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SINDROM NEFROTIK

Lestari Sukmarini, MN

KMB FIK-UI2009

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SINDROM NEFROTIK

PENGERTIANmerupakan salah satu gambaran klinikpenyakit glomerulus yang di tandaidengan: protenuria masif >3,5 gram / 24 jam / 1,73

m2 hipoalbuminemia, edema anasarka, hiperlipidemia, lipiduria,dan hiperkoagulabilitas.

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DIAGNOSIS Anamnesis : bengkak seluruh tubuh,buang air

kecil keruh Pemeriksaan fisis: edema anasarka,asites

Laboratorium:Proteinuria masif >3,5 gram / 24jam / 1,73 m2, hiperlipidemia,hipoalbuminemia (

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Patogenesis edema pd SNProteinuria

albumin plasma Tekanan osmotik koloid plasma

Pergeseran cairan

ekstraselCairaninterstisiel

Edema

Cairan

ekstrasel

CairanintravaskularRenin-angiotensin

Aldosteron

Reabsorbsi Na pd tubulus

Retensi Na &

H2O

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INVESTIGASI URINALISA Proteinuria Dipstick test

24-hour quantitative test Analisa darah Albumin < 2.5 gr/dL Lipid: LDL/VLDL ; HDL BUN/Creatinine

Biopsi ginjal Imaging studies: renal USG

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Proteinuria

Dipstick test: negative, trace

1+ (closest to 30 mg/dL)

2+ (closest to 100 mg/dL) 3+ (closest to 300 mg/dL)

4+ (greater than 2,000 mg/dL)

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Proteinuria Normal range

100mg/m2/day (150mg/day), 1 gm/ m2/day >40mg / m2/hour

Spot urine for albumin/creatinine ratio

(mg:mg) Normal =

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Indikasi biopsi ginjal Proteinuria > 1gr/hari Hematuria +

Hipertensi + Fungsi ginjal

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Etiologi NS

Penyakit ginjal primer (75-80%)

Penyakit sekunder

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Orth S and Ritz E. N Engl J Med 1998;338:1202-1211

Relative Frequency of Primary Glomerular Diseases Underlying the Nephrotic Syndrome inChildren and Adults

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Glomerulopathy lesi minimal Faal ginjal normal, respon kortikosteroid +remisi 90%

Remisi spontan 60% Glomerulopathy lesi membranosa

Faal ginjal

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Orth S and Ritz E. N Engl J Med 1998;338:1202-1211

Rare Causes of the Nephrotic Syndrome

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Orth S and Ritz E. N Engl J Med 1998;338:1202-1211

Major Factors Contributing to the Hypercoagulable State in the Nephrotic Syndrome

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Symptoms

Edema: swollen face,ascites, pleuraleffusion, swollengenital.

Oliguria

Hematuria anorexia, fatigue,

irritable, pale Diare Respiratory distress Hipertensi Infeksi Tromboemboli

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Treatment terapi spesifik untuk kelainan dasar ginjalatau penyakit penyebab (pada SNsekunder),

mengurangi atau menghilangkanproteinuria, memperbaiki hipoalbuminemi mencegah dan mengatasi penyulit.

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Patofisiologi Pengobatan

Kerusakan glomerulus Imunosupresif: mycophenolate mofetil(MMF), siklosporin

Antikoagulan:heparin/warfarinAnti agregasi trombosit: aspirin

Kehilangan protein Diit 35 kal/kgBB/hr RP 0.8-1gr/kgBB/hr atau 0.6 gr/kgBB/hr +gram proteinurin

Hipoalbuminemia dan penurunantekanan onkotik Infus albumin (15%) 300 ml/45 mnt

Sekresi aldosteron Diuretik spironolakton

Retensi natrium dan air Diuretik furosemid 40 mg/hr

Diit rendah garam 1-2 gr/hari

Sembab yang resisten ultrafiltrasi

Kontrol infeksi antibiotik

Kolesterol darah hidroxymethyl glutaryl co-enzyme A(HMG Co-A) reductase

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Kontrol hipertensi angiotensinconverting enzyme (ACE-1) inhibitors danAngiotensin Receptor antagonist

sirkulasi, tekanan darah, tekananglomerulus

kebocoran protein, memperlambatprogressive scarring glomeruli.

Non farmakologi lain: bedrest, diet rendahkolesterol

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Complications atherosclerosis "hardening of thearteries

adverse reaction to steroids and

immunisuppressant: osteoporosis, cataractdevelopment, increased risk of infection,and diabetes.

Kidney function: insufficiency CKD

Growth Delays in children Infection

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Prognosis Umur & gender: anak, wanita > baik. komplikasi,

tipe histopatologis ginjal Kematian: GGK, infeksi sekunder,

gagal sirkulasi.

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PENGKAJIAN KEPERAWATANRiwayat kesehatan : ISPA, infeksi kulit, infeksi saluran kemih,

hepatitis, obat nefrotoksik, riwayat keluarga dengan penyakit

polikistik, keganasan, nefritis herediter.Sirkulasi : hipertensi, disritmia kardia, distensi vena jugular, edemageneral (termasuk area periorbital, sakrum), pallor.

Eliminasi : perubahan pola urin, perubahan warna urin seperti merah,keruh, pekat, oliguri.

Makanan/cairan : penambahan berat badan (edema), dehidrasi, mual,

muntah, adanya penggunaan diuretik, perubahan turgor kulit, edema.Nyeri : pada area kostovertebral/pinggangPernafasan : dispnea, takipnea, adanya batuk produktif (edema paru)Pemeriksaan diagnostik :Pemeriksaan sedimen urin : urin 24 jam untuk pemeriksaan bersihan

kreatinin dan protein total untuk memperhitungkan fungsi ginjal

residual dan ekskresi protein urin. cast sel darah merah membantumengarahkan bahwa hematuria dari glomerulus.Biopsi ginjal kelainan histologi yang terjadi.Darah : Hb menurun karena anemia, BUN-creatinin meningkat, protein

albumin serum menurun.

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Pemeriksaan lain yang penting adalah : ureum serum,albumin, kolesterol, elektrolit dan jugapemeriksaan serologis seperti: autoantibodi,complement C3 C4, imunoglobulin.

Urin: jumlah urin

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Nursing diagnosis alteration in fluid volume: excess; risk for infection; alteration in nutrition: less than body

requirements, potential alteration in comfort; knowledge deficit; and

potential disturbance in self-concept: bodyimage.

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NURSING

MANAGEMENT Monitor I & Opossibly limit fluids balance (-) Weigh dailyevaluating amount of edema, abdominal

circumference Making patient comfortable

Maintaining good nutrition DietHigh protein, high CHO for protein sparing, low fat,salt restrictions

Preventing infections: universal precautions, limit invasiveprocedure,

Bedrest

Activity may increase as edema decreases Measures to prevent skin breakdown. Monitor lab Monitor side effect of medications

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Lifestyle and homeremedies

Limit salt intake to help minimize fluidretention and swelling and to reduce bloodpressure

Modify diet to decrease cholesterol andtriglyceride levels

Take vitamin D supplements Report signs of relaps Infection prevention Check regularly to doctor or dietitian

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Diet

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References:

Black, JM. & Matassarin-Jacobs, E. (1997). Medical surgicalnursing: Clinical management for continuity of care. (5thed.).WB Saunders Company, Philadelphia.

Goldman, L. & Bennett, JC. (2001). Pocket companion to ceciltextbook of medicine(21st ed.). WB Saunders Company,Philadelphia.

Reeves, CJ., Roux, G., Lochart, R. (2001). Keperawatanmedikal bedah (Ed. Setyono, J.). Penerbit Salemba Medika,Jakarta.

Sukandar, E. (1997). Nefrologi klinik. (2nd ed.). Penerbit ITB,Bandung.

Wilson, DD. (1998). Nurses guide to understanding

laboratory and diagnostic test. Lippincott William&Wilkins,Philadelphia. http://www.nephrologychannel.com/nephrotic/diagnosis.sht

ml http://nephroticsyndrome.com

http://www.nephrologychannel.com/nephrotic/diagnosis.shtmlhttp://www.nephrologychannel.com/nephrotic/diagnosis.shtmlhttp://www.nephrologychannel.com/nephrotic/diagnosis.shtmlhttp://www.nephrologychannel.com/nephrotic/diagnosis.shtml

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THANK YOU ..