Plenary discussion

Group 19 C

Scenario 6: suffer mrs

renkis
Mrs renkis, 50 years old with a body weight of 40 kg,
came to puskesmas with complaints of abdominal bulge
since 5 months ago. Besides, the lady renkis also
complained lethargy, nausea, decreased appetite. Mrs.
renkis have often treated with a midwife and was given an
ulcer drug, but the complaint was not reduced. On
examination the doctor to get a general state of weakness,
anemia conjungtiva. Blood pressure of 180/110 mmHg.
Heart found signs of LVH, Pulmonary not ronkhi. Abdominal
examination of the liver and spleen not palpable. On
bimanual palpation of the abdomen, kidney Ballotemen right
(+). The laboratory found HB 8 g / dl, 8000 leukocytes /
mm3. Urine: ++ albumin, urinary sediment: erythrocyte 46 / LPB, leukocytes 1-3 / LPB: normal.
The doctor explained to the mrs renkis that he suffered
from hypertension, anemia and protein lost from kidney,
therefore must do further tests to determine the disease.
Doctors clinic gave antihypertensive drugs and mrs renkis

In the RSUP of laboratory examination with the results of

the blood sugar of 120 mg / dl, ureum 100 mg / dl,
creatinine 4 mg / dl. Of abdominal ultrasound examination
found multiple cysts in both kidneys, liver and pancreas.
The doctor explained to the mrs renkis about her disease,
she has kidney failure, the disease is progressive and
irreversible that the moment will come to the end-stage
kidney disease that requires dialysis.
In beside mrs renkis renkis,treated a female patient of 40
years, who had undergone dialysis. According to the
treating doktor, the patient experienced acute renal
failure due to vomiting and defecation were late taken to
the hospital. How do you explain what happened to the
lady beside renkis and the female patients?

Terminology
Kidney

Failure : clinical state of reduced kidney function

Acute kidney injury :
sudden decrease in kidney function (48 hours) , the
increase in serum creatinine> 0.3 mg / dL rise in serum
creatinine> 50% from baseline or a reduction in urine
output / oliguria in 6 hours

Chronic renal failure :

kidney damage 3 months with or without lowering
GFR.
GFR <60 ml / minute for> 3 months with or without
kidney damage.

Ballotemen kidney: palpation examination of the

examination of kidney resilience, in adults by using 2
hands to suppress the movement of the abdominal wall
and then quickly release the pressure of the abdominal
wall bouncing
Urea: final results of protein metabolism

terminology
Hemodialysis: measures of removing
toxins in the body and as a substitute
for kidney function
Creatinine: products metabolism of
creatin phosphate on muscle

Problem Analyzing
1. Why Mrs. Renkis complain ascites since 5 months
ago? and also complained lethargy, nausea , and
poor appetite ?
Ascites 5 months ago is likely due to chronic
disease.
The cause of ascites
Enlargement of the abdominal organs
Because there is a tumor
Edema / ascites due to a decrease in protein
oncotic pressure because protein lost from kidney
Lethargy, nausea, decreased of appetite due to
chronic renal failure and than caused the increase
of urea creatinine levels in the blood
Then, lethargic can caused by anemia, due to

2. Why Mrs. Renkis after ulcer drug was given,

the complaint is not reduced ?
Ulcer drugs do not relieve complaint ,
because the complaint caused by impaired
kidney function
And also , the drugs will aggravate kidney
function because excreted in the kidneys so
that the complaint is not reduced

3. How interpretation of the examination the

doctor ?
General state : weakness and conjungtival
anemic caused by Anemia
180/110 blood pressure : Hypertension
LVH caused by Hypervolemic
Pulmonary not ronkhi = Normal
The liver and spleen not palpable caused by
ascites
Ballotement of right kidney ( + ) :
enlargement of the right kidney

4. How interpretation of laboratory tests ?

HB 8 gr/dl : anemia
leukocytes 8000/mm3 : normal
Albumin ++ : found albumin in the urine
(from 0.05 to 0.2 %)
Urinary sediment :
erythrocyte 4-6 /LPB : erythrocyte +
(hematuria)
leukocytes 1-3 /LPB : normal

5. How the relationship of age , gender ,

against state Mrs. Renkis ?
For sex there is no difference between men
and women
For ages, the higher the age of diminishing
kidney function.
6. Why do doctors give antihypertensive drugs
before referring Mrs. renkis ?
Antihypertensive drug given to conservative
For chronic renal failure, hypertension
medications used ACEI or ARB

7. What is the interpretation of laboratory

tests and ultrasound ?
Laboratory tests :
Blood glucose 120 mg / dl : normal
Urea 100 mg / dl : increased
Creatinine 4 mg / dl : increased
Abdominal ultrasound examination :
Multiple cysts in both kidneys, liver and
pancreas

8. Why do doctors diagnose Mrs. renkis

kidney failure ?
Based on history and physical examination
conducted investigations to Mrs. Renkis
GFR = 140 Age (TH) x Weight (KG) x
0.85
72 x Blood Creatinin
= 10,6
Based on the results of the calculation of
glomerular filtration rate Mrs. renkis suffer
stage 5 chronic renal disease ( GFR < 15
ml / minute)

9. What is essentially renal disease patients

requiring dialysis therapy ?
Dialysis therapy conducted in chronic
kidney disease stage 5 where GFR < 15
ml/min

10. Why 40 years old female patient who suffered diarhea

and vomitting can cause acute kidney injury and require
dialysis ?
Because diarhea and vomitting cause loss of body fluids that
cause hypovolemia , resulting in renal hypoperfusion ( prerenal AKI )
In acute renal failure indication for dialysis or renal
replacement therapy
Anuria , aliguria
Hyperkalemia ( K > 6.5 mEq / l )
Severe acidosis ( pH < 7.1 )
Azotemia ( urea > 200 mg / dl )
Pulmonary edema
Encephalopathy uremikum
Distnatremia weight ( Na < 160 mEq / l or < 115 mEq / l )
Drug intoxication

SCHEME
Decrease of Oncotic Pressure
Enlargement of Abdominal
Organs

Acites
Women
,
40 Y.O

Diarrhea
and
Vomiting

AKI

Men,
50 Y.O
Fatique
Nausea
Decrease
of appetite
Examination:
Weakness
Anemic
conjunctival
Increase of BP
LVH
No ronchi
Kidney
Ballotement
(+)
Hb : 8 gr/dl
Eri (+)
Leuko (-)
Albumin (++)

- Hemodialyse
- Kidney Transplantation

Increase of serum Creatinin

and Ureum
Anemia, cause the decrease
of eritropoitin production

Hypertension, Anemia, Proteinuria

Antihypertension

Reconciliation

CRD :
Stage 5

GFR =
10,7

Hospital Exam:
Increase of Creatinin
and Ureum
Normal
Glucose
Blood
USG : Multiple Cyst

Learning objektif
1.
2.
3.
4.
5.

Acute kidney injury in adults

Acute kidney injury in children
Chronic renal failure in adults
Chronic renal failure in children
Depression in kidney disease

Pathogenesis
Classification pathogenesis of acute kidney
injury (AKI) divided by the location of
disturbance

Pre renal

Renal (instrinsik)

Post renal

enal

Renal
The renal mechanism of Acute Kidney
Injury is come from the parenkim of the
kidney. The main cause of it is Tubular
necrosis acute (TNA). Etiology of TNA devided
into two:
1. Ischemic
2. Nefrotoxic

Post renal
Post renal mechanisms mostly comefrom
the obstruction of urinary tract. Blockage
can be derived from the urethra and the
bladder is also called the lower blockage or
the ureter and pelvic calises also called
upper blockage.
For the upper blockage, its can make the
AKI if the obstructon happen in bilateral of
the tractus.

LO 3

Criteria for chronic kidney

disease
1.

2.

Damage to the kidneys (renal damage) that

occurred more than three months, in the form of
structural or functional abnormalities, with or
without a decrease in glomerular filtration rate
(GFR), with manifestations:
pathology
There are signs of kidney abnormalities, including
abnormalities in blood or urine composition
imaging test abnormalities (imaging test)
glomerular filtration rate (GFR) <60 ml / min /
1.73 m 2 for 3 months, with or without renal
impairment

Classification chronic renal

failure
STADIUM

GFR ML / MiN

Treatment

GFR normal / 90

KONSERVATIF, control
risk factor

GFR mild
60 89

IDEM

GFR moderate
30 - 59

IDEM

GFR severe
15 - 29

IDEM

kidney failure
< 15

Kidney replacement
therapy

RENAL REPLACEMENT
THERAPY
Dialysis: - Hemodialysis
- PERITONIAL Dialysis
- C A P D
- A P D
kidney transplant

Etiologi CRF

DIABETES MELLITUS
HYPERTENSION
URINARY TRACT INFECTION
URINARY tract obstruction (STONE)
glomerulonephritis
Kidney Cyst
LUPUS
ACUTE RENAL FAILURE
DLL

SYMPTOMS
DIGESTIVE SYSTEM
- NAUSEA, VOMITING, bloating and
Decreased appetite
- BREATH SMELL PEE, NO SENSE
GOOD IN MOUTH
- hiccups
- gastritis
SKIN
- PALE, YELLOW, ROUGH AND DRY
- ITCHY RASH
- ecchymosis
- Scratches

SYMPTOMS
Blood
- Anemia - ERITROPOITIN DOWNHILL
- hemolysis
- LACK OF IRON
- GASTROINTESTINAL BLEEDING
- Fibrosis SUM SUM OF BONE
- Platelet : BLEEDING
NERVE MUSCLE
- SORE Limbs
- tingling
- WEAK
- CAN NOT SLEEP
- INTERRUPTION OF CONCENTRATION
- tremor
- Seizures

SYMPTOMS
HEART AND BLOOD VESSEL
` - HYPERTENSION
- CHEST PAIN
- Shortness of breath, heart trouble
- RHYTHM DISTURBANCES (POUNDING)
- Edem / DAM LUNG
ENDOCRIN
- SEXUAL DISORDERS
- DIABETES
ETC
- Bone loss
- acidosis
- hyperkalemia

EXAMINATION SUPPORT
BLOOD AND URINE ROUTINE
Urea and creatinine
L F G (= LEVEL OF HYGIENE creatinine)
= 140 - AGE (TH) x B (KG)
72 x serum creatinine
= WOMEN: x 0.85
= U x V
P
U = creatinine URINE
V = NUMBER OF URINE / MINUTES
P = blood creatinine

Radiology
BNO/IVP
U S G
RENOGRAM
R P G
SISTOSKOPI

LO 3

Laboratory picture.
decreased kidney function in the form of
increased levels of urea and serum creatinine.
blood biochemical abnormalities include
decreased levels of hemoglobin, increased
levels of uric acid, hyper- or hypokalemia,
hyponatremia, hyper- or hypochloremia,
hyperphosphatemia, hypocalcemia, metabolic
acidosis.
urinalysis abnormalities include proteinuria,
hematuria, leukosuria, cast, isostenuria

Management
specific treatment for the disease is
essentially
prevention and treatment of comorbid
conditions
slow the progression of kidney function
prevention and treatment of cardiovascular
disease
Renal replacement therapy in the form of
dialysis or kidney transplantation.

Renal Replacement
Therapy

Indication for renal replacement therapy in patients

with chronic kidney disease (CKD) include the
following:
Severe metabolic acidosis
Hyperkalemia
Pericarditis
Encephalopathy
Intractable volume overload
Failure to thrive and malnutrition
Peripheral neuropathy
Intractable gastrointestinal symptoms
In asymptomatic adults patients, a glomerular
filtration rate (GFR) of 5-9 ml/min/1.73 m2

Diet
Protein restriction
Salt restriction
Phosphate restriction starting early in CKD
Potassium restriction
Sodium and water restriction as needed to
avoid volume overload
Fruits and vegetables

Thank you