ISUE DIET HIPERTENSI DAN PENYAKIT GINJAL Isue Diet Mutakhir S2 Gizi Kesehatan IKM FK UGM Susetyowati, DCN.M.Kes.

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1 ISUE DIET HIPERTENSI DAN PENYAKIT GINJAL Isue Diet Mutakhir S2 Gizi Kesehatan IKM FK UGM Susetyowati, DCN.M.Kes

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3 FAKTOR RISIKO HIPERTENSI faktor yang tidak dapat dikontrol : keturunan, jenis kelamin, dan umur. Faktor yang dapat dikontrol meliputi kegemukan, kurang olahraga, merokok dan pola makan Faktor lain yang mempengaruhi hipertensi adalah geografi dan lingkungan stres, obesitas, kurang aktifitas, merokok dan konsumsi alkohol.

4 High Blood Pressure: Major Component of Chronic Disease Risk Proportion of incidence due to high blood pressure ( Systolic >115 mmHg) Stroke 70-75% Stroke 70-75% Congestive Heart Failure 50% Congestive Heart Failure 50% Ischemic Heart Disease 25% Ischemic Heart Disease 25% Renal Failure 20% Renal Failure 20% High blood pressure is the leading cause of mortality worldwide Lancet 2006 367:1747

5 Concept of Salt as Harmful Substance Concept of Salt as Harmful Substance Salt IntakeHypertension Disease (stroke, heart and kidney disease, osteoporosis, kidney stones)

6 Concept of Salt-Sensitivity Concept of Salt-Sensitivity Salt-sensitivity Hypertension Disease High Salt Intake

7 Ambang Cecap Rasa Asin Dan Asupan Natrium Kaitannya Dengan Hipertensi Esensial (intan, susetyowati, mirza, 2011) Asupan Na dipengaruhi oleh ambang cecap rasa asin. Asupan Na dipengaruhi oleh ambang cecap rasa asin. Semakin tinggi ambang cecap rasa asin, atau sensitivitasnya terhadap rasa asin berkurang, maka asupan natriumnya akan meningkat. Dengan meningkatnya asupan natrium ini, maka akan meningkatkan risiko hipertensi. Semakin tinggi ambang cecap rasa asin, atau sensitivitasnya terhadap rasa asin berkurang, maka asupan natriumnya akan meningkat. Dengan meningkatnya asupan natrium ini, maka akan meningkatkan risiko hipertensi. Penelitian observasional, case control terhadap 82 warga di Puskesmas Mlati I, Sleman Penelitian observasional, case control terhadap 82 warga di Puskesmas Mlati I, Sleman

8 Hasil Penelitian Rata-rata ambang cecap terhadap rasa asin pada kelompok kasus adalah 0,04 M, pada kelompok kontrol adalah 0,02 M (p-value < 0,05). Rata-rata ambang cecap terhadap rasa asin pada kelompok kasus adalah 0,04 M, pada kelompok kontrol adalah 0,02 M (p-value < 0,05). Rata-rata asupan natrium pada kelompok kasus adalah 1.956 mg, pada kelompok kontrol adalah 1.485 mg (p-value < 0,05). Rata-rata asupan natrium pada kelompok kasus adalah 1.956 mg, pada kelompok kontrol adalah 1.485 mg (p-value < 0,05). Ambang cecap rasa asin berpengaruh terhadap hipertensi dengan r=0,668 dan OR= 86,1. Ambang cecap rasa asin berpengaruh terhadap hipertensi dengan r=0,668 dan OR= 86,1. Asupan natrium berpengaruh terhadap hipertensi dengan r= 0,596 dan OR= 11,25. Asupan natrium berpengaruh terhadap hipertensi dengan r= 0,596 dan OR= 11,25.

9 A Brief History… The Yellow Emperor’s Classic of Internal Medicine written in China over 2,000 years ago notes*: “Hence if too much salt is used for food, the pulse hardens” *Veith, I. (Translator) U of California Press, 2002. For millions of years daily sodium intake < 400 mg/day - genetically programmed level For millions of years daily sodium intake < 400 mg/day - genetically programmed level Recent change to 3-4,000 mg/day - a major physiological challenge Recent change to 3-4,000 mg/day - a major physiological challenge

10 Mean sodium intake (mg) of selected Asian populations. * two provinces

11 1995 19851975 19801990 1987 < 10g/day Trend of salt intake in Japan (ave g/day) Source: Sasaki, 2006

12 Sodium Recommendations from IOM Report Upper Limit (UL): Upper Limit (UL): 2.3 g (5,8 g salt)/day for adults Adequate Intake (AI): Adequate Intake (AI): 1.5 g (3,8 g salt)/day for adults

13 Recommendations for Adequate Sodium Intake by Age Age Sodium Intake per Day (mg) 0-6 months 120 7-12 months 370 1-3 years 1000 4-8 years 1,200 9-50 years 1,500 50-70 years 1,300 > 70 years 1,200 CMAJ 2008;179(12 Suppl):E1-E93 #2.1

14 Sources of Dietary Sodium Inherent 12% Food Processing 77% At the Table 6% During Cooking 5% Mattes and Donnelly, JACN, 1991; 10: 383 (62 adults who completed 7 day dietary records)

15 PENELITIAN Tingkat asupan natrium di Indonesia ? Tingkat asupan natrium di Indonesia ? Ambang cecap rasa asin pada anak, remaja, dewasa ? Ambang cecap rasa asin pada anak, remaja, dewasa ? Distribusi Sumber natrium pada makanan sehari-hari ? Distribusi Sumber natrium pada makanan sehari-hari ?

16 Sodium and Blood Pressure Animal studies Animal studies Human Genetic Studies Human Genetic Studies Epidemiological Studies Epidemiological Studies Migration studies Migration studies Interventional Studies Interventional Studies Treatment Studies Treatment Studies Evidence:

17 Treatment Study: DASH Sodium Control diet - low in fruit, veg and dairy, fat content typical of US Control diet - low in fruit, veg and dairy, fat content typical of US DASH diet - high in fruit, veg and low-fat dairy, reduced fat content DASH diet - high in fruit, veg and low-fat dairy, reduced fat content Consume diet for consecutive 30 day periods in random order at each of 3 levels of salt Consume diet for consecutive 30 day periods in random order at each of 3 levels of salt NEJM 2001; 344:3-10 Intervention Change in mean B.P. vs. control (systolic) Control diet DASH diet 9g/d salt Control level - 6 mmHg 6g/d salt - 2 mmHg - 7 mmHg 3g/d salt - 7 mmHg - 9 mmHg Randomized 412 adults (mixed B.P. status, racial groups, sexes) to: -7 (NT) -11(HT)

18 Mineral Content in DASH Trials* NutrientControl mg (mmol) DASH Diet mg (mmol) Natrium3028 (132)2859 (124) Kalium1752 (45)4415 (113) Calcium4431265 Magnesium176480 Appel LJ et al. N Engl J Med 1997; 336:117-24 * Chemical analysis of menus

19 PENELITIAN MAHASISWA Hubungan antara asupan natrium, kalium, kalsium dan magnesium dengan hipertensi di Puskesmas Mergangsan YOGYAKARTA (annisa, susetyowati, 2009) Ada hubungan antara asupan natrium, kalium, dan kalsium dengan hipertensi. tidak ada hubungan antara asupan magnesium dengan hipertensi.

20 ISU DIET PADA BATU SALURAN KEMIH Susetyowati, DCN.M.Kes

21 Kidney Stones Basic cause is unknown Basic cause is unknown Factors relating to urine or urinary tract environment contribute to formation Factors relating to urine or urinary tract environment contribute to formation Present in 5% of U.S. women and 12% of U.S. men Present in 5% of U.S. women and 12% of U.S. men Prevalensi di Indonesia penyakit batu diperkirakan sebesar 13% pada laki-laki dewasa dan 7% pada perempuan dewasa Prevalensi di Indonesia penyakit batu diperkirakan sebesar 13% pada laki-laki dewasa dan 7% pada perempuan dewasa Major stones are formed from one of three substances: Major stones are formed from one of three substances: Calcium Calcium Struvite Struvite Uric acid Uric acid

22 Calcium Stones 70%-80% of kidney stones are composed of calcium oxalate 70%-80% of kidney stones are composed of calcium oxalate Almost half result from genetic predisposition Almost half result from genetic predisposition Other causes: Other causes: Excess calcium in blood (hypercalcemia) or urine (hypercalciuria) Excess calcium in blood (hypercalcemia) or urine (hypercalciuria) Excess oxalate in urine (hyperoxaluria) Excess oxalate in urine (hyperoxaluria) Low levels of citrate in urine (hypocitraturia) Low levels of citrate in urine (hypocitraturia) Infection Infection

23 Faktor-Faktor Risiko Kejadian Batu Saluran Kemih Pada Laki-laki (Nur Lina, 2008) Penelitian observasional dengan rancangan kasus kontrol. Penelitian observasional dengan rancangan kasus kontrol. Lokasi penelitian di RS Dr. Kariadi, RS Roemani dan RSI Sultan Agung. Jumlah responden sebanyak 44 kasus dan 44 kontrol. Lokasi penelitian di RS Dr. Kariadi, RS Roemani dan RSI Sultan Agung. Jumlah responden sebanyak 44 kasus dan 44 kontrol.

24 HASIL Faktor-faktor risiko kejadian batu saluran kemih yang terbukti signifikan : Faktor-faktor risiko kejadian batu saluran kemih yang terbukti signifikan : Kurang minum (OR adjusted=7,009; 95%CI: 1,969-24,944) Kurang minum (OR adjusted=7,009; 95%CI: 1,969-24,944) Kebiasaan menahan buang air kemih (OR adjusted=5,954; 95%CI: 1,919-18,469) Kebiasaan menahan buang air kemih (OR adjusted=5,954; 95%CI: 1,919-18,469) Diet tinggi protein (OR adjusted=3,962; 95%CI: 1,200-13,082) Diet tinggi protein (OR adjusted=3,962; 95%CI: 1,200-13,082) Duduk lama saat bekerja (OR adjusted= 3,154; 95%CI: 1,007-9,871) Duduk lama saat bekerja (OR adjusted= 3,154; 95%CI: 1,007-9,871)

25 Water for preventing urinary calculi (Review) Ke Z, Wei Q (2009) Background : Urinary calculi is a common condition characterized of high incidence and high recurrence rate. For a long time, increased water intake has been the main preventive measure for the disease and its recurrence. Background : Urinary calculi is a common condition characterized of high incidence and high recurrence rate. For a long time, increased water intake has been the main preventive measure for the disease and its recurrence. Objectives : To access the effectiveness of increased water intake for the primary and secondary prevention of urinary calculi. Objectives : To access the effectiveness of increased water intake for the primary and secondary prevention of urinary calculi.

26 Search methods : Relevant RCTs were identified by electronic and documental searches of MEDLINE, EMBASE, the Chinese Biomedical Disk and the Cochrane Central Register of Controlled Trials. No language restriction was applied. Date of last search: November 2005. Search methods : Relevant RCTs were identified by electronic and documental searches of MEDLINE, EMBASE, the Chinese Biomedical Disk and the Cochrane Central Register of Controlled Trials. No language restriction was applied. Date of last search: November 2005. Selection criteria : Randomised controlled trials (RCTs) and quasi-RCTs of increased water intake for the prevention of urinary calculi and its recurrence. Selection criteria : Randomised controlled trials (RCTs) and quasi-RCTs of increased water intake for the prevention of urinary calculi and its recurrence.

27 Main results : Main results : No trials of increased water intake for the primary prevention of urinary calculi met the inclusion criteria. No trials of increased water intake for the primary prevention of urinary calculi met the inclusion criteria. One trial with 199 patients provided results of increased water intake for the recurrence of urinary calculi. The recurrence rate was lower in the increased water intake group than that of the no intervention group (12% versus 27%, P = 0.008, RR = 0.45, 95% CI 0.24 to 0.84). One trial with 199 patients provided results of increased water intake for the recurrence of urinary calculi. The recurrence rate was lower in the increased water intake group than that of the no intervention group (12% versus 27%, P = 0.008, RR = 0.45, 95% CI 0.24 to 0.84). The average interval for recurrences was 3.23 ± 1.1 years in increased water intake group and 2.09 ± 1.37 years in the no intervention group (P = 0.016, MD = 1.14, 95% CI 0.33 to 1.95). The average interval for recurrences was 3.23 ± 1.1 years in increased water intake group and 2.09 ± 1.37 years in the no intervention group (P = 0.016, MD = 1.14, 95% CI 0.33 to 1.95).

28 Effects of Water Consumption on Kidney Function and Excretion Ivan Tack, MD, PhD (2010) Water homeostasis depends on fluid intake and maintenance of body water balance by adjustment of renal excretion under the control of arginine vasopressin hormone. Water homeostasis depends on fluid intake and maintenance of body water balance by adjustment of renal excretion under the control of arginine vasopressin hormone. The human kidney manages more efficiently fluid excess than fluid deficit. The human kidney manages more efficiently fluid excess than fluid deficit.

29 Small-fluid-volume intake does not alter renal function but is associated with an increased risk of renal lithiasis and urinary tract infection. In that case, increasing fluid intake prevents recurrence. Small-fluid-volume intake does not alter renal function but is associated with an increased risk of renal lithiasis and urinary tract infection. In that case, increasing fluid intake prevents recurrence. Two recent studies from Danone Research indicate that increasing water intake in such people leads to a significant decrease of the risk of renal stone disease (assessed by measuring Tiselius’ crystallization risk index) Two recent studies from Danone Research indicate that increasing water intake in such people leads to a significant decrease of the risk of renal stone disease (assessed by measuring Tiselius’ crystallization risk index)

30 Drinking enough fluid’ provide adequate fluid to restore or maintain total body water, it also should dilute urinary wastes enough to reduce the risk of urinary tract infection and renal lithiasis. Drinking enough fluid’ provide adequate fluid to restore or maintain total body water, it also should dilute urinary wastes enough to reduce the risk of urinary tract infection and renal lithiasis. This point appears particularly critical in SFV drinker adults and those who eat a large amount of proteinated food each day since the resulting increase in urine osmotic load does not produce fluid intake adjustment in the absence of dedicated renal feedback, resulting in an increased risk of stone formation. This point appears particularly critical in SFV drinker adults and those who eat a large amount of proteinated food each day since the resulting increase in urine osmotic load does not produce fluid intake adjustment in the absence of dedicated renal feedback, resulting in an increased risk of stone formation.

31 CAIRAN Cairan Cairan banyak, minimal 2500 mgl sehari banyak, minimal 2500 mgl sehari Rendah cairan  keluaran volume air kemih rendah  peningkatan konsentrasi kalsium dan oksalat Rendah cairan  keluaran volume air kemih rendah  peningkatan konsentrasi kalsium dan oksalat Jenis cairan  minuman ringan > 1 lt/mg dalam 3 tahun  kejadian batu kambuh Jenis cairan  minuman ringan > 1 lt/mg dalam 3 tahun  kejadian batu kambuh

32 HIPOSITRAURIA Hipositrauria (sitrat < 320 mg/hr)  penurunan ekskresi sitrat  inhibitor pebentukan kristal dalam urine Hipositrauria (sitrat < 320 mg/hr)  penurunan ekskresi sitrat  inhibitor pebentukan kristal dalam urine Ekskresi sitrat menurun  masukan tinggi protein  peningkatkan ekskresi asam dalam urin Ekskresi sitrat menurun  masukan tinggi protein  peningkatkan ekskresi asam dalam urin Perbaikan hipositrauria lebih mudah dari yang lain Perbaikan hipositrauria lebih mudah dari yang lain

33 ASAM SITRAT Asam Sitrat dianjurkan tinggi  mencegah hipositrauria sehingga urine lebih jenuh dan mendorong pertumbuhan batu kalsium. Asam Sitrat dianjurkan tinggi  mencegah hipositrauria sehingga urine lebih jenuh dan mendorong pertumbuhan batu kalsium. sumber : jeruk nipis, apel, anggur, nanas, jeruk lemon. sumber : jeruk nipis, apel, anggur, nanas, jeruk lemon.

34 ANALISIS ZAT GIZI JERUK (Sja’bani, et al, 1995) Sitrat g/kg Kalium g/kg Ca mg/kg Na mg/kg Mg mg/kg Jeruk keprok Jeruk manis J. Nipis Bk Jeruk lemon J.Nipis lokal 5,48,7539,648,655,61,581,841,691,441,534154353902553357555707565135175195265210

35 DIIT RENDAH KALSIUM  SUDAH TIDAK DIANJURKAN Kalsium  Kalsium  sesuai kebutuhan normal 400 – 600 mg/hari sesuai kebutuhan normal 400 – 600 mg/hari Diit rendah calsium  menyebabkan hiperoxalouria dan pengeroposan tulang. Diit rendah calsium  menyebabkan hiperoxalouria dan pengeroposan tulang.

36 TERIMA KASIH