pem.lab. pasien gagal ginjal -rev 2

8/19/2019 Pem.lab. Pasien Gagal Ginjal -Rev 2

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WindarwatiSMF PK dan kedokteran

Laboratorium RSUP Dr. sardjito


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Snyder dan Pendergraph, Detection and Evaluation of CKD, American Family Physian,

2005New Jersey Academy of Family Physicians, lipid manag. of the CKD Patients,2011

NKF-KDOQI, Cinical Practice Guidelines for CKD : Evaluation, Classification andStratification, 2002


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Snyder dan Pendergraph, Detection and Evaluation of CKD, American Family Physian,


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Diagnosis and management of CKD, Scottish Intercolegiate Guidelinesnetwork, 2008


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Proteinuria- Urine dipstick testing- Protein/creatinine ratio

- Albumin/creatinine ratioHematuriaRenal Tract Ultrasound

Diagnosis and management of CKD,Scottish Intercolegiate Guidelines network, 2008


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Glomerular filtration rateThe volume of plasma which is filtered by theglomeruli per unit time and is usuallymeasured by estimating the rate of clearanceof a substance from the plasma.

Glomerular filtration rate varies with body

size and conventionally is corrected to a bodysurface area (BSA) of 1.73 m2.



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Creatinine24-hours urinary creatinine clearancePredictions equations

- Cockcroft and Gault creatinineclearance,

- Modification of Diet in Renal DiseaseGFR.

Cystatin C



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1. PERSIAPAN PASIEN:

Makanan dan Obat bersifat mereduksi : vitamin C,Penicilin, streptomicin, salisilatObat yang mengubah warna urin :PIRIDIUM mengganggu pemeriksaan bilirubin,urobilinogenPENAMPUNG : BERSIH, KERING & BERTUTUP RAPAT

LABEL


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2. PENAMPUNG URIN:

LABEL:NAMA PASIEN, RUANGAN, WAKTU PENGAMBILAN, NAMADOKTER YG MEMINTAMELEKAT PADA BADAN PENAMPUNG

TIDAK DIANJURKAN MEMAKAI PENAMPUNG BEKAS PAKAI

PENAMPUNG DARI PLASTIK BERMULUT LEBAR , BERTUTUPRAPAT, BERSIH, KERING, TRANSPARAN & VOLUME 50 ML

URIN DITAMPUNG MINIMAL 15 ML DISERTAI DENGANFORMULIR PERMINTAAN

URIN YANG TIDAK JELAS IDENTITASNYA DITOLAK(CATAT TANGGAL, JAM PENERIMAAN & TAND A TANGAN)


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3. PENGAMBILAN URIN:

URIN RUTIN ATAU LENGKAP DITAMPUNGLANGSUNG KE DALAM PENAMPUNG, TIDAKDIPERLUKAN PENGAMBILAN KHUSUSUNTUK MENCEGAH KONTAMINASI HAID ATAUFLUOR ALBUS DISARANKAN URIN PORSI TENGAHMACAM PORSI URIN: URIN PAGI, URIN POSTPRANDIAL, URIN 24 JAM, URIN SEWAKTUPENUNDAAN PEMERIKSAAN PALING LAMA 1 JAMSETELAH BERKEMIH ATAU 2– 8 0C 8 JAM


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4. PENUNDAAN PEMERIKSAAN:

HARUS DIPERIKSA PALING LAMBAT 1 JAM SETELAH

URIN DITAMPUNG (URIN SEGAR)URIN TIDAK BOLEH MENGGUNAKAN PENGAWETPENUNDAAN PEMERIKSAAN PALING LAMA 1 JAMSETELAH BERKEMIH ATAU SIMPAN: 2 – 8 0C 8 JAM.PERUBAHAN TERJADI PADA :

ERITROSITLEUKOSITSILINDERGLUKOSA

KETONBILIRUBINUROBILINOGEN

BAHAN KONTROL URIN HARUS DISIMPAN DALAMSUHU 2 – 8 0C


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12

1.PelaporanInterpretasiVerifikasi

2.Dokumentasi

1.Pemeriksa2.Reagensia3.Alat4.Cara Pemeriksaan

5.Identifikasi UnsurSedimen6.Bahan kontrol7.Keselamatan Kerja

1.Penampung Urin2.Cara Pengambilan3.Penundaan

Pemeriksaan

PASCAANALITIK

ANALITIKPRA ANALITIK

PEMERIKSAAN MIKROSKOPI (SEDIMEN URIN)


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CARA KERJA TES MIKROSKOPI: Sampel tes sedimen, sebaiknya urin pagi

15 ml urin disentrifuse 5 menit pd 1500 –2000 rpm.Buang cairan atas hingga volume tinggal 0,5 –1ml,kocok untuk meresuspensikan sedimen.Letakkan 2 tetes suspensi di atas kaca objek tutup dgkaca penutup.

Periksa dg mikroskop: objektif 10X (LPK), objektif 40X(LPB).


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a

b

c

a

bc

a: Sel Skuamousb: Leukositc: Silinder Granular

a: Leukositb: Eritrositc: Silinder Granular


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b

a

a

b

b

a

c

a: Leukosit,

b: Silinder Epitel

a: Silinder Eritrositb: Eritrosit

a: Silinder Granular b: Bakteri c: Epitel Skuamous yang over ly ing


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Unsur Sedimen Ringsrud &Linné

KovaSystem

Schumann Iris

Eritrosit

LekositEpitel tubulus ginjalEpitel transisionalEpitel skuamousBakteriSilinder hialinSilinder granular Kristal abnormal

0-2/LPB

0-5/LPBSedikit/LPBSedikit/LPBSedikit/LPBNegatip/LPB

0-2/LPK0Negatip/LPK

0-3/LPB

0-5/LPBNegatip/LPBNegatip/LPBNegatip/LPB0-5/LPB

0-1/LPKNegatip/LPKNegatip/LPK

0-5/LPB

0-5/LPB0-2/LPB0-5/LPBJarang/LPBNegatip/LPB

0-3/LPK0-1/LPKNegatip/LPK

0-3/LPB

0-5/LPB0-1/LPB0-2/LPB0-4/LPBNegatip/LPB

0-3/LPKNegatip/LPKNegatip/LPK


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TES KIMIA URIN DENGAN REAGEN STRIP

Penilaian semikuantitatif dg melihat skala warna pdarea tes yg dibaca dg alat fotometer reflektans.

Sampel sebaiknya urin pagi tanpa pengawet & tidakperlu disentrifuse.


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1 2 3

456

Cara pemeriksaan dengan reagen carik celup (Manual)


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Cara pemeriksaan dengan reagen carik celup

(Semiotomatik/full otomatik


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NO PARAMETER NILAI RUJUKAN1 Berat Jenis (BJ) 1,010 – 1,0202 pH 4,5 – 8,0.3 Leukosit negatif

4 Nitrit negatif 5 Protein negatif 6 Glukosa negatif 7 Keton negatif

8 Urobilinogen negatif / < 1 mg/dl.9 Bilirubin negatif 10 Eritrosit negatif


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No Parameter Sensitivitas Range

1 Glukosa 50 mg/dL (3 mmol/L) 50-1000 mg/dL (3-60 mmol/dL)

2 Protein 15 mg/dL (0,15 g/L) 15-1000 mg/dL (0,15-10,0 g/L)

3 Bilirubin 0,5 mg/dL (8,5 µmol/L) 0,5- 6,0 mg/dL ( 8,5-100 µmol/L

4 Urobilinogen 2 mg/dL (35 µmol/L) 2 -8 mg/dL (35 -150 µmol/L)

5 pH 1,0 unit : 5-9 5-9

6 Berat jenis 1,000-1,030 1,000-1,030

7 Darah Hb 0,06 mg/dL,

eritrosit 20 / µL

Hb 0,06-1,0 mg/dL

8 Keton As. Aseoasetat 5 mg/dL (0,5 mmol/L) 5-150 mg/dL (0,5-15 mmol/L)

9 Nitrit 0,08 mg/dL 0,08 mg/dL

10 Leukosit 25 leukosit/ µL 25 leukosit/ µL

Aution sticks


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No Parameter Spesifisitas

1 Glukosa β-D glukosa

2 Protein Albumin

3 Bilirubin Bilirubin direk

4 Urobilinogen Urobinogen di urin

5 pH 1 unit (pH 5-9)

6 Berat jenis 1,000-1,030

7 Darah Hemoglobin, mioglobin

8 Keton Asam asetoasetat lebih sensitif dari aseton

9 Nitrit nitrit

10 Leukosit Esterase leukosit

Aution sticks


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No Parameter Prinsip kerja Negatif palsu Positif palsu

1 Glukosa GOD-POD Vit C, ISK Oksidatif (detergen)HCL

2 Protein Non spesific bindingto indicator day

Urin berwarna Urin > 9, detergen,

chlorhexidine, polivinylpyrrolidone

3 Bilirubin Reaksi Azo dan garamdiazonium

Vit C, nitrit ↑,paparan cahaya

Urin berwarna,Chlorpromazine

4 Urobilinogen Reaksi Erlich Formaldehyde,

paparan cahaya

Sulphonamide, urin

berwarna,porphobilinogen

Europan Urinalisis Guidelines ,2000Henry, et al. , 2001, Basic Examination of urine


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No Parameter Prinsip kerja Negatif palsu Positif palsu

5 pH 2 indikator Methylred & bromthymol blue

↓: F ormaldehid

6 Berat jenis Ion dalam urinberekasi dengan polyelectrolytes

↓ : Glukosa, urea,urin alkali

↑ : Protein > 1 g/L,ketonuria, asam laktat

7 Eritrosit Pseudoperoxidase Nitrit ↑ , pem.tertunda, BJ ↑,formaldehid.

Bakteri, oksidatif (deterjen), HCL

8 Keton Reaksi Rothera Penyimpanantdk sesuaistandar

Sulfhidryl bebas :captopril, L-dopa

Europan Urinalisis Guidelines ,2000Henry, et al. , 2001, Basic Examination of urine


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No

Parameter Prinsip kerja Negatif palsu Positif palsu

9 Leukosit Aktivitas esteraseleukosit

Vit C,protein > 5 g/L,kontaminasi mukus,cephalosporins,nitrofurantoin,asam borat

Oksidatif (detergen),formaldehid,sodium azide,urin berwarna

10 Nitrit Azo dye Sayuran


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PRAANALITIKPersiapan pasien : Tdk ada

Jenis sampel : urin sewaktu, urin 24 jam

Persiapan sampel :- Sebaiknya urin segar. Tes dilakukan < 2 jamsetelah urin dikemihkan

- Wadah penampung urin dari plastik, tanpabahan pengawet

- Albumin urin stabil pada suhu 4˚ C 1 minggu.Sampel simpan lama, albumin urin stabil padasuhu - 20 ˚ C s/d - 80 ˚ C


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Prinsip tes :Berdasarkan ikatan kuat antara sulfonephthalein

dg albumin menghasilkan perubahan warna laludiukur secara fotometrik

Alat dan Bahan : Alat Clinitek,reagen strips : Multistix

ANALITIKCara kerja : Sesuai dengan alat yang digunakanNilai rujukan :

< 20 mg/L (


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Intended useIn vitro test for the quantitative determination ofalbumin in human urine, serum, plasma and CSF(albumin CSF/serum ratio) on Roche/Hitachicobas c systems.

Test principleImmunoturbidimetric assay.Anti-albumin antibodies react with theantigen in the sample to formntigen/antibodycomplexes which, following agglutination, aremeasured turbidimetrically.


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SpecimenUrine , Serum, Plasma: Li-heparin and K2-EDTAplasma, CSF

Urine Spontaneous, 24-hour urine/2nd morning urine .

Stability urine:7 days at 15-25 °C1 month at 2-8 °C6 months at (-15)-(-25) °C


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Stability serum, plasma

Expected values


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PASCA ANALITIKInterpretasi:

Kategori Urin 24 jam Urin waktu ttt Urin sewaktu

mg/24 jam mg/menitmg/mgkreatinin

Normal < 30 < 20 < 30

Mikro-albuminuria 30 -299 20 - 199 30 - 299

Makro-abuminuria

> 300 ≥ 200 ≥ 300


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Intended useIn vitro test for the quantitative determinationof creatinine concentration in human serum,plasma and urine.

The enzymatic method is based on the establisheddetermination of sarcosine after conversion ofcreatinine with the aid of creatininase, creatinase, and

sarcosine oxidase. The liberated hydrogen peroxide ismeasured via a modified Trinder reaction. Moreover,the results of this method correlate with thoseobtained by ID/MS.


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Serum.

Plasma: Li-heparin and K2-EDTA plasmaUrine: Collect urine without using preservatives

Stability in serum/plasma:7 days at 15-25 °C7 days at 2-8 °C3 months at (-15)-(-25) °C

Stability in urine:2 days at 15-25 °C6 days at 2-8 °C6 months at (-15)-(-25) °C

Centrifuge samples containing precipitates beforeperforming the assay


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Serum/plasma : 5-2700 μmol/L (0.06-30.5 mg/dL)

Urine : 100-54000 μmol/L (1.1-610 mg/dL)


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Kt/V urea : pedoman yang akurat untukmerencanakan peresepanUrea reduction ratio = Rasio reduksi ureum(RRU)

National Cooperative Dialysis Study (NCDS) :

Kt/V < 0,8 meningkatnya morbiditasKt/V : 1,0-1,2 mortalitas yang rendah

National Kidney Foundation-Dialysis Outcome Quality Initiative(NKF -DOQI) memakai batasan bahwa HD harus dilakukan denganRRU ≥ 65 .


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BUN pra HDAV-vistula atau graft jalur arteri sebelumdihubungkan dengan blood linePastikan tdk ada cairan lain pada jarum arteri

BUN post HDEquilibrium 30-60 menit post HD

Gedess CC dkk : 4 menit setelah berhentinyacairan dialisat sama antara arteri dgn vena


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HypertensionDyslipidemia : LDL, HDL, TG, Chol totAnemia : As per the Kidney Disease

Outcomes Quality Initiative guidelines,the goal for hemoglobin levels is 100 –120 g/L, and it is recommended thatpatients be treated with erythropoiesis-

stimulating agents (ESAs) if hemoglobinis found to be less than 100 g/L

Ganesh & lee, UBCMJ, 2011


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FerritinSaturasi Transferin

Goal for Iron Stores

1 HD - CKD PD-CKD

2 Ferritin > 200 ng/mLTSAT > 20%

Ferritin > 100 ng/mLTSAT > 20%


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Hemato ogy

http://store3.yimg.com/I/cardianet_1782_7824http://store3.yimg.com/I/cardianet_1782_7824


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e ato ogyAutomati on

Two General Principles◦ Electronic resistance ( impedance)◦ Light scattering

http://store3.yimg.com/I/cardianet_1782_7824http://store3.yimg.com/I/cardianet_1782_7824


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Kriteria Pengendalian Kriteria A1c (%)

Baik < 6,5

Sedang 6,5 - 8

Buruk > 8


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Lipid Management in yhe CKD Patient, NJAFP,2011


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Lipid Management in yhe CKD Patient, NJAFP, 2011


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Spektrofotometer : kuantitatif (mg / dl)ISE : Ionic Selective Electrode : kuantitatif (mmol/L)


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Natrium/sodiumSpesimen : serum, plasma-whole blood heparinpemeriksaan tertunda 2-4ºC/freezerNilai rujukan : 136-145 mmol/LKalium/potassium

Spesimen : serum, plasma-whole bood heparinpemeriksaan tertunda : 2-4 ºCNilai rujukan : 3,5-5,1 mmol/L

ChoridaSpesimen : serum, plasma-whole blood heparinNilai rujukan : 98-107 mmol/L.


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Choice of site

Fisrt choice

Alternative sitesAlternative sitesAlternative sites


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pre-heparinized syringe; needles (20, 23 and 25 gauge)(a safety syringe with a needle cover ) *

a bandage to cover the puncture site after collectiona container with crushed ice (transportation laboratory)where applicable, local anesthetic and an additional single-use sterile syringe and needle.

Equipment and supplies

WHO guidelines on drawing blood: best practices in phlebotomy

© World Health Organization 2010


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Deltran® Plus is an arterial blood sampling Anaerobic Pulsator Plus syringes

RAPIDLyte Arterial Blood Sampling Syringes BD A-Line Arterial Blood Collection Syringe


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Radiometer's safe PICO blood gas syringes are preheparinised with dry,electrolyte-balanced heparin

http://www.radiometer.co.uk/en-gb/products/samplers/our-solutions/safepico-samplerhttp://www.radiometer.co.uk/en-gb/products/samplers/our-solutions/safepico-samplerhttp://www.radiometer.co.uk/en-gb/products/samplers/our-solutions/safepico-samplerhttp://www.radiometer.co.uk/en-gb/products/samplers/our-solutions/safepico-sampler


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Spesimen should never be storedpH ↓ : 0,04 -0,08 unit/hr at 37°C: 0,008 unit/hr 4°C

PCO2 ↑ : ± 5 mmHg at 37°C0,5 mmHg at 2-4°C

PO2 ↓: 2 -6 mmHg/hr at room temperature4-12 mmHg at 37°C

Adverse effects of glicolysis on pH, ct CO2, pO2, PCO2are best avoided by analysis within 30 minutes

Burtis & ashwood, Tietz Fundamentals of Clinical Chemistry , 4th ed, 2006


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Arteri Venacampuran

Vena

pH

PaO 2pCO 2Saturasi O 2HCO 3Base exsess

7,40

( 7,37 - 7,44 )80 – 100

35 - 45> 9522 - 26(- 2) - (+ 2)

7,36

( 7,31 – 7,41 )35 - 40

41 - 5160 - 8022 - 26

(- 2) - (+ 2)

7,36

( 7,31 – 7,41 )30 - 5040 - 5260 - 8522 - 28(- 2) - (+ 2)


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pem.lab. pasien gagal ginjal -rev 2

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