slide belajar hipertensi
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Nephrology Hypertension Division ofInternal Medicine Medical Faculty
Sebelas Maret University of Surakarta
HipertensiHipertensi
Prof. Dr. HM.Bambang Purwanto, dr. SpPD-KGH, FINASIM
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PENDAHULUAN
Faktor risiko mayor
Coronary Heart Disease (CHD)
Myocard Infarct (MI)
Cerebrovascular Accidents (CVA)
Chronic Kidney Diseases (CKD)
Congestive Heart Failure (CHF)
!isiko men"adi hipertensi # $%&
!eappraisal of 'uropean (uidelines on Hypertension Management) 'uropean Society of Hypertension *ask Force Document+Blood ressure! "##$% &' #'*+,
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KLASIFIKASI
,N- . !eport /%%0
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1H23ISH Statement on Management of Hypertension /%
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'SH3'S- (uidelines for the Management of )rterial Hypertensi
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4rimerBelu- di.etahui(-isgeneti.)
Sekunder /enal
AdrenalFa.tor Biologi lain0.sogen
ETIOLOGI
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Hypertension and Chronic Rena Disease!He"odyna"ic A#nor"aities
Mean BPTotal Systemic
Vascular Resistance= X
Increased Cardiac OutputIntravascular Volume Glomerular filtration
Sodium excretion
Extracellular Fluid
Renal Nerve ActivityMyocardial Performance Adrenergic Activity
Increased Cardiac OutputIntravascular Volume Glomerular filtration Sodium excretion
Extracellular Fluid
Renal Nerve ActivityMyocardial Performance
Adrenergic Activity
IncreasedVasoconstriction
Adrenergic Stimuli Angiotensin II Endothelin Endothelium-derived
Contracting Factors
Thromoxane
IncreasedVasoconstriction Adrenergic Stimuli
Angiotensin II Endothelin
Endothelium-derived
Contracting Factors Thromoxane
CardiacOutput
DecreasedVasodilation !rostacyclin
Nitric oxide E"#F$
DecreasedVasodilation !rostacyclin Nitric oxide
E"#F$
Tetor SC! "tlas of Diseases of t#e $idney% &''(!
$Endothelium-derived#y%er%olari&ing Factors
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Hypertension ; basic mechanism..
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Serangan Stroke
4enyakit )rteri
(angguan pada ,antung (angguang Fungsi (in"
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Hipertensi kronisHipertensi kronis
Merusak autoregulasi ginjalMerusak autoregulasi ginjal
Permeabilitas kapilerPermeabilitas kapiler
Proteinuri (miProteinuri (mikkroalbuminuri)roalbuminuri)
Hukum HomeostasisHukum Homeostasis
Reabsorbsi proteinReabsorbsi protein
oleh sel tubulus berlebihanoleh sel tubulus berlebihan
(stressor)(stressor)
Ekspresi sitokin :Ekspresi sitokin :- TNFTNF poptosis! nekrosispoptosis! nekrosis- "#$%"#$% PlagPlag teroskleroristeroskleroris
- T&F%$T&F%$
FibrosisFibrosis
Patogenesis Komplikasi Hipertensi pada GinjalPatogenesis Komplikasi Hipertensi pada Ginjal
Robbin! '
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Chronic hypertensionChronic hypertension
En*othelial +tressorEn*othelial +tressor
E,pressionE,pression
TNFTNF "#$"#$%%T&FT&F%%$$
poptosispoptosis PlauePlaue FibrosisFibrosisNe.rosisNe.rosis
theros.lerosistheros.lerosis
RenalRenal
FailureFailure
/oronar0/oronar0
Heart 1iseaseHeart 1isease
CerebralCerebral- +troke+troke
- 1ementia1ementia- ParkinsonParkinson
Hypertension Complication PathogenesisHypertension Complication Pathogenesis
Robbin! '2
"#3"#3
H/RPH/RP
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TNF $$
Hypotalamus
PG2
+ ILIAspirin
FEVER
(Endogenic Pyrogen)
Hepatosit
Syntase
Coagulation
Strong Activation
Chachexia
Seru Ay!oid
"i#rinogen
C$P
% Contraction& 'ascu!ar sooth usc!e ce!!s& eart
'asodi!atation
Shock
Fat Cells
Perea#i!ityEudation
In!aation ce!!s
Congestion
%
Endhotel
& *issue "actor
& % *ro#o odu!in
& Shring,ing
Protea!itic
e#rane $eceptor -isruptionEritropoietin $eceptor -isruption
!nemia
& 'asopressor receptors& Proteo!itic
(.rata /id0aya1 234 .a#ang P1 25)
I'II'(
6A6E6*I7 % Appetite CACEC*IC (*I7)
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Dis%&n'si EndotheDis%&n'si Endothe
oxLDLoxLDL
HipertensiHipertensi Angiotensin IIAngiotensin II MerokokMerokok
HomoHomosisisteinstein
DiabetesDiabetes
()a"#an' P* Pre+ent ,asc&ar Da"a'e -./01
2Anti Oksidan 2 Bradikinin
Stres O3sidati%
RISIKO KARDIO,ASKULER DANRISIKO KARDIO,ASKULER DANDISFUNGSI ENDOTHELDISFUNGSI ENDOTHEL
NatriumNatrium
EN4I5 NADPH OKSIDASE
N!"N!"
Ateros3erosisAteros3erosis
#ndothe$in#ndothe$in
%D&!%D&!
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Res&t o% A Ris3 Factors in Kidney Disease
A'e Fa"iy History
Gender Dia#etes
Ure"ia2reated /. 6 -. 7 5or#iditas 8 5ortaitas
Hypertensio S"o3in' Hi'h o7idant stress
Dysipide"ia In%a"ation
Non2"odi%ia#e
5odi%ia#e
Ane"ia 9 ET
9PTH 9 CRP
9 PO: ROS
;GFR 2 AGEP9 AD5A 2 AOPP
2 Ho"osistein
Ure"ia2reated
L,H
CHF
P,D CAD
5I
()a"#an' P* Pre+ent ,asc&ar Da"a'e -./01
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L2Ar'inineL2Ar'inine
NO SynthaseNO Synthase
NONO'' (itru$$ine(itru$$ine
ADMAADMAAsymetric Dimethy$Asymetric Dimethy$
ArginineArginine
(itru$$ine(itru$$ine
Rena e7cretionRena e7cretion
DDAHDDAHDimethy$aminoDimethy$amino
hydro$asehydro$ase
O7idati+eO7idati+e
stressstress
)A*N +,-*/ 011)A*N +,-*/ 011
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(2eiss et a$./ 01+3; Obasi et a$./ 01+01
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Merusak
&$iko %rotein 4 Nephrin
A%O%O*I*
#NDO#LMerusak I5B
A$buminuri 6 *itokin %ro In7$amasi
8N!"/ IL"+/ IL"9:
6 N!5B
A#O*5L#O*I*
*O5# 5OON# %&5
PGK
ROS
Age1A2Ho-osistein
8Bambang %/ 01+0
5a3ro%a'
SKE5A PENGARUH STRES OKSIDATIF (ROS1 PADA PGK
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Angiotensin II
Endotelin
Vasokonstriksi
Iskemi
Defisiensi Aerob Metabolik
angguan pompa !a
Retensi !a
Retensi Air Intra "el
#dem Intra "el
"el pecah $ %nkosis
Robbin& '(()
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he renin system p$ays a centra$ ro$e inregu$ation o7 B%
)uxtag$omeru$ar ce$$s
&$omeru$us
enin is re$eased
into the
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enin secretion is regu$ated by = mechanisms
Dista$ tubu$e
%ressure in the
a77erent arterio$e
1
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enin secretion is regu$ated by = mechanisms
Na'at the macu$a densa
Dista$ tubu$e
3
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enin secretion is regu$ated by = mechanisms
Negati
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!enin )ngiotensin!enin )ngiotensinSystemSystem 567567
-lassical 8circulating8 system 5!)S7
Angiotensin II
Angiotensin I
Angiotensinogen
Aldosterone
3a45retentionK45loss
glo-erular 6one
)-'
!enin
Blood1ressure3a4
7y-1atheticsyste-
!enin
-aculadensa
adrenalglands
Ada1t! fro- Do-inia. 8 9nger (eds!) in Ang II5A:&5/ece1tor Antagonists; 7tein.o1< (&$$,)
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t5A = tissue 1las-inogen activCA>0 = chy-ostatin5sensitiveangiotensin generating en6y-e
9ocal 8tissue:bound8 system 5!)S7
A:& A:"
Brady.inin
inactive frag-ents
B"B&
Angiotensin II
Angiotensin I
Angiotensinogen
)-'
/enin
s1eci?c cellular res1onse
Chy-asesCathe1sin >
CA>0
t5A
Cathe1sin >:onin
s1eci?c cellular res1onse
Ada1t! fro- Do-inia. 8 9nger (eds!) in Ang II5A:&5/ece1tor Antagonists; 7tein.o1< (&$$,)
!enin )ngiotensin!enin )ngiotensinSystemSystem 5/75/7
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Distribution of )-'
Mod! fro- D6au V; Arch Intern Med &@ (&$$)
!enin )ngiotensin!enin )ngiotensinSystemSystem 507507
! ) S6%&6%&
)cute and short:term e;ectscardiovascular
renal ho-eostasis
9ong:term e;ects
local organ ada1tation
$%&$%&
Circulating (las-a) ocal (:issue)
PROTECTIONPROTECTION
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6< Monitoringtekanan darah = faktor resiko
/< Managemen pola hidup
0< Farmakologi
Pen'eoaan Hipertensi
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Base$ine tekanan darah diukur periodik pada semuade>asa muda/ $ebih intensi7 pada pasien dengan -
+.*udah?baru terdeteksi hipertensi0.%unya kerusakan target kardio
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&! :ida.Mero.o. *sa-a se.ali; hindari secondhand
s-o.e
"! A.tivitas Fisi.*+5,-g; #5E#-nt; s.ala sedang;
dina-i.
! engurangan Berat Badan *BMI nor-al; $#c-
'#c-
+! /e.o-endasi Diet*tinggi seratsayuran; rendah
le-a..olest
Managemen 4ola Hidup
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>2NDISI *'>)N)ND)!)H
Hi1ertensi 7istoli.Diastoli. &+#$#
Diabetes $#
CKD $#
roteinuria &gra-"+Ga- &"@,@
*arget *erapi
*he -anadian Hypertension 'ducation 4rogram 5-H'47 (uidelines+ /%%$
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Diuretik
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Diuretik
*hort acting
!urosemid 8$asix:0
ch$orothia@ide8Diuri$:3
Intermediate
Hidroc$rotia@ide8Apo"Hydro/ Aua@ideH/Dich$otride/ Hydrodiuri$/ Hydro*a$uric/ Hydroch$orot/ Micro@ide/
#sidrex/ and Oretic:=
Ben@thia@ide 8Auatag/ Dihydrex/ Diucen/ #demax/ #xna/ !o
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Obat"Obat Beta B$ocker+
+. *e$ekti7 dan Non *e$ekti7
a. *e$ekti7- b. Non *e$ekti7
" Asebuto$o$ " %ropano$o$
" Metopro$o$ " imo$o$
" Ateno$o$ " Nado$o$
" Bisopro$o$ " *ota$o$
" %indo$o$
" Okspreno$o$
" A$preno$o$
" Labeta$o$C
0. Hidro7i$ik dan Lipo7i$ik
a. Hidro7i$ik c. Hidro7i$ik dan LIpo7i$ik
" *ota$o$ " Okspreno$o$
" Nado$o$ " Labeta$o$C
" Ateno$o$ " Metopro$o$
b. Lipo7i$ik " imo$o$
" %ropano$o$ " Bisopro$o$
" A$preno$o$ " Asebuto$o$
" %indo$o$
3. I*A8Intrinsic *ympatomimetic Acti
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(aantagonis+
+. Long Acting-
Am$odipin8Nor
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+. %encegahan hipertensi harus sedini mungkin 8pre"hipertensi:0. %enge$o$aan hipertensi harus di>aspadai 7aktor resiko yg $ain
8sindrom metabo$ik:
3. %rogram non"drug treatment >aib dia$ankan penderita
=. %atogenesis hipertensi harus dipe$aari dengan baik da$am rangka -
a. Memi$ih obat yang tepatb. Memi$ih kombinasi obat
c. Meminima$kan e7ek samping
,. arget penurunan tensi sedapat mungkin mendekati idea$ 8harusbertahap:
9. %enge$o$aan krisis hipertensi harus memi$ih obat yg tepat/ targetpenurunan tensi sesuai protoko$ 8supaya re'SIM4U9)N
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:eri-a .asih
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