usus,limpa,paru,paru,otak, ekstraks daging/kaldu,bebek, angsa, burungbebek, angsa, burung

Minuman : alkoholMinuman : alkohol

Bumbu : ragiBumbu : ragi

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Protective FoodsProtective Foods

Water.Water. Water dilutes the urine and keeps calcium,Water dilutes the urine and keeps calcium,

oxalates, and uric acid in solution.oxalates, and uric acid in solution.

In research studies, those subjects whose totalIn research studies, those subjects whose totalfluid intake (from all sources) over 24 hours wasfluid intake (from all sources) over 24 hours wasroughly 2.5 liters, the risk of a stone was aboutroughly 2.5 liters, the risk of a stone was aboutoneone--third less than that of subjects drinking onlythird less than that of subjects drinking only

half that much. (They do not need to drink 2.5half that much. (They do not need to drink 2.5liters of water per day; rather this is the totalliters of water per day; rather this is the totalfluid consumption, including juices, soups, etc.)fluid consumption, including juices, soups, etc.)

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HighHigh--Potassium Foods.Potassium Foods.

A study of 46,000 men conducted by HarvardA study of 46,000 men conducted by HarvardUniversity researchers found that a highUniversity researchers found that a high

potassium intake can cut the risk of kidneypotassium intake can cut the risk of kidneystones in half.stones in half.

Potassium helps the kidneys retain calcium,Potassium helps the kidneys retain calcium,rather than sending it out into the urine.rather than sending it out into the urine.

Potassium supplements are not generallyPotassium supplements are not generallynecessary. Rather, a diet including regularnecessary. Rather, a diet including regularservings of fruits, vegetables, and beansservings of fruits, vegetables, and beanssupplies plenty of potassium.supplies plenty of potassium.

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Calcium.Calcium.

Although most stones contain calcium, the calcium inAlthough most stones contain calcium, the calcium infoods does not necessarily contribute to stones. Calciumfoods does not necessarily contribute to stones. Calciumsupplements taken between meals may increase the risksupplements taken between meals may increase the risk

of stones, because about 8 percent of any extra dietaryof stones, because about 8 percent of any extra dietarycalcium passes into the urine.calcium passes into the urine.

On the other hand, calcium consumed with meals hasOn the other hand, calcium consumed with meals hasthe opposite effect, reducing the risk of stones.Thethe opposite effect, reducing the risk of stones.Thereason, apparently, is that calcium binds to oxalates inreason, apparently, is that calcium binds to oxalates infoods and holds them in the digestive tract, rather thanfoods and holds them in the digestive tract, rather thanallowing them to be absorbed.allowing them to be absorbed.

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Caffeine.Caffeine.

Caffeinated beverages reduce the risk of stones.Caffeinated beverages reduce the risk of stones.Caffeines diuretic effect causes the loss of bothCaffeines diuretic effect causes the loss of both

water and calcium, but the water loss iswater and calcium, but the water loss isapparently the predominant effect.apparently the predominant effect.

alcoholic beverages are associated with aalcoholic beverages are associated with areduced risk of kidney stones, again presumablyreduced risk of kidney stones, again presumably

due to a diuretic effect.This is not a compellingdue to a diuretic effect.This is not a compellingreason to drink either coffee or alcohol, but theirreason to drink either coffee or alcohol, but theirdiuretic actions do present this advantage.diuretic actions do present this advantage.

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Problem FoodsProblem Foods

Animal proteins causeAnimal proteins cause calciumcalcium to be leached from theto be leached from thebones and excreted in the urine where it can formbones and excreted in the urine where it can formstones.stones.Diets rich in animal proteins alsoDiets rich in animal proteins also increase uric acidincrease uric acid

excretionexcretion.In a controlled research study, published in

.In a controlled research study, published inthethe American Journal of Clinical NutritionAmerican Journal of Clinical Nutrition, research, research

subjects on a diet eliminating animal protein had lesssubjects on a diet eliminating animal protein had lessthan half the calcium loss that they had on their baselinethan half the calcium loss that they had on their baselinediet.diet.

The Harvard study mentioned earlier found that even aThe Harvard study mentioned earlier found that even a

modest increase in animal protein, from less than 50modest increase in animal protein, from less than 50grams to 77 grams per day, was associated with a 33grams to 77 grams per day, was associated with a 33percent increased risk of stones in men.The same ispercent increased risk of stones in men.The same istrue for women.true for women.

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The association between animal proteins and stones probablyThe association between animal proteins and stones probablyrelates both to the amount ofrelates both to the amount ofproteinproteinthey contain and to theirthey contain and to theircontent of thecontent of the sulfursulfur--containing amino acidscontaining amino acids

Sulfur in cystine and methionineSulfur in cystine and methionine is converted to sulfate, whichis converted to sulfate, whichtends to acidify the blood. As a part of the process of neutralizingtends to acidify the blood. As a part of the process of neutralizingthis acid, bone is dissolved, and bone calcium ends up in the urine.this acid, bone is dissolved, and bone calcium ends up in the urine.Meats and eggs contain two to five times more of these sulfurMeats and eggs contain two to five times more of these sulfur--containing amino acids than are found in grains and beans.containing amino acids than are found in grains and beans.

Between 1958 and the late 1960s, there was a sharp increase in theBetween 1958 and the late 1960s, there was a sharp increase in theincidence of kidney stones in Great Britain. During that period, thereincidence of kidney stones in Great Britain. During that period, therewas no substantial change in the amount of calcium or oxalatewas no substantial change in the amount of calcium or oxalate--containing foods consumed.However, the consumption ofcontaining foods consumed.However, the consumption ofvegetables decreased, and the use of poultry, fish, and red meatvegetables decreased, and the use of poultry, fish, and red meatincreased. Statistical analyses showed a strong relationship betweenincreased. Statistical analyses showed a strong relationship between

the incidence of stones and animal protein consumption.the incidence of stones and animal protein consumption.

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Sodium.Sodium.

Sodium increases the passage of calcium through theSodium increases the passage of calcium through thekidney and increases the risk of stones.When people cutkidney and increases the risk of stones.When people cuttheir salt (sodium chloride) intake in half, they reducetheir salt (sodium chloride) intake in half, they reduce

their daily need for calcium by about 160 milligrams.their daily need for calcium by about 160 milligrams.

Plants of any kindPlants of any kindgrains, vegetables, legumes, andgrains, vegetables, legumes, andfruitsfruitscontain almost no sodium at all unless it is addedcontain almost no sodium at all unless it is added

during canning or other processing.

Dairy products andduring canning or other processing.

Dairy products andmeats contain more salt than plant products, and tablemeats contain more salt than plant products, and tablesalt, frozen meals, and canned and snack foods are thesalt, frozen meals, and canned and snack foods are thehighesthighest--sodium food products.sodium food products.

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Surprisingly,Surprisingly,

oxalateoxalate--rich foodsrich foods, such as chocolate,, such as chocolate,nuts, tea, and spinach, are not associatednuts, tea, and spinach, are not associatedwith a higher risk of renal stones, nor iswith a higher risk of renal stones, nor isvitamin Cvitamin C, even though it can be, even though it can beconverted to oxalate. A large study of menconverted to oxalate. A large study of mentaking vitamin C supplements found thattaking vitamin C supplements found thatthey had no more kidney stones than menthey had no more kidney stones than menwho do not take them.who do not take them.

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Sugar.Sugar.

Sugar accelerates calcium losses through the kidney.Sugar accelerates calcium losses through the kidney.

In the NursesHealth Study, those who consumed, onIn the NursesHealth Study, those who consumed, onaverage, 60 grams or more of sugar (sucrose) per dayaverage, 60 grams or more of sugar (sucrose) per dayhad a 50 percent higher risk of stones than those whohad a 50 percent higher risk of stones than those whoconsumed only about 20 grams.consumed only about 20 grams.

Climate.Climate. Kidney stones are also more common in warmKidney stones are also more common in warmclimates, presumably because perspiration leads toclimates, presumably because perspiration leads to

dehydration and a more concentrated urine, anddehydration and a more concentrated urine, andbecause sunlight increases the production of vitamin Dbecause sunlight increases the production of vitamin Din the skin which, in turn, increases calcium absorptionin the skin which, in turn, increases calcium absorptionfrom the digestive tract.17from the digestive tract.17

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Here are simple steps to help yourHere are simple steps to help your

patients avoid kidney stones.patients avoid kidney stones.

Encourage patients to drink plenty of water orEncourage patients to drink plenty of water orother fluids, staying ahead of their thirst.other fluids, staying ahead of their thirst.

Diets including generous amounts of vegetables,Diets including generous amounts of vegetables,fruits, and beans are rich in potassium and veryfruits, and beans are rich in potassium and verylow in sodium.low in sodium.

If you prescribe calcium supplements,If you prescribe calcium supplements,encourage patients to take them with meals,encourage patients to take them with meals,rather than between meals.rather than between meals.

Encourage patients to avoid animal products.Encourage patients to avoid animal products.Their proteins and sodium content increase theTheir proteins and sodium content increase therisk of stones.risk of stones.

Patients should keep salt and sugar use modest.Patients should keep salt and sugar use modest.