PRESENTASI KASUS CKD+NSTEACS

8/19/2019 PRESENTASI KASUS CKD+NSTEACS

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Tugas Presentasi Kasus

Analisis Kefarmasian pada Kasus Chronic Kidney

Disease stage V + NSTE-ACS + Anemia Renal

(riwayat DM tipe dan !T"

Oleh:

Denok Ayu M. R. 051513143106

Anistya Martia P. 051513143114

Maruti W. 051513143115

Mirmatania K. 05151314311

PRAKTEK KERJA PROFESI APOTEKER PERIODE 102RSU Dr. SAIFUL ANWAR MALAN


2/48

Definisi CKD

Kerusakan !in"al selama # 3 $ulan yan! %ilihat %aria$normalitas struktur %an &un!si !in"al' %en!anatau tan(a (enurunan )*R' %an %imani&estasikan

%en!an:• Kelainan (atolo!is' atau (etan%a kerusakan

!in"al' termasuk kelainan %alam %arah' urine'atau stu%i (en+itraan.

)*R ,60 ml-menit-1'3 m/ selama #3 $ulan'%en!an atau tan(a kerusakan !in"al

!NKF KDO"I#2002$


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Penatalaksanaan CKD

!NKF KDO"I#2002$


4/48

Etiologi CKD

!NKF KDO"I#2002$


5/48

Etiologi CKD

!NKF KDO"I#2002$


6/48

PatogenesisCKD

!W%ng# 2012$


7/48

Manifestasi Klinis CKD

!Mas%n an& Assi'%n#201($


8/48

Manifestasi Klinis CKD

!Mas%n an& Assi'%n#201($


9/48

Komplikasi CKD

!W%ng# 2012$


10/48

Dise)ut anemiarenal *i+a +a&ar

,) -1 g/&!a+ia+i$ &an

-12 g/&!ere'uan$

3ang teruta'a&ise)a)+anenurunan+aasitasr%&u+si

eritr%%ietina&a 4KD.

FAKTORLAIN

PEN5E6A6ANEMIARENAL

• De7siensi )esi&an asa' 8%at#u'ur eritr%sit

3ang'e'en&e+#

9ieraratir%i&se+un&er &an

in8e+siin:a'asi.

• 6esi %ra atau arentera• Trans8usi PR4 !&i'uai saat

,) -; g/& &engan target ;<g/&$

• Erit%%ietin !&i'uai saat ,)-10 g/& &engan target 1012g/&$

Anemia Renal

PERNEFRI, 2011


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ACS (Acute Coronary Sindrome)

in%rom Koroner Akut KA2 meru(akanistilah untuk !e"ala klinis yan! $erhu$un!an

%en!an iskemik miokar%ial akut yan!%ihasilkan %ari keti%akseim$an!an antarake$utuhan %an keterse%iaan oksi!enmiokar%ial aki$at a%anya (enurunan aliran

%arah koronerAmster%am et al' /0142.


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• Disfungsi endotel• Inflamasi

• Pementukan fatty

streaks• !ipe"lipidemia

#$pinle" and Denus, 201%&

Etiologi


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#Ande"son, 200'&

Patofisiologi


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E$C guidelines, 201(

Komplikasi ACS


15/48

Risk Factor ACS

)NC ', 200*


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STU! KASUS

Inisia Pasien= N3. S 6erat 6a&an= (0 Kg

U'ur = (2 ta9un Tinggi 6a&an= 1< >'

Aa'at = Maang Tg MRS = 10/2/201?

Keu9an uta'a = yeri %a%a kiri men"alar ke (un!!un!

Keu9an ta')a9an = Mual' muntah %an $erkerin!at%in!in

Diagn%sis = KD st. ' 7A

Ri@a3at Pen3a+it = Dia$etes ti(e /' 8i(ertensi

keluar!a %ia$etes %an hi(ertensi2Ri@a3at Peng%)atan = Pasien ti%ak men!!unakan o$at

Aergi# 'er%+%+# a+%9%: 9

Keatu9an: i%ak (atuh minum o$at


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Catatan Perkem"angan Pasien

Tangga Pr%)e'/Ke*a&ian/Tin&a+an Kinisi

10/2/201?

Pasien %iterima %i )D %en!an keluhan nyeri %a%a 3 hari se$elumMR' hilan! tim$ul %alam ;aktu < 30 menit' se"ak 6 "am MRnyeri terus sam(ai tem$us (un!!un! men"alar ke len!an kiri'mual' muntah' kerin!at %in!in . Kemu%ian (asien %i(in%ahkan ke=. Pasien menolak %ilaksanakan hemo%ialisa

11/2/201

?

K= lemah sesak mulai $erkuran!'

12/2/201?

K= lemah' mual' su%ah ti%ak sakit %a%a

1/2/201?

Pasien %i(in%ahkan ke Run!a /4A' K= lemah

1/2/201

?

K= lemah

1(/2/201?

K= lemah

1?/2/201?

K= lemah' sesak' nyeri (a%a (in!!an! %an %a%a' (osisi ti%ur %an$er$arin! se+ara kontinyu

1;/2/201

?

K= lemah' sesak

1B/2/201 K= lemah' (asien men"alani %ou$le lumen' (asien muntah hitam


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ata Klinik


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DATA

KLINIK

Tangga10-/ 11-/ 1/-/ 13-/ 14-/ 15-/ 16-/ 1-/ 1?-/ 1-/ /0-/

K%n&isi

u'u'/ 4S

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456

@ema

h-456Na&i !B0

100

C/'enit$

110 ? ?0 0 6/ / ? 11? 30

RR

!-20 C /

'enit$

/? /3 // /1 /1 /4 // 1?

Su9u !?

; 4$ 36'4 36'/

TD

!10/


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Jenis

Pe'eri+saa

n

Data

La)%rat%riu

'

Tangga

10/2 1/2 1;/21B/2!1

$1B/2!$

1B/2!

$

Dara9

Leng+a

W> 4 C 10

103-E@211'44 '4 1/'1 '16 '06

P@ 1509450

103-E@213 10 /0/ 1?

8 4/95/ F2 1' 1 /5'? /6'4 //'1 //'1

8)> 1391

m!-%@2

6'1 5'/ ?'4 '5 '5

M ?0 C 100

&@2?6' ?6' '4

M8 /?C 34

(!-sel2/6' /6'5 /6'4 /6'1 /6'1

M8 3/ C 36

!-%@2

30' 30'6 34'1 33' 33'

ata #a"oratorium


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JenisPe'eri+saan

Data La) 11/2 1/2 1;/21B/2!1

$

1B/2!2$

1B/2!$ 1


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Jenis

Pe'eri+saanData La) Tangga

Meta)%is'e

Kar)%9i&rat

11/2 1B/2!1$ 1B/2!$ 1B/2!$

)D se;aktu ,/00

m!-%@2

45 ? ?

)DP ,1/6 m!-%@2 11

8$A1+ G 6F2 5'?F

Faa ,ati

10/2 1;/2 1B/2!1$ 1


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1/2

UrinaisisDeskri(si Kunin! keruh

(e+. !raHity 1'00191'0352 1'0/

(8 4'59?'52 ?

@eukosit erla+ak

itrit 9

Protein-al$umin ne!ati&2 3I)lukosa ne!ati&2 9

Keton ne!ati&2 9

>iliru$in ne!ati&2 9

=ro$ilino!en ne!ati&2 9

Darah

e%imen7ritrosit /'41

@eukosit ?'5

7(itel 0'

ilin%er 9

Kristal ri(le (hos(hate

>akteri 1/?/'? 103-ml

ata #a"oratorium


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Data La) Tangga

Anaisa as

Dara9

10-/

(8 %arah '359'452 '/

(O/ 35945 mm8!2 //'

(O/ 59100 mm8!2 11'1

8O3 /1 9 /? mmol-@2 ?'atO/ 59F O/2 4'6

Pr%7 Le'a+

11/2

Kolesterol total , /00

m!-%@2 1/3 ri!liseri%a 35 9 135

m!-%@211

@D@ ,130 m!-%@2 64

8D@ 30 C 0 m!-%@2 43

ata #a"oratorium


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Data La) 10/210/

2

11/

21/2

1B/2!

$

1B/2!

$1 /60 C 445 E!-%@2 14 13? 13? 146

aturasi trans&erin/0 C 50F2 31F 31F /6F

*erritin /09300 [email protected]

/.6

/

/.6

/

1.54

6

ro(onin 090'4 n!-m@2 /'0 0'/

K M> ,/4 =-@2 30 / Asam laktat 0'69/'/

mmol-@20'

K A /4910 =-@2 1/0

Asam urat

/' C '3 m!-%@2 '5 5' 6'6

ata #a"oratorium


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PR$F!# TERAP!


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Na'a D%sis

Tangga e')erian10/

2

11/

2

12/

2

1/

2

1/

2

1(/

2

1?/

2

1;/

2

1B/

2

1


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Na'a D%sis

Tangga e')erian

10/

2

11/

2

12/

2

1/

2

1/

2

1(/

2

1?/

2

1;/

2

1B/

2

1trai& 10 = s+2 B

De+str%se0 / &@ B

4a gu>%nas 1 1 ! iH2 B


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Na'a D%sis

Tangga e')erian

10/

2

11/

2

12/

2

1/

2

1/

2

1(/

2

1?/

2

1;/

2

1B/

2

1


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A%A#!SA TERAP!


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P"olem Medik+ Pasien sesak dan lema

S/O Terai Tu*uan M%nit%ring

esakna&as

O//94 l(m

era(i (a%a kon%isihi(oksia

M%nit%ringe8e+tiHitas:

keluhan sesakmenurun-ti%ak a%a

@emah 0'F Resusitasi +airan M%nit%ringe8e+tiHitas:kon%isi umum $aik


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P"olem Medik+ AC$



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ro(onin I2KM> I2yeri %a%asam(ai

menem$us(un!!un!

AA1?0 m!(o

Anti(latelet M%nit%ring e8e+tiHitas= i%ak ter"a%i seran!anulan!M%nit%ring ESO= $lee%in!

hematemesis' melena2P)15 m!(o

Anti(latelet

imHastatin /0 m! (omalam2

Pleiotro(ik(er$aikan%is&un!si

en%otel'sta$ilisasi (lakaterosklerosi'(er$aiki (roseskoa!ulasi2

M%nit%r e8e+tiHitas= i%ak a%a seran!an ulan!'(lak sta$il-ti%ak ter"a%i

ru(tur@D@ , 0 m!-%@M%nit%r ESO= Rha$%omyolisis yan!%i(resi(itasi oleh interaksi%en!an amlo%i(in

D35 m! (o

aso%ilator M%nit%ring e8e+tiHitas: D 140-0 mm8! tar!et D (a%a (asien KDmenurut ?' /0142 %annyeri %a%a

M%nit%ring ESO:8i otensi


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S/O Terai Tu*uan K%'entar M%nit%ring

Mualmuntah'muntah%arahhitam(a%atan!!al1?-/

Ome(raLole1 40m! iH

Menekansekresi asamlam$un! PP2

Ome(raLole%i$erikan karena(asienmen!alami mualmuntah saat MR

M%nit%ringe8e+tiHitas:Mual muntah Mual muntah

M%nit%ringESO: Konsti(asi@anso(raLole6 m!-"am iH

%ri(2

Menekansekresi asamlam$un! PP2

@anso(raLolele$ih (otensehin!!a%i$erikan t!l1?-0/ saat (asienmen!alamimuntah %arahhitam %an nyeriulu hati

Meto+lo(rami%e1 10 m! iH2

Antiemetikanta!onisrese(tor%o(amin2

Kom$inasi%en!anome(raLolekarena (a%a saatMR (asien

M%nit%ringe8e+tiHitas:Mual muntah

Raniti%ine Menekan

P"olem Medik+ D-spepsia $-nd"ome . /I leeding

i d i d GI bl di


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e"api dyspepsia syndrome . GI bleeding


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Data la$ ka%arkaliumN119*e$ 5'4mmol-@

149*e$ 5'?4mmol-@19*e$ 6'45mmol-@

a!lukonas1 1 !ramiH2

ar%io(rote+tiHe M%nit%ringe8e+tiHitas terai:

ar!et ka%ar kalium:3'595'5 mmol-@

M%nit%ring ESOInsuin:Ka%ar !ula %arah 09130 m!-%@

(re(ran%ial2 %an,1?0 m!-%@(ost(ran%ial2menurut K* KDO/002

a(olystyrenesul(honate3 5 !ram

(o

e$a!ai resin(enukar ion(a%a kon%isihi(erkalemia

A+tra(i%10 = 2

Mana"emenhi(erkalemia

D40 Men+e!ahhi(o!likemia

P"olem Medik+ !ipe"kalemi


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D *urosemi%1 /0m! iH%ri(2

Antihi(ertensi!olon!an loo(%iureti+

*urosemi%%i$erikan (a%atan!!al 10-/karena (asienmen!alamifuid overloadse%an!kan

(a%a tan!!al1-/ %i$erikankarena D(asien tin!!i


D 140-0mm8! ?'/01428eart rate:?0-menit

M%nit%ringESO:8i(okalemi

Amlo%i(in1 5 m!(o2

Antihi(ertensi!olon!an >

P"olem Medik+ !ipe"tensi


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8$: 5'/0!-%@

A :

31F*erritin :10.1

PR1 &@-hari

Antianemia

Karena(asienmen!alami

anemiamaka (asien%i$erikanPR


ar!et out+ome

tera(i anemiarenal menurut K*KDO /002yaitu:8$ :1091/ m!-%@

A:


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usahti%ur

DiaLe(am

Antianietas

Pasienmen!alamisusah ti%ur %ari

a;al MRsehin!!a%i$erikan%iaLe(am %an(a%a tan!!al1-/ (asienmelakukan(emasan!an%o$el lumensehin!!a%i$erikan

trama%ol untuk

M%nit%ringESO= RRnormal

/0-menit2

M%nit%ringe8e+tiHitas=kala nyeri

yeri (ost

o(

rama%ol Anal!esik

o(ioi%

P"olem Medik+ N-e"i postop dan susa tidu"

P l M dik !i i i


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Asam urat

N '5m!-%@

Allo(urin

ol 1 100m!

Anti

hi(erurisemia

Karena (asien

men!alamihi(erurisemiamaka%i$erikanallo(urinol

M%nit%ring

e8e+tiHitas=Ka%ar asam urat, m!-%@

P"olem Medik+ !ipe"u"isemia

P"olem Medik+ Konstipasi


usah

$uan! air$esar

@aa%in

1 (o

Pen+aha

r

Pasien men!alami

konsti(asisehin!!a %i$erikanlaa%in. u!amen+e!ah(enin!katan ker"a

"antun! karena

men!e"an.

M%nit%ring

e8e+tiHitas=*rekuensi >A>/93 kali sehari

l d "l


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Anaisis Re+%'en&asiData la$ ka%ar al$umin19*e$: 3'0119*e$: /'55Ka%ar al$umin ,3'4

teta(i ti%ak men%a(attera(i al$umin

Di$erikan asu(an asam aminoesensial /0!-hari %an monitorin!>=

Pasien men!alami$akteriuriaData la$ urinalisis 149*e$1/?/'? 103-ml

Perlu a%a monitorin! tan%a9tan%ain&eksi yan! selan"utnya (erlu%i$erikan tera(i anti$akteri.Menurut Pe%oman Pen!!unaanAnti$iotik RA/01/2' untuk tera(iK $a;ah %irekomen%asikan tera(ikotrimoksaLol (o 60 m! tia( 1/

"am2Q si(roJoksasin (o /50 m! tia(1/ "am2 selama 3 hari em(iris2.

rug Related Pro"lem


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Anaisis Re+%'en&asi

Data la$ t!l 109*e$(8 %arahN'/ Q 8O3 N ?'

Q (O/N //'

menan%akan (asienmen!alami asi%osismeta$olik

Perlu a%anya tera(i a$i+ar$onat /95 m7-k!>>selama 49? "am in&ussion

Pen!!unaan allo(urinol1100 m! tia( hari %en!anka%ar asam urat (asien '5m!-%@

Dosis allo(urinol seharusnya100 m! (er 4? "am alternateday 2

Pa%a tan!!al 1?9*e$ 8$: m!-%@ namun ti%ak

men%a(at tera(i 7PO

Di$erikan tera(i eritro(oietinhin!!a ka%ar 8$ 1091/

m!-%@ %en!an %osis 7PO ?091/0 =-k >> se+ara su$kutan

rug Related Pro"lem

A & K f i


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Asu&an Kefarmasian

DRP Anaisis Pen3eesaian

A%a in%ikasi'ti%ak a%atera(i

Data la$ ka%aral$umin19*e$: 3'0119*e$: /'55Ka%ar al$umin ,3'4teta(i ti%akmen%a(at tera(ial$umin

SAsu(an (rotein'monitorin! >='Al$umin

A%a in%ikasi'

ti%ak a%atera(i

Pasien men!alami

$akteriuria

SMonitorin! tan%a9tan%a

in&eksi suhu tu$uh'W>2SKonTrmasi ke %oktertentan! (erlunya tera(ianti$akteri

A & K f i


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DRP Anaisis Pen3eesaianA%a in%ikasi'ti%ak a%atera(i

Data la$ t!l 109*e$(8 %arahN'/ Q 8O3

N ?' Q (O/N //'

menan%akan (asien

men!alami asi%osismeta$olik

SKonTrmasi ke %okterterkait (erlunya tera(ia $i+ar$onat

A%a in%ikasi'ti%ak a%a

%itera(i

i%ak a%a tera(iantianemia setelah

(em$erian PR(a%ahal 8$ (asien m!-%@

SKonTrmasi ke %okterterkait (em$erian 7PO

(a%a (asien setelah(em$erian PR.SDosis 7PO yan!%isarankan K* KDOa%alah ?091/0 =-k!>>

2

Asu&an Kefarmasian


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KIE

Pasien

•

Meme"ikanpen3elasan untuk"utin meminumoat -angdie"ikan sesuaidengan atu"an

pakain-a

okter

•

Melakukanpemantauante"adappe"kemangante"api -angdie"ikan dan

kondisi pasien

Pera'at• Melakukan

pemantauante"adappe"kemangankondisi pasientiap a"in-a

• Meme"ipen3elasan te"kaitadminist"asi oatpada pasien

i l d


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Kesimpulan dan Saran

•

e"api CKD st4 ( dengan anemia "enal pada pasien inisesuai dengan guideline PERNEFRI 2011, namun pe"ludie"ikan te"api EP5 mengingat ! pasien -ang masi"enda

•

e"api N$EAC$ pada pasien ini suda sesuai dengan/uideline E$C 201(

• Pasien meninggal tgl 2062617 diseakan cardiac arrest

f k


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aftar Pustaka

Anderson, J. L., 2004. ST-elevation Acute Myocardial Infarction and Comlication, In!

L. "oldman, and #. Ausiello, Cecil Textbook of Medicine, $d. 22nd, %SA!

$lsevier Inc.

Amsterdam, $&ra A., et. al., 20'4. 20'4 ACC(A)A *uideline for t+e mana*ement of

atients it+ nonST-elevation acute coronary syndromes! a reort of t+e

American Colle*e of Cardiolo*y( American )eart Association Tas /orce onractice "uidelines. Circulation. 20'41'0!e44e423.

C+oanian A5, 6aris "L, 6lac )7, Cus+man 8C, "reen LA, I&&o JL. T+e sevent+

reort of 9oint national committee on revention, detection, evaluation, and

treatment of +yertension. T+e J:C ; reort. JAMA. 2001 230-2>;2

James A, ?aril S, Carter 6L, Cus+man 8C, #ennison-)immelfar C, )andler J, et

al . 20'4 $vidence-6ased "uideline for t+e Mana*ement of )i*+ 6lood ressure

in Adults! 7eort /rom t+e anel Memers Aointed to t+e $i*+t+ Joint :ational

Committee @J:C


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aftar Pustaka

:ational Bidney /oundation, 2002. B#?DI Clinical ractice "uidelines for C+ronic

Bidney #isease! $valuation, Classification, and Stratification. Am J Kidney Dis

5ol.=!'233

:ational Bidney /oundation, 200;. B#?DI Clinical ractice "uidelines and Clinical

ractice 7ecommendations for #iaetes and C+ronic Bidney #isease. Am J

Kidney Dis 5ol.4= @2 sul 2! S'2-S'>4edoman en**unaan Antiiotia 7S%# #r. Saiful Anar Malan* Ta+un 20'2.

er+imunan :efrolo*i Indonesia, 20''. Konsensus Mana$emen Anemia !ada

%enyakit &in$al Kronik.

8on*, $ric, 20'2. Chronic Kidney Disease E?nlineF. #iases dari

+tt!((.at+o+ys.or*(cd( ada tan**al 2= /eruari 20'3.
http://www.pathophys.org/ckd/http://www.pathophys.org/ckd/

PRESENTASI KASUS CKD+NSTEACS

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