bab i dr rastri

7/26/2019 BAB I DR RASTRI

1/19

REFLEKSI KASUS

DIABETES MELLITUS TYPE 1, NEFROPATI DIABETIKUM

DAN CHRONIC KIDNEY DISEASE (CKD)

Disusun oleh:

NITAMI OKTAVIA INDIARTI

20100310032

Pemimin!: "#$ R%si' S($PD

RSUD Ko&% S%l%&i!%

KEPANITERAAN KLINIK ILMU PEN)AKIT DALAM

PRO*RAM PENDIDIKAN PROFESI DOKTER FAKULTAS KEDOKTERAN

DAN ILMU KESE+ATAN UNIVERSITAS MU+AMMADI)A+

)O*)AKARTA

RSUD KOTA SALATI*A


2/19

+ALAMAN PEN*ESA+AN

Tel%h "ise&u,ui "%n "is%h-%n' #e.le-si -%sus "en!%n ,u"ul

DIABETES MELLITUS TYPE 1, NEFROPATI DIABETIKUM

DAN CHRONIC KIDNEY DISEASE (CKD)

Disusun oleh:

N%m%: Ni&%mi O-&%/i% In"i%#&i

No$ M%h%sis%: 20100310032

Tel%h "i(#esen&%si-%n

+%#iT%n!!%l:

Dis%h-%n oleh:

Dosen Pemimin!'

"#$ R%si' S($ PD


3/19

BAB IKASUS

Rangkuman Kasus

%$ I"en&i&%s P%sien

N%m% : An$ T$U

Umu# : 2 &%hun

enis Kel%min : Pe#em(u%n

A!%m% : Isl%m

Pe-e#,%%n : 4

$ An%mnes%

Keluh%n U&%m%

P%sien mu%l "%n mun&%h &e#us4&e#us%n$

Ri%5%& Pen5%-i& Se-%#%n!:

P%sien "%&%n! "en!%n -eluh%n %"%n &e#%s% lem%s -%#en% mu%l

"%n mun&%h se&i%( -%li m%-%n "%n minum$ Se&i%( mun&%h se(e#&i %(%

5%n! "i% m%-%n "%n ,uml%hn5% se-i&%# 1 !el%s 5%n! "imun&%h-%n' (e#u&

&e#%s% (e#ih "%n s%-i&$ P%sien men!%&%-%n %h% (%sien (en"e#i&%

Di%e&es Meli&us se,%- usi% 16 &%hun "%n 7u7i "%#%h su"%h "il%-u-%n

"%l%m -u#un %-&u 2 min!!u se%n5%- "u% -%li (e#min!!u$

Ri%5%& Pen5%-i& D%hulu:

P%sien se#in! -elu%# m%su- #um%h s%-i& %-i%& Di%e&es 5%n! i%

%l%mi s%m(%i &%- &e#hi&un! ,uml%hn5%' sel%in Di%e&es (%sien ,u!%

men!eluh-%n se#in! m%su- #um%h s%-i& -%#en% hi(e#&ensi 5%n! i% %l%mi$

P%sien men!un%-%n (en!o%&%n insulin se,%- i% "i-e&%hui men"e#i&%

"i%e&es$ P%sien su"%h (e#n%h men7o% ee#%(% ,inis insulin %i-

insulin %s%l' #%(i"' "%n mi8$ P%sien ,u!% (e#n%h e#hen&i "ie#i-%n

insulin -%#en% -%"%# !ul% 5%n! "imili-i no#m%l %-%n &e&%(i se&el%h

ee#%(% ul%n ,ul% men,%"i n%i- l%!i "%n "ie#i-%n l%!i insulin #%(i"$

Ri%5%& Pen5%-i& Kelu%#!% :

Kelu%#!% (%sien &i"%- %"% 5%n! men!%l%mi -eluh%n 5%n! s%m%

"%n &i"%- %"% #i%5%& (en5%-i& +i(e#&ensi' Di%e&es Meli&us$ A"%

#i%5%& (en5%-i& -elu%#!% ,%n&un! -o#one# 5%n! "i%l%mi oleh nene-

(%sien$

Ri%5%& Pe#son%l Sosi%l:


4/19

Di-e&%hui %h% (%sien memili-i huun!%n 5%n! %i- "en!%n

-elu%#!%n5%$ P%sien su"%h meni-%h "%n memili-i seo#%n! %n%- l%-i4

l%-i e#usi% 3 &%hun$ P%sien sel%lu sem%n!%& men!onol "%n men,%!%

%!%# !ul% "%#%h s&%il "%n -om(li-%si &i"%- e#&%m%h (%#%h "en!%n

#u&in (e#i-s% "%n sel%lu sem%n!%& un&u- mel%-u-%n hemo"i%lisis se7%#%

#u&in 2 -%li s%&u min!!u$

Re/ie Sis&em:

o Ke(%l% lehe# : -e(%l% (usin!' m%&% (u7%&' ii# -e#in!$

o Kuli& : %n5%- en5%- e!%s lu-% -%#en% !%&%l$

o T+T : &i"%- %"% -eluh%n

o Res(i#%si : %!%- ses%- n%.%s$

o *%soin&es&in%l : (e#u& &e#%s% (e#ih "%n n5e#i se#&% mun&%h

o K%#"io/%s-ul%# : &i"%- %"% -eluh%n

o Pe#-emih%n : &i"%- %"% -eluh%n

o Sis&em Re(#o"u-si : &i"%- %"% -eluh%n

o E-semi&%s : &i"%- %"% -eluh%n

7$ Ri%5%& Pe#,%l%n%n Pen5%-i& P%sien

S9 Su5e-&i.:

;%"%n &e#%s% lem%s -%#en% mu%l "%n mun&%h se&i%( -%li m%-%n "%n

minum$ Se&i%( mun&%h se(e#&i %(% 5%n! "i% m%-%n "%n ,uml%hn5%

se-i&%# 1 !el%s 5%n! "imun&%h-%n' (e#u& &e#%s% (e#ih "%n s%-i&$

P%sien men!%&%-%n %h% (%sien (en"e#i&% Di%e&es Meli&us se,%-

usi% 16 &%hun "%n 7u7i "%#%h su"%h "il%-u-%n "%l%m -u#un %-&u 2

min!!u se%n5%- "u% -%li (e#min!!u$

O 9O5e-&i. :

1 Ke%"%%n Umum : 0'02 9+ 10

3

L

An!-% E#iosi& @'B2 10

L

+emo!loin 12'B !"L

+em%&o-#i& 3B'1

M


7/19

2 Kimi% D%#%h 9 1= Deseme# 201@

P%"% &%n!!%l 21 %nu%#i s%%& m%l%m h%#i se&el%h isun&i-%n insulin' !ul%

"%#%h (%sien &u#un "#%s&is "i"%(%&-%n *DS B6 m!"l' (%sien men!eluh

lem%s "%n -e#in!%& "in!in se&el%h i&u "i!%n&i in.us D> *DS "i7e- l%!i

men,%"i 11= m!"l$ Dosis no/omi- men,%"i "i&u#un-%n "%#i 14041@

men,%"i 124046 &%(i se&el%h "i!%n&i *DS men,%"i n%i- l%!i 3=0 m!"l$ A 9Assessmen& :

Di%e&es Meli&us &5(e 1'


8/19

Menu#u& ADA 201@ Di%e&es melli&us %"%l%h (en5%-i& -#onis

5%n! -om(le-s 5%n! meme#lu-%n -onol 5%n! #u&in "im%n% memili-i

#esi-o mul&i.%-&o#i%l' "en!%n (en"e-%&%n s%&e!i !li7emi- -onol

un&u- (ene&%l%-s%n%%nn5%$ Den!%n (en"e-%&%n s%&e!i (%&ien& sel.4

m%n%!emen& e"u7%&ion %n" su((o#& "ih%#%(-%n "%(%& men7e!%h

-om(li-%si %-u& "%n menu#un-%n -om(li-%si ,%n!-% (%n,%n!$

Di%e&es melli&us %"%l%h !%n!!u%n me&%olisme 5%n! "%(%&

"ise%-%n e#%!%i m%7%m e&iolo!i' "ise#&%i "en!%n %"%n5%

hi(e#!li-emi% -#onis %-i%& !%n!!u%n se-#esi insulin %&%u !%n!!u%n

-e#,% "%#i insulin' %&%u -e"u%n5% 9Pu#n%m%s%#i' 200=$

-) Kas$#$kas$

enis "%nTi(e Di%e&es Meli&us ADA 201@ :

1$ Di%e&es Meli&us Ti(e 1

P%"% Di%e&es Meli&us Ti(e s%&u "i-en%l "en!%n Di%e&es &e#!%n&un!

Insulin$ Ti(e ini e#-em%n! ,i-% sel4sel ;e&% PGn-#e%s

mem(#o"u-si insulin &e#l%lu se"i-i& %&%u &i"%- mem(#o"u-si s%m%se-%li' 5%n! "ise%-%n %u&oimuni&%s %&%u i"io(%&i-$ Di%e&es Ti(e 1

"ise%-%n -%#en% -e#us%-%n sel e&% 5%n! men5e%-%n "e.isiensi

insulin %slu&$ Pen"e#i&% Di%e&es Ti(e 1 ini se-i&%# >410 (en"e#i&%

DM 9Nu#' 2013$

2$ Di%e&es Meli&us Ti(e 2

Di%e&es Meli&us &i(e 2 "i-en%l se%!%i Di%e&es &i"%- &e#!%n&un!

insulin$ Di%e&es &i(e ini e#-em%n! -e&i-% &uuh m%sih

men!h%sil-%n insulin &e&%(i &i"%- 7u-u( "%l%m (emenuh%nn5% %&%u

is% ,u!% insulin 5%n! "ih%sil-%n men!%l%mi #esis&ensi 5%n!

men5e%-%n insulin &i"%- "%(%& e-e#,% se7%#% m%-sim%l$ Kon"isi

(%"% (%sien &i(e 2 e#/%#i%si' mul%i "%#i #esis&ensi insulin "ise#&%i

"e.isiensi insulin #el%&i. s%m(%i 5%n! "omin%n "e.e- se-#esi insulin

"ise#&%si #esis&ensi insulin$ Se-i&%# =04=> (en"e#i&% DM %"%l%h

Di%e&es Ti(e 2 9Nu#' 2013$


9/19

3$ Di%e&es Meli&us *es&%sion%l 9DM*

DM* "i%-i%&-%n "%#i -omin%si -em%m(u%n #e%-si "%n

(en!elu%#%n ho#mon insulin 5%n! &i"%- 7u-u($ ;i%s%n5% &e#,%"i (%"%

-eh%mil%n "%n %-%n semuh se&el%h mel%hi#-%n$ Pen"e#i&% DM*

&e#,%"i 24> "%#i selu#uh -eh%mil%n 9Nu#' 2013$

@$ Di%e&es Meli&us Ti(e L%in

DM "ise%-%n -%#en% -el%in%n !ene&i7' (en5%-i& (%n7#e%s' o%&'

in.e-si' %n&io"5' sin"#om% (en5%-i& l%in$ Di%e&es &i(e l%in "%(%&

,u!% "ise%-%n "e.e- !ene&i- .un!si insulin' "e.e- !ene&i- -e#,%

insulin' (en5%-i& e-so-#in (%n-#e%s' en"o-#ino(%&i' -%#en% o%& %&%u

%& -imi% 9Nu#' 2013$

.) Fak&*% R"s$k*

DIABETES MELITUS TYPE 1

a)! D"#$n$s$

Di%e&es Meli&us &5(e 1 %"%l%h (en5%-i& -#oni- 5%n! "ise%-%n

-&i"%-m%m(u%n &uuh mem(#o"u-si insulin -%#en% "eu-si %u&oimun

(%"% sel e&% (%n-#e%s$ Onse& &e#,%"in5% DM &i(e 1 se#in! "i&emu-%n

(%"% %n%-' &%(i (en5%-i& ini "%(%& "i&emu-%n (%"% o#%n! "e%s% 5%i&u

(%"% %-hi# usi% 30 "%n %%l @0 9Kh%#"o#i' 201@$

Di%e&es ,enis ini &e#,%"i %-i%& -e#us%-%n sel H (%-#e%s$ D%hulu'

DM &i(e 1 "iseu& ,u!% "i%e&es onse&4%n%- 9%&%u onse&4#em%,% "%n

"i%e&es #en&%n -e&osis 9-%#en% se#in! menimul-%n -e&osis$ Onse& DM

&i(e 1 i%s%n5% &e#,%"i seelum usi% 2>430 &%hun 9&e&%(i &i"%- sel%lu

"emi-i%n -%#en% o#%n! "e%s% "%n l%nsi% 5%n! -u#us ,u!% "%(%&

men!%l%mi "i%e&es ,enis ini$ Se-#esi insulin men!%l%mi "e.isiensi9,uml%hn5% s%n!%& #en"%h %&%u &i"%- %"% s%m% se-%li$ Den!%n

"emi-i%n' &%n(% (en!o%&%n "en!%n insulin 9(en!%%s%n "il%-u-%n

mel%lui (eme#i%n insulin e#s%m%%n "en!%n %"%(&%si "ie&' &i"%-

se(e#&i DM &i(e 2 (%"% MD &5(e 1 i%s%n5% &i"%- oese "%n i%s%n5%

"i%%li %"%n5% "i%e&i7 -e&o%7i"osis 9DKA 9A#ism%n' 2011$

-)! E&$**g$ D$a-"&"s &/'" 1


10/19


11/19

3$ +i(o&esis Susu S%(i

Teo#i ini men,el%s-%n %h% e-s(osu# &e#h%"%( susu s%(i "%l%m susu

.o#mul% (%"% ul%n (e#&%m% (%"% %5i "%(%& men5e%-%n

-e-%7%u%n (%"% sis&em -e-e%l%n &uuh "%n menin!-%&-%n #isi-o

un&u- men!em%n!-%n "i%e&es melli&us &i(e 1 "i -emu"i%n h%#i$

Dim%n% (#o&ein susu s%(i h%m(i# i"en&i- "en!%n (#o&ein (%"%

(e#mu-%%n sel e&% (%n-#e%s 5%n! mem(#o"u-si insulin' sehin!!%

me#e-% 5%n! #en&%n "%n (e-% &e#h%"%( susu s%(i m%-% %-%n "i#es(on

oleh leu-osi&' "%n sel%n,u&n5% %-%n men5e#%n! sel sen"i#i 5%n!

men5e%-%n -e#us%-%n sel e&% (%n-#e%s sehin!!% &e#,%"i "ie&es

melli&us &i(e 1$ Penin!-%&%n (eme#i%n ASI "i 1=60 &i"%-

men5e%-%n (enu#un%n &e#,%"in5% "i%e&es &i(e 1' &e&%(i &e#,%"i

(enin!-%&%n "u% -%li li(%& "i%e&es melli&us &i(e 1$ N%mun' -e,%"i%n

"i%e&es &i(e 1 leih #en"%h (%"% %5i 5%n! "ie#i ASI sel%m% 3

ul%n$

@$ +i(o&esis POP

+i(o&esis ini men,el%s-%n %h% e-s(osu# &e#h%"%( (olu&%n o#!%ni-

5%n! (e#sis&en 9POP menin!-%&-%n #isi-o -e"u% ,enis "i%e&es$

Puli-%si ,u#n%l oleh Ins&i&u& N%sion%l Ilmu Keseh%&%n Lin!-un!%n

menun,u--%n (enin!-%&%n 5%n! si!ni.i-%n se7%#% s&%&is&i- "%l%m

&in!-%& #%%& in%( un&u- "i%e&es "%#i (o(ul%si 5%n! e#%"% "i

&em(%& Ko"e JIP 5%n! men!%n"un! lim%h e#%7un$

>$ +i(o&esis A-sele#%&o#

Seu%h &eo#i 5%n! menun,u--%n %h% &i(e 1 "i%e&es me#u(%-%n

%!i%n se"e#h%n% "%#i -on&inum 5%n! s%m% "%#i &i(e 2' &e&%(i mun7ul

leih "ulu$ +i(o&esis %-sele#%&o# men5%&%-%n %h% (enin!-%&%n

e#%& "%n &in!!i %n%-4%n%- (%"% %%" &e#%-hi# ini &el%h "i(e#7e(%&'

sehin!!% -e7en"e#un!%n me#e-% un&u- men!em%n!-%n &i(e 1

"en!%n men5e%-%n sel e&% "i (%n-#e%s "i %%h &e-%n%n un&u-

(#o"u-si insulin$ ;ee#%(% -elom(o- men"u-un! &eo#i ini' &e&%(i

hi(o&esis ini elum me#%&% "i&e#im% oleh (#o.esion%l "i%e&es$


12/19

$ F%-&o# -e&u#un%n 9!ene&i-

F%-&o# *ene&i- "i"u!% se%!%i (en5e% u&%m% mes-i(un

-e%n5%-%n %n%- &e#n5%&% &i"%- (un5% #i%5%& DM (%"% -elu%#!%$

Se%li-n5%' "%(%& (ul% &e#,%"i "%l%m s%&u -elu%#!% &e#"%(%& leih "%#i

s%&u %n%- 5%n! men!i"%( DM &i(e 1$ Seseo#%n! 5%n! memili-i !en

&e#&en&u leih #en&%n &e#-en% DM &i(e 1$ *en i&u %-%n %-&i.

il%"i7e&us-%n .%-&o# lin!-un!%n se(e#&i /i#us %&%u #%7un$

En&e#o/i#us me#u(%-%n (en7e&us 5%n! (%lin! ,el%s "%n (%lin! se#in!

"i&eli&i' s%l%h s%&un5% (%"% (en5%-i& &%n!%n' -%-i' "%n mulu& 9hand,

foot, and mouth disease "%n (olio$ Di"u!% /i#us men!u%h !en

&e#seu& sehin!!% !en 5%n! &%"in5% %"em %5em men,%"i %-&i.

memen&u- %n&io"i 5%n! men5e#%n! &uuh sen"i#i "iseu&

%u&o%n&io"i$

-)! E'$0"m$**g$

.)! Pa&*#$s$**g$


13/19

DM &i(e 1 %"%l%h (en5%-i& %u&oimun -#onis 5%n! e#huun!%n "en!%n

-eh%n7u#%n sele-&i. sel e&% (%n-#e%s 5%n! mem(#o"u-si insulin$ Timuln5%

(en5%-i& -linis me#u(%-%n &%h%( %-hi# "%#i -e#us%-%n sel e&% 5%n! men!%#%h -e

&i(e 1 DM $

P%"% DM &i(e I' "i-en%l 2 en&u- "en!%n (%&o.isiolo!i 5%n! e#e"% :


14/19


15/19

leih l%n,u& (en!u-u#%n !lu-os%$ Di%!nosis "%(%& "i"u-un! oleh

-en%i-%n +A17$

2$ A(%il% "i%e&es "i"i%!nosis' &e&%(i "i7u#i!%i "i%e&es &i(e 2' "i%!nosis

"i%e&es &i(e 1 h%#us "i(e#&im%n!-%n ,i-%:

-e&onu#i% &e#"e&e-si' %&%u

(enu#un%n e#%& %"%n "i&%n"%i' %&%u

o#%n! &e#seu& &i"%- memili-i .i&u# "%#i sin"#om me&%oli- %&%u

e#-oniusi l%inn5% (en5%-i&

3$ ;il% "i%e&es "i"i%!nosis (%"% o#%n! 5%n! leih mu"%' -emun!-in%n

%h% "i%e&es u-%n "i%e&es &i(e 1 h%#us "i(e#&im%n!-%n ,i-%

me#e-% men!%l%mi oesi&%s %&%u memili-i #i%5%& -elu%#!% "i%e&es'

&e#u&%m% ,i-% me#e-% %"%l%h e&nis non4-uli& (u&ih$

@$ Pen!u,i%n un&u- men"e&e-si %u&o4%n&io"i s(esi.i- %&%u un&u-

men!u-u# "e.isiensi

")! P"%-"0aan D$a-"&"s M"$&us &/'" 1 0an D$a-"&"s M"$&us &/'" 2


16/19

Menen&u-%n %(%-%h (%sien memili-i &i(e 1 %&%u &i(e 2 DM me#u(%-%n

m%s%l%h "i%!nos&i- "%n &e#%(eu&i- (en&in! -%#en% (%sien "en!%n DM &i(e 1

e#!%n&un! (%"% insulin e-so!en &e#us mene#us un&u- e#&%h%n hi"u($

Seo#%n! (%sien 5%n! "i%e&es "i-en"%li-%n "en!%n "ie& %&%u %!en %n&i"i%e&i-

,el%s me#u(%-%n &i(e 2 DM$ Seo#%n! (%sien -u#us 5%n! memili-i "i%e&es

se,%- -e7il' 5%n! sel%lu e#!%n&un! (%"% insulin' %&%u 5%n! memili-i se,%#%h

"i%e&i7 -e&o%7i"osis 9DKA h%m(i# (%s&i memili-i &i(e 1 DM 9Kh%#"o#i'

201@$

Un&u- meme"%-%n -e"u% ,enis Di%e&es Meli&us menu#u& !ui"elines

The American Association of Clinical Endocrinologists 209AA40' nmoll$


17/19

IA2 %u&o%n&io"i "%l%m %-&u ul%n se&el%h "i%!nosis "i%e&us meli&us

"%(%& mem%n&u meme"%-%n %n&%#% &i(e 1 "%n &i(e 2 DM$ Ti&e# ini menu#un

se&el%h ul%n$ An&io"i %n&i4*AD> "%(%& h%"i# (%"% "i%!nosis DM &i(e 1

"%n &e#us4mene#us (osi&i. "%#i %-&u -e %-&u

#! P"na&aaksanaan

g! K*m'$kas$

+! P%*gn*s$s


18/19

Pharmacological and OverallApproaches to Treatment1. Insulin Therapy for Type 1 Diabetes

c Most people with type 1 diabetesshould be treated with MDI inections!three to four inections per day of basaland prandial insulin" or continuoussubcutaneous insulin infusion !#$II". Ac Most people with type 1 diabetesshould be educated in how to matchprandial insulin dose to carbohydrateinta%e& premeal blood glucose& andanticipated activity. 'c Most people with type 1 diabetesshould use insulin analogs to reducehypoglycemia ris%. A$creening

c #onsider screening those with type 1diabetes for other autoimmunediseases !thyroid& vitamin (1)de*ciency& celiac" as appropriate. (

The D##T clearly showed that intensiveinsulin therapy !three or more inectionsper day of insulin& or #$II !or insulinpump therapy" was a %ey part ofimproved glycemia and betteroutcomes !+,&-)". The study was carriedout with short and intermediateactinghuman insulins. Despite bettermicrovascular outcomes& intensive

insulin therapy was associated with ahigh rate of severe hypoglycemia !,)episodes per 1// patientyears oftherapy". $ince the D##T& a number ofrapidacting and longacting insulinanalogs have been developed. Theseanalogs are associated with lesshypoglycemia with e0ual A1# loweringin type 1 diabetes !1/&1/,".2ecommended therapy for type 1diabetes consists of the followingcomponents31. 4se MDI inections !567 inectionsper day of basal and prandial insulin"or #$II therapy.). Match prandial insulin tocarbohydrate inta%e& premealblood glucose& and anticipatedactivity.5. 8or most patients !especiallywith hypoglycemia"& use insulinanalogs.7. 8or patients with fre0uentnocturnal hypoglycemia and9orhypoglycemia unawareness& use ofsensoraugmented low glucosesuspend threshold pump may be

considered.


19/19

There are e:cellent reviews to guidethe initiation and management ofinsulin therapy to achieve desiredglycemic goals !1/&1/+&1/;". Althoughmost studies of MDI versus pumptherapy have been small and of shortduration& a systematic review andmetaanalysis concluded that therewere no systematic diM and activepatient9family participation should bestrongly encouraged !1/-6111". 8orselected individuals who havemastered carbohydrate counting&education on the impact of protein andfat on glycemic e:cursions can beincorporated into diabetesmanagement !11)".$creening

(ecause of the increased fre0uency ofother autoimmune diseases in type 1diabetes& screening for thyroiddysfunction& vitamin (1) de*ciency& andceliac disease should be consideredbased on signs and symptoms. Periodicscreening in asymptomatic individualshas been recommended& but thee

bab i dr rastri

Documents