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Plenary discussionGroup 19 CMrs 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 4-6 / 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 refer to the RSUP.Scenario 6: suffer mrs renkisIn 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?Kidney Failure : clinical state of reduced kidney functionAcute 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 hoursChronic renal failure : kidney damage 3 months with or without lowering GFR.GFR 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 bouncingUrea: final results of protein metabolism

TerminologyHemodialysis: measures of removing toxins in the body and as a substitute for kidney functionCreatinine: products metabolism of creatin phosphate on muscle

terminology1. 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 kidneyLethargy, 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 impaired production of eritropoitin in kidneyProblem Analyzing2. 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 reduced3. How interpretation of the examination the doctor ? General state : weakness and conjungtival anemic caused by Anemia180/110 blood pressure : Hypertension LVH caused by HypervolemicPulmonary not ronkhi = Normal The liver and spleen not palpable caused by ascitesBallotement 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 : normal5. 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 conservativeFor 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. RenkisGFR = 140 Age (TH) x Weight (KG) x 0.85 72 x Blood Creatinin = 10,6Based 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/min10. 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 ( pre- renal 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 intoxicationSCHEMEAcitesMen, 50 Y.OFatiqueNauseaDecrease of appetiteDecrease of Oncotic Pressure Enlargement of Abdominal OrgansIncrease of serum Creatinin and UreumAnemia, cause the decrease of eritropoitin productionExamination:WeaknessAnemic conjunctivalIncrease of BPLVHNo ronchiKidney Ballotement (+)Hb : 8 gr/dl Eri (+)Leuko (-)Albumin (++)Hypertension, Anemia, ProteinuriaAntihypertensionReconciliationHospital Exam:Increase of Creatinin and UreumNormal Glucose BloodUSG : Multiple CystGFR = 10,7CRD : Stage 5HemodialyseKidney TransplantationWomen, 40 Y.ODiarrhea and VomitingAKI1. Acute kidney injury in adults2. Acute kidney injury in children3. Chronic renal failure in adults4. Chronic renal failure in children5. Depression in kidney diseaseLearning objektifPathogenesisClassification pathogenesis of acute kidney injury (AKI) divided by the location of disturbance Pre renalRenal (instrinsik)Post renalPre renalThe 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:IschemicNefrotoxic RenalPost 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.Post renalLO 3Damage 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:pathologyThere are signs of kidney abnormalities, including abnormalities in blood or urine compositionimaging test abnormalities (imaging test)glomerular filtration rate (GFR)