This presentation is about nutritional care in system nephrotic disorders, which is more in depth on nutritional management to reduce complaints and worsen the condition of the nephrons of the system.
2. DEFINISI
• Adalah kumpulan gejala klinis yang ditandai dengan
proteinuria massif ( >3,5 gr/24 jam), hipoalbuminemia,
edema dan kadang-kadang disertai hiperlipidemia dan
lipiduria.
• Characterized by a group of symptoms that result from
nephron tissue damage and impaired function.
3. Disease process
• Nephrotic syndrome or nephrosis :
•Results form nephron tissue damage to the major
filtering membrane of the glomerulus, thereby
allowing protein to pass into the tubule
•This high protein concentration may cause further
damage to the tubule
•The functions of the nephron including filtration
and reabsorption is disrupted
4. ETIOLOGI
1. SINDROM NEFROTIK IDIOPATIK (TIDAK DIKETAHUI ADALAH PENYAKIT GLOMERULO
PRIMER DG. LESI-LESI GLOMERULER
• Minimal change disease
• Mesangial proliferative glomerulonephritis
• Fecal dan segmental glomerulosklerosis
• Membranous glomerulopathy
• Mesangiocapilary glomerulonephritis
• Dll
2. Penyakit sindrom nefrotik sesudah penyakit lain.
• Infeksi
• Obat-obatan
• Neoplasia
• Penyakit multi system
• Heredofamilial : DM, sickle disease, sindrom nefrotik congenital, dll
• Lain-lain : toksemia pre eklamsia, hipertensi renovaskuler dll.
6. Gejala klinis sindrom nefrotik
• Gejala
• Edema : dari ringan tanpa keluhan sampai massif anasarka
meliputi peritoneal, tungkai, effuse pleural dan scrotal
vulva.
• Peningkatan berat badan
• Hiperlipidemia
• Hipovitaminosis, hipokalemia,
• Anemia
• Infeksi
• Malnutrisi
7. DIAGNOSIS
• KELUHAN
• SESAK NAFAS, ANOREKSIA, KAKI TERASA BERAT DAN DINGIN, “AKUT
ABDOMEN” SPT MUAL, MUNTAH, DAN DINDING PERUT TEGANG
• PEMERIKSAAN FISIK
• Sembab yang terjadi dlm bbrp hari sampai minggu sampai akhirnya
menetap. Sembab pada daerah kelopak mata (putty face), subkutis,
dinding dada, abdomen, tungkai, genitalis, seluruh tubuh (anasarka),
asites, hidrotoraks.
8. PEMERIKSAAN KLINIS
• Tekanan darah naik : Hipertensi ringan dan sedang.
• Nyeri dada
• Lemah
• Berat badan (naik ?)
9. • PEMERIKSAAN LABORATORIUM
• Darah :
• Hb (anemia normokrom normositer),
• Ht,
• transferin,
• feritin,
• serum iron.
• Albumin serum rendah < 3 gr%
• Urine :
• proteinuria (> 3,5 gr/dl), esbach, asupan dan keluaran urin
• Lipid :
• hipertrigliserida,
• hiperkholesterol,
• hiperlipidemia
• Fungsi hati : SGOT tinggi, albumin rendah, globulin &
alkalifosfatase tinggi
• Fungsi ginjal : ureum, kreatinin, laju filtrasi glomerulus.
11. Medical Nutrition Therapy
Goals:
•To control major symptoms
•To replace that are lost in the urine
•To reduce the progression to CKD
•To decrease the risk of atherosclerosis
12. Tujuan Utama Terapi Diet pada
NEPHROTIC SYNDROME
• Memastikan penggunaan protein dari makanan yang efisien dengan
memberikan kalori yang adekuat. Mencegah terjadinya katabolisme
protein dari otot.
• Mendukung terjadinya diuresis
• Mengurang udema
• Mengurangi terjadinya proteinuria
• Meningkatkan serum albumin menjadi normal
• Mencegah malnutrisi
• Mengurangi lipidemia menjadi normal
• Mengatasi anoreksia
13. SYARAT DIET
• Kalori diberikan sesuai kebutuhan
• dewasa : 35-50 Kal/kgBB/hari,
• pada anak-anak 75-100 Kal/kgBB/hari.
• Kalori : Nitrogen = 150 : 1
• Sumber energi terutama berasal karbohidrat
(kompleks) dan lemak yang cukup.
14. Energy
• Total energy intake should be adequate to
support nutrition status.
• Needs may be as high as 35 kcal/kg/day.
• To provide sufficient energy in kilocalories,
complex carbohydrates should be
given liberally, which also helps to combat the
catabolism of tissue protein and to prevent
starvation ketosis.
15. PROTEIN
• Asupan protein yang terlalu tinggi akan menyebabkan
hiperfiltrasi dan memperberat proteinuria
• Secara umum berikan 0,8-1 gr/kgBBI/hari, bila tjd malnutrisi,
fungsi ginjal msh bagus, dan proteinuria massive.
• Bila terjadi penurunan GFR berikan Protein 0,7 – 1,0 g/kg
BB/hari + 1,0 g/hari protein bernilai biologis tinggi setiap
kehilangan 1 gram protein
• Untuk anak-anak berikan protein sesuai AKG
• Protein nabati mungkin lebih aman dibandingkan “high quality
protein” :
• Decrease urinary protein excretion, increase serum protein
and blood lipids
16. Nutrition standard
Protein:
• The diet is usually moderate in protein (0.8
to 1.0 g/kg of body weight/day), with an emphasis
on protein from high biologic value sources, including soy
protein.
• Total protein intake may be modified on the basis of
blood urea nitrogen and GFR results. If blood urea
nitrogen level is elevated and urine output is decreased,
dietary protein may be restricted.
17. Calculate dietary protein intake
PCR = (10,7 + [24-hour urinary urea excretion/ 0,14]
g/day + urinary protein excretion
PCR = protein Catabolic Rate
18. Fat
• Total fat intake should not exceed 30% total kcal/ day,
• Cholesterol intake should not exceed 200 mg/
day
• Trans fats should be limited, and up to 10% of
kilocalories should come from polyunsaturated fats,
including fish.
• Controlling the dietary intake of fat and cholesterol may
help to alleviate dyslipidemia and the resulting risk for
atherosclerosis.
19. Lemak
• Berikan lemak tidak lebih dari 30% dari total kalori untuk mengatasi
dislipidemia
• Kholesterol rendah (kurang dari 200 mg/hari)
• Tinggi PUFA (10% energy)
• Minyak ikan bermanfaaf pada IgA nephropathy (12 g/hari)
20. Cairan & elektrolit
• Bila disertai edema dan hipertensi batasi asupan natrium 1000 – 2000
mg/hari
• Dapat diberikan diet rendah natrium (500 mg/hari) untuk membantu
pengeluaran cairan.
• Apabila edema dan keseimbangan natrium sudah tercapai, asupan
natrium bisa lebih moderate (1500 mg/hari)
• Perhatikan terjadinya hiponatremia.
• Perhatikan asupan kalium
21. Fluid
•Fluid intake may be restricted in
response to urine output and
insensible losses.
•If restriction is
not indicated, fluids can be
consumed as desired.
22. Sodium and potassium
• To reduce symptoms of edema, a sodium restriction of 1
to 2 g/day is advised to maintain the sodium and fluid
balance.
• Sodium overload is difficult to treat because of the
characteristic hypoalbuminuria and hypotension;
therefore, careful monitoring is necessary.
• The renal clearance of potassium is impaired with
oliguria. Thus, potassium intake should be monitored
and adjusted in accordance with individual needs.
23. Calcium and phosphorus
• Some calcium is bound to albumin in the blood. As albumin is
lost through the
tubule, bound calcium is also lost. In addition, low serum levels
of active vitamin D decrease calcium absorption.
• The recommendations is to consume 1 to 1.5 g of calcium per
day and to limit
phosphorus intake to 12 mg/kg/day
• Keseimbangan kalsium negatif dan , hypocalcemia pada terapi dengan
ACTH.
• Calcium chlorida sebanyak 1-2 gram perlu diberikan setiap hari.
24. Summary
Diet pada sindroma nefrotik seharusnya :
• Protein adekuat, tinggi kalori, rendah natrium, lemak
yang cukup, serta kalsium & kalium cukup
• Dapat dikonsumsi pasien, bervariasi, dan mudah
cerna.
