The Impaired of Renal, Heart and Liver

Functions Due to Complications of Dengue

Infection by Heparinization and
Hemodialysis
Abstract
Multiple organ complication because of Dengue infection, in hyper
endemic Dengue such as Indonesia will be difficult to avoid
Dengue infection with complication of acute renal failure (CCT 7,24), acute
lung edema et causa STEMI anterior septal (CKMB 85,9 U/L) and hepatic
insufficiency (total bilirubin 3,3 mg/dL)
Hemodialysis, heparanization and high doses of corticosteroid
(methylprednisolone 2 x 250mg/day) for 5 days
In a result, the patient went home in good condition.
Background of the Study

Dengue infection is a disease happened in tropic countries such as Indonesia

Based on the Indonesian healthy record of 2016, Dengue fever was the 3rd of 10
highest causes of people using public health insurance for hospitalization in 2016
WHO, the death rate caused by Dengue infection under 1% to more than 20%
Spreading of complex immune and multiple organ impairment, including renal
impairment were also reported
Prathima, et al reported that hemodialysis was given to the patient of acute renal
failure who also liver function impairment caused by Dengue fever.
No special report about the treatment report for more than two organs, included
renal failure caused by Dengue infection. Which Hemodialysis played parts and
reported to be given to treat acute renal failure.
This article reported there were three organs affected by infection : STEMI, hepatic
insufficiency and acute renal failure. Whereas in the treatment of this patient gave
Heparanazation to treat cardiac problem and hemodyalisis to treat acute renal
failure.
Case Report
Women, 59 years old, weight 50 kg, care to emergency room (18-10-
16) because of fever that last for 3 days before admission. The patient had
dyspnea, painful chest paint that was spreading to the left arm and back,
these symptoms last for one day before she came to the hospital. The patient
also complaint about coughing up white phlegm, nausea but didnt vomit,
body and joint aches had been felt for 3 days before she came to the hospital.
History for coughing, diabetes mellitus, hypertension, and the other systemic
diseases were denied. History of bleeding was denied.
In the emergency room
BP 90/60
HR 133x/minute
RR 26x/minute
T 38,8C
SPO2 90%
Thorax : Rh (+/+) smooth wet in
basal
Abdomen : mild hepatomegaly
(+), epigastric tenderness (+),
ascites (-)
Extremitas : Petechie (+) in arm
and leg, edema (-)
pee : urination is smooth,
painless, light yellow urine
Laboratory test :
Hb 14,7%
hematocrit 38%
leukocytes 6100/mm3
platelet count 48.000/mm3
diff count 0/0/1/93/6/0
SGOT 130,7 U/L
SGPT 39,8 U/L
total bilirubin 3,3 mg/dL
potassium 6,36 mg/dL
ureum 161,1 mg/dL
creatinine 5,87 mg/dL
urinary : erit 250/ul, leuko 550/ul
blood glucose 122 mg/dL
albumin 2,86 mg/dL
CKMB 85,9 U/L
total cholesterol 159,5 mg/dL
HDL 7,2 mg/dL
LDL 87 mg/dL
triglyceride 308,5 g/dL
antibody IgG Dengue (+), IgM (-)
 Thorax radiology
slightly enlarged heart and pulmonary congestion. Infiltrates in the lungs
(+)
EKG
ST-segment elevation in lead V1 V4 with heart rate 140x/minute
USG
no enlargement of the hepar, no acites, no node, fatty liver (+), slightly
enlarged sized and appearance what seems like small stones in renal
dextra. In the renal sinistra there was also imaging of small stones, the size
is normal. Gall bladder and lien showed in normal range.

Dx : cardiogenic shock, acute pulmonary edema et causa anteroseptal STEMI

and acute kidney injury, that were all caused by severe Dengue infection,
also thought of secondary infection (urinary tract infection).

Patient admitted to Intensive Care Unit. On progress BUN and creatinine

on fourth day treatment increased to 318 mg/dL and 6,6 mg/dL. Lowest
platelet count finding was 13.000/mm3.
 The treatment had given in the patient :
Ringer lactate
hydroxyl ethyl stracth (widahess)
dobutamin injection
enoxaparine sodium (lovenox) injection
furosemide injection
fargoxin injection/6 hours
high doses methylprednisolone injection
sliding scale blood glucose every 6 hours
omeprazole injection, antiemetic injection, electrolyte correction
imbalance, antibiotic injection, aspillet, clopidogrel, nitric and O2, and
cito hemodialysis on the fourth day of the treatment.
The patient was discharged on the 10th day of treatment in good
condition. The patient then never did follow up internal department and
finally she only came to follow up on 22 December 2016 because of GI
Tract problem. Laboratory results finding Hb 10,2 gr%, HT 31%, platelet
239.000 /mm3, leucocytes 7800 /mm3, MCV/MCH/MCH 84/28/33
(normal limit), Sodium 145 mg/dL, pottasium 4.4 mg/dL, chloride 124
mg/dL, BUN 18.3 mg/dL, creatinine 1.32 mg/dL.
Discussion
The incidence of renal failure (CCT <60), in dengue infected patient based
on creatinine value 4.04% of all patients infected by Dengue
28,75% of 4,04% death
CCT <15 45% death
While deaths from dengue infections in hospitals in children (<15 years)
0.5-3.5% (data on adults not yet agreed)
The presence of AKI, in patients infected dengue, based on BUN 35.7%
when using creatinine data at the time of entry and return, then the
impaired renal function in patients infected Dengue virus 27.1%
The details based on RIFLE value are Risk 21.6% (CCT 60-89), Injury 2.9%
(CCT 15-59) and Failure 2,6% (CCT <15).
 most patients with impaired renal function that occurs due to Dengue viral
infection, will heal itself Lizarraga and Ali Nayer said
the kidney function disorder (CCT <15) 45% death
Renal failure (CCT <15) + acute myocard infarct mortality (Data in the
US in 2008 mentioned 1 of 4 deaths caused by heart disease)
this case is an interesting case to report renal failure (CCT <15) + acute
myocard infarct + hepatic insufficiency
decided to do hemodialysis in this patient
Pre-HD : BUN 318 mg/dL and creatinine 6,6 mg/dL (CCT 7,24),
potassium 6,04 mg/dL, sodium 138,8 mg/dL, calcium 8,32 mg/dL, and
platelet count 19,000 /mm3, CKMB 11,83 U/L, while the patient isnt
breathless. Blood pressure 160/90 mmHg.
HD formula given to this patient: 400cc pull (UFG) within 3 hours and
without heparin. QB 150 and QD 300, and the administration of bicnat
was raised by 1 level. Other settings are provided by default.
Post HD : ur 138.4 mg/dL, cr 2.63 mg/dL, potassium 4.56 mg/dL,
sodium 136.4 mg/dL, calcium 8.49 mg/dL. But the platelet count fell
13,000 /mm3.
 The patient was discharged on the 10th day of care in good condition.
Unfortunately the patient just went to follow up to internal department
on December 22th 2016 with laboratory results Hb 10,2 gr%, HT 31%,
platelet 239.000 /mm3, leucocytes 7800 /mm3, MCV/MCH/MCH 28/28/33
(normal limit), Sodium 145 mg/dL, pottasium 4.4 mg/dL, chloride 124
mg/dL, BUN 18.3 mg/dL, creatinine 1.32 mg/dL.
Another important point from this patient is the corticosteroid IV in high
doses (500mg/day of methylprednisolon which were given 2x250 mg in
each administration) was given for 5 days. Meanwhile, to prevent the
occurance of tachycardia and hyperglichemic on the patient as a result of
corticosteroid in high doses, the patient was given fargoxin 1 cc/ 6 hours
and a sliding scale of blood sugar in every 6 hours.
Corticosteroid in high doses prevents severe attack of Dengeu viral
Hypersensitivity type 3 its basically pathogenesis and pathophysiology of
hemorragic dengue fever from T.Mudwal is correct
Which is effect and reaction of hypersensitivity type 3 on the patient with
hypersensitive with dengue viral its accusating on lupus nephritis
incidents. However ANA or DNA its not evaluated we must considering of
lupus nephritis.
 Laboratory value development

Item Early entry During treatment Final

CKMB 85,9 37,75 11,33
Ureum 161 318 19,3
Creatinine 5,8 6,6 1,3
Potassium 6,3 6,04 4,5
Total Bilirubin 3,3 1,4
SGOT 130,7 30,2
SGPT 39,8 41,2
Platelet 48.000 13.000 239.000
 Imaging of EKG
When entry

Last imaging
Conclusion
Its hard to avoid that this case is a lost case. If the case can give a very
satisfactory result then the possible cause can be attributed to the
administration of high dose corticosteroid injection besides other
therapies given to this patient.