Problem batu ginjalProblem batu ginjal

Penyebab utama batu ginjal belum Penyebab utama batu ginjal belum diketahuidiketahuiBentuk utama batu : Bentuk utama batu : Calcium,Calcium,struvite,struvite,asam urat,asam urat,cystinecystine

The prevalence of kidney stones is The prevalence of kidney stones is three times three times higher in men than women, and is higher among higher in men than women, and is higher among Caucasians than Asians or African Americans, Caucasians than Asians or African Americans, for reasons that are not clearfor reasons that are not clear. .

They are especially likely to strike between the ages They are especially likely to strike between the ages of of 40 and 60.40 and 60.

Nutritional steps are important in Nutritional steps are important in preventing stones preventing stones and can also help prevent recurrencesand can also help prevent recurrences, which is , which is important given that 30-50 percent of people important given that 30-50 percent of people diagnosed with a renal stone have a recurrence within diagnosed with a renal stone have a recurrence within five years.five years.

Preventing stones is like keeping a salt crystal Preventing stones is like keeping a salt crystal from forming in a glass of salty water. You can from forming in a glass of salty water. You can either reduce the concentration of salt or add either reduce the concentration of salt or add more water. more water.

Epidemiologic studies have shown that certain parts of Epidemiologic studies have shown that certain parts of the diet help reduce the amount of calcium that filters the diet help reduce the amount of calcium that filters into the urine. It is a simple matter to put these into the urine. It is a simple matter to put these factors to work clinically.factors to work clinically.

Batu calciumBatu calcium 70%-80% tersusun dari calcium 70%-80% tersusun dari calcium

oksalat dengan atau tanpa fosfatoksalat dengan atau tanpa fosfat Kelebihan calcium dalam urine dapat Kelebihan calcium dalam urine dapat

disebabkan oleh :disebabkan oleh : 1. intake berlebihan makanan yang 1. intake berlebihan makanan yang

mengandung calcium tinggimengandung calcium tinggi 2. kelebihan vitamin D,2. kelebihan vitamin D,absorbsi calcium absorbsi calcium 3. imobilisasi lama3. imobilisasi lama 4. hiperparatiroidism 4. hiperparatiroidism ekskresi calcium ekskresi calcium

Batu struviteBatu struvite

Terdiri dari MgNHTerdiri dari MgNH44POPO44 Sering disebut batu infeksiSering disebut batu infeksi Tidak berhubungan dengan makanan Tidak berhubungan dengan makanan

spesifikspesifik Tidak ada terapi diet spesifikTidak ada terapi diet spesifik Biasanya berukuran besar Biasanya berukuran besar perlu perlu

operasioperasi Angka kejadiannya : seringAngka kejadiannya : sering

Batu asam uratBatu asam urat Kelebihan ekskresi asam urat, Kelebihan ekskresi asam urat,

gangguan metabolisme purin.gangguan metabolisme purin. Terjadi pada penyakit gout, atau Terjadi pada penyakit gout, atau

karena pemecahan jaringan yang karena pemecahan jaringan yang cepat selama ‘kelaparan’cepat selama ‘kelaparan’

Batu cystineBatu cystine Angka kejadiannya jarangAngka kejadiannya jarang Terjadi karena defect genetik pada Terjadi karena defect genetik pada

metabolisme asam amino cystine, metabolisme asam amino cystine, akan terjadi gangguan reabsorbsi akan terjadi gangguan reabsorbsi asam amino cystineasam amino cystine cystinuria cystinuria

Terjadi pada anak dengan riwayat Terjadi pada anak dengan riwayat penyakit genetikpenyakit genetik

Tanda-tanda klinisTanda-tanda klinis Tanda utama batu ginjal :Nyeri hebat, Tanda utama batu ginjal :Nyeri hebat,

general weakness, general weakness, kadang ada panaskadang ada panas Pengelolaan : Pengelolaan :

Intake cairan : banyak minumIntake cairan : banyak minum urine encer urine encer mencegah akumulasi material pembentuk batumencegah akumulasi material pembentuk batu

Membatasi diet sesuai dengan komposisi Membatasi diet sesuai dengan komposisi batubatumenghambat kekambuhanmenghambat kekambuhan

Mengatur pH urineMengatur pH urine Binding agents : mis, sodium phytate untuk Binding agents : mis, sodium phytate untuk

mengikat calcium, dan aluminium gel untuk mengikat calcium, dan aluminium gel untuk mengikat fosfat, glisin untuk mengikat oksalat mengikat fosfat, glisin untuk mengikat oksalat dalam usus dalam usus menghambat absorbsi, dan menghambat absorbsi, dan mengeluarkan dari tubuh.mengeluarkan dari tubuh.

Diit pada batu ginjalDiit pada batu ginjal Memperlambat pertumbuhan batu Memperlambat pertumbuhan batu

ginjal atau membantu mencegah ginjal atau membantu mencegah pembentukan batu ginjalpembentukan batu ginjal

Perencanaan nutrisi dihubungkan Perencanaan nutrisi dihubungkan dengan jenis batu.dengan jenis batu.

Mengurangi jenis makanan yang Mengurangi jenis makanan yang berperan dalam pembentukan batu.berperan dalam pembentukan batu.

Macam diit dan indikasi pemberianMacam diit dan indikasi pemberian

Diit rendah calcium tinggi sisa asamDiit rendah calcium tinggi sisa asam Diberikan pada penderita dengan batu Kalsium : Diberikan pada penderita dengan batu Kalsium :

Ca Fosfat, Ca carbonat, dan Ca oksalat.Ca Fosfat, Ca carbonat, dan Ca oksalat. Makanan ini cukup kalori, protein, besi, vitaminA, Makanan ini cukup kalori, protein, besi, vitaminA,

thiamin dan vitamin Cthiamin dan vitamin C Syarat : banyak cairan ; 2500 ml/hari,Syarat : banyak cairan ; 2500 ml/hari, rendah calsium : 400mg/harirendah calsium : 400mg/hariMakanan yang boleh diberikan :Makanan yang boleh diberikan :KH : beras, bulgur,roti,mie, makaroni, bihun, KH : beras, bulgur,roti,mie, makaroni, bihun,

tepung- tepung- tepungantepunganProtein hewani : telur, daging, unggas, ikan tanpa Protein hewani : telur, daging, unggas, ikan tanpa tulangtulang

Makanan yang boleh diberikanMakanan yang boleh diberikan

Protein nabati : tahu/tempe maks 50Protein nabati : tahu/tempe maks 50 g/hari, g/hari, kacang-kacangan kering maks: 25 g/harikacang-kacangan kering maks: 25 g/hari

Lemak : minyak,mentega, margarinLemak : minyak,mentega, margarin Sayuran : semua kecuali yang dilarang maks : Sayuran : semua kecuali yang dilarang maks :

200 g/ hari200 g/ hari Buah : semua buah- buahan segar maks: 200 g/ Buah : semua buah- buahan segar maks: 200 g/

harihari

Makanan yang tidak boleh diberikanMakanan yang tidak boleh diberikan

KH : kentang, ubi,singkong, biskuit dan kue yang KH : kentang, ubi,singkong, biskuit dan kue yang dibuat dengan susudibuat dengan susu

Protein hewani : susu,keju, udang, kepiting, ikan Protein hewani : susu,keju, udang, kepiting, ikan teri, ikan asin, sardin, otak, ginjal, hati,jantungteri, ikan asin, sardin, otak, ginjal, hati,jantung

Sayuran : bayam, daun mangkokan, daun Sayuran : bayam, daun mangkokan, daun melinjo, daun pepaya, daun lamtoro, daun melinjo, daun pepaya, daun lamtoro, daun singkong, daun talas, daun katuk, daun kelor, singkong, daun talas, daun katuk, daun kelor, jantung pisang, buah melinjo, sawi, leunca.jantung pisang, buah melinjo, sawi, leunca.

Buah-buahan : semua buah-buahan yang Buah-buahan : semua buah-buahan yang dikeringkandikeringkan

Minuman : yang mengandung soda, coklat, soda Minuman : yang mengandung soda, coklat, soda kue, yeastkue, yeast

Diit tinggi sisa basaDiit tinggi sisa basa Diberikan pada penderita dengan batu cystine dan asam Diberikan pada penderita dengan batu cystine dan asam

urat, makanan ini cukup kalori, mineral, dan vitaminurat, makanan ini cukup kalori, mineral, dan vitamin Syarat : banyak cairan : 2500 ml/hari, rendah asam amino Syarat : banyak cairan : 2500 ml/hari, rendah asam amino

yang mengandung sulfuryang mengandung sulfur Makanan yang bpleh diberikan : Makanan yang bpleh diberikan :

KHKH : nasi maks: ½ gelas/ hari, roti 4 potong, kentang : nasi maks: ½ gelas/ hari, roti 4 potong, kentang ubi,singkong, kue-kue yang dibuat dari tepung maezena, ubi,singkong, kue-kue yang dibuat dari tepung maezena, hunkwee, tapioka, agar-agar, sirop.hunkwee, tapioka, agar-agar, sirop.

Protein hewaniProtein hewani : daging 50 g, atau telor: 1 bt/ hari, susu. : daging 50 g, atau telor: 1 bt/ hari, susu. LemakLemak : minyak, mentega, margarin : minyak, mentega, margarin Protein nabatiProtein nabati : kacang-kacangan kering :25g/hari atau : kacang-kacangan kering :25g/hari atau

tahu, tempe,oncom : 50 g/haritahu, tempe,oncom : 50 g/hari sayuransayuran : semua sayuran paling sedikit 300 g/hari : semua sayuran paling sedikit 300 g/hari buah-buahanbuah-buahan : semua buah-buahan paling sedikit 300 : semua buah-buahan paling sedikit 300

g/harig/hari minumanminuman : sari buah, the kopi, coklat : sari buah, the kopi, coklat

Diit rendah purinDiit rendah purin Tujuan :Tujuan :

Mengurangi pembentukan asam uratMengurangi pembentukan asam urat Menurunkan berat badan bila pasien gemuk, dan Menurunkan berat badan bila pasien gemuk, dan

mempertahankan BB dalam batas normalmempertahankan BB dalam batas normalSyarat :Syarat :Rendah purin : 120-150 mg/hari, normal : 600-1000 Rendah purin : 120-150 mg/hari, normal : 600-1000

mg/harimg/hariCukup kalori, protein, mineral, dan vitaminCukup kalori, protein, mineral, dan vitaminTinggi hidrat arang, untuk membantu pengeluaran asam Tinggi hidrat arang, untuk membantu pengeluaran asam

uraturatLemak sedang : cenderung menghambat pengeluaran Lemak sedang : cenderung menghambat pengeluaran

asam uratasam uratBanyak cairan ; membantu mengeluarkan kelebihan asam Banyak cairan ; membantu mengeluarkan kelebihan asam

uraturat

Bahan makan yang boleh diberikanBahan makan yang boleh diberikan : : KH : semuaKH : semua Protein hewani : daging, ayam, ikan tongkol, ikan Protein hewani : daging, ayam, ikan tongkol, ikan

tenggiri, bawal, bandeng: 50 g/hari, telor, susu, kejutenggiri, bawal, bandeng: 50 g/hari, telor, susu, keju Sumber protein nabati : kacang-kacangan Sumber protein nabati : kacang-kacangan

kering :25g/hari atau tahu, tempe, oncom : 50 g/harikering :25g/hari atau tahu, tempe, oncom : 50 g/hari Lemak : minyak dalam jumlah terbatasLemak : minyak dalam jumlah terbatas Sayuran : semua sayuran, kecuali asparagus, Sayuran : semua sayuran, kecuali asparagus,

kacang polong, kacang buncis, kembang kol, bayam, kacang polong, kacang buncis, kembang kol, bayam, jamur maksimum : 50 g/ harijamur maksimum : 50 g/ hari

Buah-buahan : semua macam buahBuah-buahan : semua macam buah Minuman : teh, kopi, minuman yang Minuman : teh, kopi, minuman yang

mengandung sodamengandung soda Bumbu : semua macam bumbuBumbu : semua macam bumbu

Makanan yang tidak boleh diberikan Makanan yang tidak boleh diberikan

Sumber protein hewani : sardin, kerang, jantung, Sumber protein hewani : sardin, kerang, jantung, hati, usus,limpa,paru,paru,otak, ekstraks hati, usus,limpa,paru,paru,otak, ekstraks daging/kaldu, bebek, angsa, burungdaging/kaldu, bebek, angsa, burung

Minuman : alkoholMinuman : alkohol Bumbu : ragi Bumbu : ragi

Protective FoodsProtective Foods Water.Water. Water dilutes the urine and keeps calcium, Water dilutes the urine and keeps calcium,

oxalates, and uric acid in solution. oxalates, and uric acid in solution.

In research studies, those subjects whose In research studies, those subjects whose total fluid intake (from all sources) over 24 total fluid intake (from all sources) over 24 hours was roughly 2.5 liters, the risk of a hours was roughly 2.5 liters, the risk of a stone was about one-third less than that of stone was about one-third less than that of subjects drinking only half that much. subjects drinking only half that much. (They do not need to drink 2.5 liters of (They do not need to drink 2.5 liters of water per day; rather this is the total fluid water per day; rather this is the total fluid consumption, including juices, soups, etc.)consumption, including juices, soups, etc.)

High-Potassium Foods.High-Potassium Foods. A study of 46,000 men conducted by A study of 46,000 men conducted by

Harvard University researchers found that a Harvard University researchers found that a high potassium intake can cut the risk of high potassium intake can cut the risk of kidney stones in half.kidney stones in half.

Potassium helps the kidneys retain calcium, Potassium helps the kidneys retain calcium, rather than sending it out into the urine. rather than sending it out into the urine. Potassium supplements are not generally Potassium supplements are not generally necessary. Rather, a diet including regular necessary. Rather, a diet including regular servings of fruits, vegetables, and beans servings of fruits, vegetables, and beans supplies plenty of potassium.supplies plenty of potassium.

Calcium.Calcium. Although most stones contain calcium, the Although most stones contain calcium, the

calcium in foods does not necessarily contribute calcium in foods does not necessarily contribute to stones. Calcium supplements taken between to stones. Calcium supplements taken between meals may increase the risk of stones, because meals may increase the risk of stones, because about 8 percent of any extra dietary calcium about 8 percent of any extra dietary calcium passes into the urine.passes into the urine.

On the other hand, calcium consumed with meals On the other hand, calcium consumed with meals has the opposite effect, reducing the risk of has the opposite effect, reducing the risk of stones. The reason, apparently, is that calcium stones. The reason, apparently, is that calcium binds to oxalates in foods and holds them in the binds to oxalates in foods and holds them in the digestive tract, rather than allowing them to be digestive tract, rather than allowing them to be absorbed.absorbed.

Caffeine.Caffeine. Caffeinated beverages reduce the risk of Caffeinated beverages reduce the risk of

stones. Caffeine’s diuretic effect causes the stones. Caffeine’s diuretic effect causes the loss of both water and calcium, but the water loss of both water and calcium, but the water loss is apparently the predominant effect. loss is apparently the predominant effect.

alcoholic beverages are associated with a alcoholic beverages are associated with a reduced risk of kidney stones, again reduced risk of kidney stones, again presumably due to a diuretic effect. This is presumably due to a diuretic effect. This is not a compelling reason to drink either coffee not a compelling reason to drink either coffee or alcohol, but their diuretic actions do or alcohol, but their diuretic actions do present this advantage.present this advantage.

Problem FoodsProblem Foods

Animal proteins cause Animal proteins cause calciumcalcium to be leached from to be leached from the bones and excreted in the urine where it can the bones and excreted in the urine where it can form stones. form stones.

Diets rich in animal proteins also Diets rich in animal proteins also increase uric increase uric acid excretionacid excretion. In a controlled research study, . In a controlled research study, published in the published in the American Journal of Clinical American Journal of Clinical NutritionNutrition, research subjects on a diet eliminating , research subjects on a diet eliminating animal protein had less than half the calcium loss animal protein had less than half the calcium loss that they had on their baseline diet.that they had on their baseline diet.

The Harvard study mentioned earlier found that The Harvard study mentioned earlier found that even a modest increase in animal protein, from even a modest increase in animal protein, from less than 50 grams to 77 grams per day, was less than 50 grams to 77 grams per day, was associated with a 33 percent increased risk of associated with a 33 percent increased risk of stones in men. The same is true for women.stones in men. The same is true for women.

The association between animal proteins and stones The association between animal proteins and stones probably relates both to the amount of probably relates both to the amount of proteinprotein they contain they contain and to their content of the and to their content of the sulfur-containing amino acidssulfur-containing amino acids

Sulfur in cystine and methionineSulfur in cystine and methionine is converted to sulfate, is converted to sulfate, which tends to acidify the blood. As a part of the process of which tends to acidify the blood. As a part of the process of neutralizing this acid, bone is dissolved, and bone calcium neutralizing this acid, bone is dissolved, and bone calcium ends up in the urine. Meats and eggs contain two to five ends up in the urine. Meats and eggs contain two to five times more of these sulfur-containing amino acids than are times more of these sulfur-containing amino acids than are found in grains and beans.found in grains and beans.

Between 1958 and the late 1960s, there was a sharp Between 1958 and the late 1960s, there was a sharp increase in the incidence of kidney stones in Great Britain. increase in the incidence of kidney stones in Great Britain. During that period, there was no substantial change in the During that period, there was no substantial change in the amount of calcium or oxalate-containing foods consumed. amount of calcium or oxalate-containing foods consumed. However, the consumption of vegetables decreased, and the However, the consumption of vegetables decreased, and the use of poultry, fish, and red meat increased. Statistical use of poultry, fish, and red meat increased. Statistical analyses showed a strong relationship between the incidence analyses showed a strong relationship between the incidence of stones and animal protein consumption.of stones and animal protein consumption.

Sodium.Sodium. Sodium increases the passage of calcium through the Sodium increases the passage of calcium through the

kidney and increases the risk of stones. When people kidney and increases the risk of stones. When people cut their salt (sodium chloride) intake in half, they cut their salt (sodium chloride) intake in half, they reduce their daily need for calcium by about 160 reduce their daily need for calcium by about 160 milligrams.milligrams.

Plants of any kind—grains, vegetables, legumes, and Plants of any kind—grains, vegetables, legumes, and fruits—contain almost no sodium at all unless it is fruits—contain almost no sodium at all unless it is added during canning or other processing. Dairy added during canning or other processing. Dairy products and meats contain more salt than plant products and meats contain more salt than plant products, and table salt, frozen meals, and canned and products, and table salt, frozen meals, and canned and snack foods are the highest-sodium food products. snack foods are the highest-sodium food products.

Surprisingly,Surprisingly, oxalate-rich foodsoxalate-rich foods, such as , such as

chocolate, nuts, tea, and spinach, are chocolate, nuts, tea, and spinach, are not associated with a higher risk of not associated with a higher risk of renal stones, nor is renal stones, nor is vitamin Cvitamin C, even , even though it can be converted to oxalate. though it can be converted to oxalate. A large study of men taking vitamin C A large study of men taking vitamin C supplements found that they had no supplements found that they had no more kidney stones than men who do more kidney stones than men who do not take them.not take them.

Sugar.Sugar. Sugar accelerates calcium losses through the Sugar accelerates calcium losses through the

kidney.kidney. In the Nurses’ Health Study, those who consumed, In the Nurses’ Health Study, those who consumed,

on average, 60 grams or more of sugar (sucrose) per on average, 60 grams or more of sugar (sucrose) per day had a 50 percent higher risk of stones than day had a 50 percent higher risk of stones than those who consumed only about 20 grams.those who consumed only about 20 grams.

Climate.Climate. Kidney stones are also more common in Kidney stones are also more common in warm climates, presumably because perspiration warm climates, presumably because perspiration leads to dehydration and a more concentrated urine, leads to dehydration and a more concentrated urine, and because sunlight increases the production of and because sunlight increases the production of vitamin D in the skin which, in turn, increases vitamin D in the skin which, in turn, increases calcium absorption from the digestive tract.17calcium absorption from the digestive tract.17

Here are simple steps to help your Here are simple steps to help your patients avoid kidney stones.patients avoid kidney stones.

Encourage patients to drink plenty of water or Encourage patients to drink plenty of water or other fluids, staying ahead of their thirst. other fluids, staying ahead of their thirst.

Diets including generous amounts of Diets including generous amounts of vegetables, fruits, and beans are rich in vegetables, fruits, and beans are rich in potassium and very low in sodium. potassium and very low in sodium.

If you prescribe calcium supplements, If you prescribe calcium supplements, encourage patients to take them with meals, encourage patients to take them with meals, rather than between meals. rather than between meals.

Encourage patients to avoid animal products. Encourage patients to avoid animal products. Their proteins and sodium content increase Their proteins and sodium content increase the risk of stones. the risk of stones.

Patients should keep salt and sugar use Patients should keep salt and sugar use modest.modest.