scenario 5

Haloha teman2..maap banget kl telat ngepostnya.,maap bnget kl banyak kekurangan..semoga bermanfaat..:))

As the positive impact of development undertaken by the government within 60 years of independence, the pattern of disease in Indonesia has shifted quite convincing. Infectious diseases and malnutrition gradually fall, but admitted that the rate of infection is questionable with the emergence of new diseases. On the other hand chronic disease caused by degenerative diseases such as diabetes increased sharply the days that will come (Sudoyo, 2006).

Diabetes is a major threat to human health in the 21st century. According to a survey conducted WHO, Indonesia ranks fourth in the number of diabetics in the world's largest after India, China and the United States. With a prevalence of 8.6% of the total population, estimated in 1995 there were 4.5 million people with diabetes and in 2025 is estimated to increase to 12.4 million people. While the data from the MOH, the number of diabetes patients hospitalized or outpatient hospital ranks first of all endocrine diseases (www.republika.co.id, 2008).

glucose levels. If this situation lasts a long time can cause acute and chronic complications, one urinary tract infection. The number of patients affected by urinary tract infection (UTI) are very much in the world, especially in older women because the urethra channel (the channel from the bladder) short. Thus, the germs are easily entered kesaluran urine can even come from the vagina (http://www.prodia.co.id/info_terkini/eduk asi/2007). Direct contact of the first symptom of high blood sugar levels, if your blood sugar up above 160-180 mg / dl, then it will be up kekandung urinary glucose so that the kidneys will get rid Diabetes mellitus is a heterogeneous group of disorders characterized by increased blood of extra water to dilute the amount of glucose is lost (http://medicastore.com / med / detail, 2008).

Nb:nah ada beberapa diagnosis yang berkaitan dengan faktor penyebabnya diabetes..

-Pyelonephritis acute
Definition: Infection of the kidney.
• Overview:
· More common in women than in men.
· Infection of the kidney can occur due to organisms spreading to the kidney from the bladder (ascending infection) or from the bloodstream.
· Ascending infection is more common.
· E. Coli is the most common organism.
· Abnormalities of the heart valves can be the source of organisms being spread by the bloodstream.
• Types:
· Bacterial
· Fungal
• Symptoms:
· Typically the patient experiences flank pain (pain in the back just below the ribcage), fevers and often nausea and vomiting.
· The pain can be located in the upper right abdomen as well.
· Kidney infection may or may not be accompanied by symptoms of bladder infection (see acute cystitis) and on occasion the urine will have blood that is visible.
• Complications:
· If not treated completely and in a timely manner an abscess can form in the kidney or in rare cases the infection can get into the bloodstream and make one very ill requiring hospitalization.
· If pyelonephritis develops as a patient is passing a kidney stone, immediate intervention may be necessary to decompress the kidney and allow proper drainage of the kidney for infection to clear.
• Clinical Findings/signs:
· Pyelonephritis remains a clinical diagnosis. The findings on examination include flank or upper abdominal tenderness, fever and usually a positive urine analysis and culture for bacteria. Nausea and vomiting are often present. If the bladder is infected there may be tenderness of the lower abdomen overlying the bladder as well. Imaging with ultrasound, CT or other modality can be used when there is suspicion of a stone or other complicating factor. Patients can have a wide range of symptoms including septic physiology (critically low blood pressure and unstable vital signs) if the infection has spread to the bloodstream.
• Treatment:
· Lifestyle – there are no lifestyle modifications to decrease the chances of pyelonephritis unless one is prone to recurrent bladder infections.
· Medication – Antibiotics are generally used to treat the infection. The length of time the patient is on antibiotics depends upon the specific antibiotic and the clinical situation. Though most pyelonephritis episodes can be treated on an outpatient basis, admission to the hospital may be warranted for IV antibiotics.
· Surgery: Surgical intervention may be necessary if the pyelonephritis is complicated by renal abscess or a urinary stone. The type of surgery or intervention depends upon the clinical situation. Occasionally the intervention can be performed by the radiologist without going under an anesthetic.
• Prognosis: The prognosis for acute bacterial pyelonephritis is good assuming that there is no complicating factor such as abcess, sepsis or stone. In children, whose kidneys are still developing, bacterial pyelonephritis can cause scarring of the kidney tissue and, if recurrent, can lead to overall decreased kidney function later in life.

-sindrom nefrotik
Nephrotic syndrome is a clinical picture of glomerular disease characterized by massive proteinuria> 3.5 gram/24 hours / 1.73 m ² with hypoalbuminemia, edema anasarka, hyperlipidemia, lipiduria, and hiperkoaguabilitas. Nephrotic syndrome can be caused by glomerulonephritis (GN) due to primary and secondary infection, malignancy, drugs or toxins, connective tissue disease, systemic disease. Abnormalities histopathological lesions in the SN SN includes a minimum of (MCNS), focal segmental glomerulosclerosis (FSGS), mesangial proliferative glomerulonephritis (MPGN), Membranoproliferative glomerulonephritis (MPGN), membranous glomerulopati (GM). Management of nephrotic syndrome consists of specific and non specific treatment. Specific treatment is aimed at the underlying disease, while non spseifik treatment aimed at reducing proteinuria, edema, and treat complications. In patients with nephrotic syndrome accompanied by diabetes, the use of   corticosteroids administered with caution because it can increase blood sugar levels. It has been reported the case of a man aged 59 years with swelling in both legs which when pressed will form a basin, and it takes time to get back to normal. Painful urination and Anyang-anyangan. Patient had a history of hypertension and diabetes mellitus. blood pressure 155/90 mmHg Conjunctiva anemis epigastric tenderness and suprapubic region on both the inferior extremity edema with pitting edema. decrease in hemoglobin levels (9.8 mg / dl), erythrocyte (3.59 million / mL), and hematocrit (27.5%). Blood chemistry examination results when blood glucose increased (GDS 557 g / dl), decreased total protein (4.5), albumin (2.06), and globulin (2.43). Routine urine examination results proteinuria (+3). Routine stool examination found the worm eggs. Abdominal ultrasound examination within normal limits. patients diagnosed as nephrotic syndrome with diabetes mellitus and UTI. Patients were given diuretic therapy, ACE inhibitors, and sliding scale insulin.
Keywords: Management; nephrotic syndrome; Diabetes mellitus

Therapy
Do restrictions on fluid intake with intravenous administration flabot/24 RL 1 hour and urinary catheters. To reduce edema, furosemide administered once daily in the morning. To lower blood pressure and proteinuria control, given captopril 6.25 mg orally three times daily. To control hyperglycemia, given regular insulin sliding scale starting from 10 iu the sub cutaneous. Given pirantel pamoate 500mg once a day to cope with worm infestation. For urinary tract infections, ciprofloxacin 500 mg given twice daily.
Discussion
Nephrotic syndrome (SN) is a syndrome caused by various diseases that attack the kidneys and cause edema, proteinuria ≥ 3.5 g/24 hours / 1.73 m2 or more than 3 + proteinuria by dipstick (or the ratio of protein: creatinine more than 200 mg / mmol or> 2.0 mg / dL), decrease in blood levels of albumin <3.5 g / dl (hipoalbiminemia), and increased levels of fats in the blood of more than 220 mg / dL (hyperlipidemia), lipiduria, and hiperkoaguabilitas.
Nephrotic syndrome can be caused by glomerulonephritis (GN) of primary and secondary. Primary GN is the commonest cause histologic abnormalities consisting of minimal SN lesions (MCNS), focal segmental glomerulosclerosis (FSGS), mesangial proliferative glomerulonephritis (MPGN), Membranoproliferative glomerulonephritis (MPGN), membranous glomerulopati (GM). Secondary GN can be caused by infections (HIV, tuberculosis, leprosy, syphilis, malaria, skistosoma, hepatitis virus B and C), malignancy, connective tissue diseases (SLE, rheumatoid arthritis), drugs or toxins (NSAIDs, captopril, penisilinamin, heroin) , and the result of systemic disease (diabetes mellitus, amyloidosis, preeclampsia, vesicoureteric reflux, etc.).
Treatment of nephrotic syndrome (SN) consists of specific treatments aimed at the basis of disease and non-specific treatment to reduce proteinuria, edema control, and treat complications.
Diuretics with low-salt diet and bed rest may help control edema. In patients with oliguria experiencing overload, diuretics may induce diuresis and urine output to stabilize again. The most commonly used diuretics are loop diuretics, especially furosemide. Oral furosemide may be given and if the resistance can be combined with a thiazide, metazolon, and or asetazolamid. In SN, there can be resistant to furosemide. Some strategies to overcome the tubular resistance to furosemide in SN include increasing doses of furosemide, a combination of furosemide and albumin, or in combination with the diuretic furosemide acting on the distal tubule. The addition of 2-3 times the dose of furosemide may overcome the decrease in proximal tubule transport.
ISKDC recommend starting steroid therapy with prednisone 60 mg / m ² / day (or 2 mg / kg / day, maximum 80 mg / day) in divided doses for 4 weeks. Dose was lowered to 40 mg / m ² / day (or 1.5   mg / kg / day, maximum 60 mg / day) for 4 weeks. But the Arbeitsgemeinschaft fur Padiatrische Nephrologie recommend giving steroids to alternate-day system for 4 weeks is more effective than the way ISKDC. Failure to achieve remission after the administration of this therapy is called a state of steroid resistance.
Control can improve proteinuria and hypoalbuminemia reduces the risk of complications. Restriction of protein intake from 0.8 to 1.0 g / kg / day can reduce proteinuria. Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin II receptor antagonists can reduce blood pressure and a combination of both has an additive effect in reducing proteinuria. ACE inhibitors reduce proteinuria by reducing intraglomerular capillary pressure by dilating the efferent arterioles and affect glomerular permeability. Low dose of captopril or enalapril, and the dose increased after 2 weeks. Angiotensin converting enzyme inhibitors reduce glomerular protein ultrafiltration by lowering pressure and fixing intrakapiler glomerular size selective glomerular barrier effect of this drug antiproteinurik last long (about 2 months after the drug is stopped) Angiotensin receptor blocker (ARB) were also able to improve proteinuri for inhibiting inflammation and fibrosis interstisium, inhibiting the release of cytokines, growth factors, adhesion molecules due to the work of local angiotensin II in the kidney.
Alkilating drugs, cyclophosphamide and chlorambucil are used in the treatment of steroid-dependent SN and SRNS. Cyclophosphamide given remission longer than corticosteroids (75% for 2 years) at a dose of 2-3 mg / kg bw. / Day for 8 weeks. Side effects of cyclophosphamide is bone marrow depression, infections, alopecia, hemorrhagic cystitis and infertility when administered over 6 months. Chlorambucil given at a dose of 0.1 to 0.2 mg / kg / day for 8 weeks. Chlorambucil side effects were azoospermia and agranulocytosis. Because the cause of FSGS and MCNS-mediated immune process, cyclosporine is an appropriate therapy for SRNS. Cyclosporine causes immunosuppression especially T lymphocytes by inhibiting the production of interleukin-2 and other lymphokines. Cyclosporine A may also be used in combination with prednisolone in the case of SN in combination with other therapies fail. Drug side effects are gingival hyperplasia, hypertrichosis, hiperurisemi, hypertension and nefrotoksis.
Non-steroidal anti-inflammatory drugs (NSAIDs), such as indomethacin 3x50mg. NSAIDs can be used in patients with membranous nephropathy and focal segmental glomerulosclerosis to reduce prostaglandins. This leads to renal vasoconstriction, decreased glomerular capillary pressure, filtration surface area and reduces proteinuria to 75%. In addition NSAIDs may reduce fibrinogen levels, and prevents platelet aggregation. However, to be concerned that NSAIDs cause a progressive decline in renal function in some patients. This drug should not be given if the creatinine clearance <50 ml / min.
Can be used to overcome the obstacle hidroxymethyl hiperlipidemi glutaryl co-enzyme A (HMG Co-A) reductase is effective in lowering plasma cholesterol. Gemfibrozil, bezafibrat, klofibrat significantly lowered triglyceride levels and slightly lower cholesterol levels. Klofibrat can be toxic to normal levels due to increased levels of free klofibrat cause muscle damage and acute renal failure. Probukol lower total cholesterol and LDL cholesterol, but minimal effect on triglycerides. Nicotinic acid (niacin) can lower cholesterol and more effective when combined with gemfibrozil. Cholestyramine and kolestipol effectively lower total cholesterol and LDL cholesterol, but the drug is not recommended because of its effect on intestinal absorption of vitamin D in vitamin D deficiency is exacerbated in the SN.
SN increased risk of thromboembolism and should receive treatment. Although the provision of long term anticoagulation remains controversial but in one study proved beneficial. Fat-lowering drugs known as statins, like simvastatin, pravastatin, and lovastatin can lower LDL cholesterol, triglycerides, and increase HDL cholesterol.
In this case, patients suffering from nephrotic syndrome characterized by limb edema, hypoalbuminemia (<3.5 g / dl) and proteinuria (≥ 3.5 g / day). Risk factors that are owned by the patient and is likely to be the cause of the nephrotic syndrome is diabetes mellitus. The exact cause of nephrotic syndrome can be detected by doing a kidney biopsy. In these patients required restriction of fluid intake and restriction of protein intake for reducing proteinuria. Diuretic furosemide administered orally to reduce edema. Also given the ACE inhibitor captopril has the effect of lowering blood pressure and reduce proteinuria. In patients not given corticosteroid therapy. Corticosteroids increase the occurrence of gluconeogenesis, the formation of glucose from protein, so the risk of increasing blood sugar levels. In patients with diabetes mellitus, treatment with corticosteroids SN there is need for caution in the administration. To work around this, if you do have to take corticosteroids, the patient is expected to reduce consumption of sugar and carbohydrates. Will have an effect is not good, especially on the use of corticosteroids in the long term and high doses. In the patients were also given a sliding scale insulin for hyperglycemia.
Conclusion
Nephrotic syndrome is a clinical picture of glomerular disease characterized by massive proteinuria> 3.5 gram/24 hours / 1.73 m ² with hypoalbuminemia, edema anasarka, hyperlipidemia, lipiduria, and hiperkoaguabilitas. Nephrotic syndrome secondary to systemic disease may be caused by diabetes mellitus. Management of nephrotic syndrome consists of specific and non specific treatment which includes the control of edema (mainly with diuretics furosemide and bed rest), control of proteinuria (by administering an ACE inhibitor, restriction of protein intake), corticosteroids, alkilating drugs, NSAIDs, cyclosporine A, or therapies hyperlipidemia. In patients with diabetes mellitus, treatment with corticosteroids SN need for prudence in the administration because the risk of increasing blood sugar levels.

atau...

Exams and Tests

The doctor will perform a physical exam. Laboratory tests will be done to see how well the kidneys are working. They include:

• Albumin blood test
• Blood chemistry tests such as basic metabolic panel or comprehensive metabolic panel
• Blood urea nitrogen (BUN)
• Creatinine - blood test
• Creatinine clearance - urine test
• Urinalysis

Fats are often also present in the urine. Blood cholesterol and triglyceride levels may be high.
A kidney biopsy may be needed to find the cause of the disorder.
Tests to rule out various causes may include the following:

• Antinuclear antibody
• Cryoglobulins
• Complement levels
• Glucose tolerance test
• Hepatitis B and C antibodies
• HIV test
• Rheumatoid factor
• Serum protein electrophoresis (SPEP)
• Syphilis serology
• Urine protein electrophoresis (UPEP)

This disease may also change the results of the following tests:

• Vitamin D level
• Serum iron
• Urinary casts

Treatment

The goals of treatment are to relieve symptoms, prevent complications, and delay kidney damage. To control nephrotic syndrome, you must treat the disorder that is causing it. You may need treatment for life.
Treatments:

• Keep blood pressure at or below 130/80 mmHg to delay kidney damage. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are the medicines most often used. ACE inhibitors may also help decrease the amount of protein lost in the urine.
• You may take corticosteroids and other drugs that suppress or quiet the immune system.
• Treat high cholesterol to reduce the risk of heart and blood vessel problems. A low-fat, low-cholesterol diet is usually not very helpful for people with nephrotic syndrome. Medications to reduce cholesterol and triglycerides (usually statins) may be needed.
• A low-salt diet may help with swelling in the hands and legs. Water pills (diuretics) may also help with this problem.
• Low-protein diets may be helpful. Your health care provider may suggest eating a moderate-protein diet (1 gram of protein per kilogram of body weight per day).
• You may need vitamin D supplements if nephrotic syndrome is long-term and not responding to treatment.
• Blood thinners may be needed to treat or prevent blood clots.

Definition 

Nephrotic syndrome is a collection of symptoms which occur because the tiny blood vessels (the glomeruli) in the kidney become leaky. This allows protein (normally never passed out in the urine) to leave the body in large amounts. 

Description 

The glomeruli (a single one is called a glomerulus) are tiny tufts of capillaries (the smallest type of blood vessels). Glomeruli are located in the kidneys, where they allow a certain amount of water and waste products to leave the blood, ultimately to be passed out of the body in the form of urine. Normally, proteins are unable to pass through the glomerular filter. Nephrotic syndrome, however, occurs when this filter becomes defective, allowing large quantities of protein to leave the blood circulation, and pass out or the body in the urine.

Patients with nephrotic syndrome are from all age groups, although in children there is an increased risk of the disorder between the ages of 18 months and four years. In children, boys are more frequently affected; in adults, the ratio of men to women is closer to equal. 

Causes and symptoms 

Nephrotic syndrome can be caused by a number of different diseases. The common mechanism which seems to cause damage involves the immune system. For some reason, the immune system seems to become directed against the person's own kidney. The glomeruli become increasingly leaky as various substances from the immune system are deposited within the kidney.

A number of different kidney disorders are associated with nephrotic syndrome, including:

·         minimal change disease or MCD (responsible for about 80% of nephrotic syndrome in children, and about 20% in adults) MCD is a disorder of the glomeruli

·         focal glomerulosclerosis

·         membranous glomerulopathy

·         membranoproliferative glomerulonephropathy

Other types of diseases can also result in nephrotic syndrome. These include diabetes, sickle-cell anemia, amyloidosis, systemic lupus erythematosus, sarcoidosis, leukemia, lymphoma, cancer of the breast, colon, and stomach, reactions to drugs (including nonsteroidal anti-inflammatory drugs, lithium, and street heroine), allergic reactions (to insect stings, snake venom, and poison ivy), infections (malaria, various bacteria, hepatitis B, herpes zoster, and the virus which causes AIDS), and severe high blood pressure.

The first symptom of nephrotic syndrome is often foamy urine. As the syndrome progresses, swelling (edema) is noticed in the eyelids, hands, feet, knees, scrotum, and abdomen. The patient feels increasingly weak and fatigued. Appetite is greatly decreased. Over time, the loss of protein causes the muscles to become weak and small (called muscle wasting). The patient may note abdominal pain and difficulty breathing. Because the kidneys are involved in blood pressure regulation, abnormally low or abnormally high blood pressure may develop.

Over time, the protein loss occurring in nephrotic syndrome will result in a generally malnourished state. Hair and nails become brittle, and growth is stunted. Bone becomes weak, and the body begins to lose other important nutrients (sugar, potassium, calcium). Infection is a serious and frequent complication, as are disorders of blood clotting. Acute kidney failure may develop. 

Diagnosis 

Diagnosis is based first on the laboratory examination of the urine and the blood. While the urine will reveal significant quantities of protein, the blood will reveal abnormally low amounts of circulating proteins. Blood tests will also reveal a high level of cholesterol. In order to diagnose one of the kidney disorders which cause nephrotic syndrome, a small sample of the kidney (biopsy) will need to be removed for examination. This biopsy can be done with a long, very thin needle which is inserted through the skin under the ribs. 

Treatment 

Treatment depends on the underlying disorder which has caused nephrotic syndrome. Medications which dampen down the immune system are a mainstay of treatment. The first choice is usually a steroid drug (such as prednisone). Some conditions may require even more potent medications, such as cyclophosphamide or cyclosporine. Treating the underlying conditions (lymphoma, cancers, heroine use, infections) which have led to nephrotic syndrome will often improve the symptoms of nephrotic syndrome as well. Some patients will require the use of specific medications to control high blood pressure. Occasionally, the quantity of fluid a patient is allowed to drink is restricted. Some patients benefit from the use of diuretics (which allow the kidney to produce more urine) to decrease swelling. 

Key terms 

Glomeruli — Tiny tufts of capillaries which carry blood within the kidneys. The blood is filtered by the glomeruli. The blood then continues through the circulatory system, but a certain amount of fluid and specific waste products are filtered out of the blood, to be removed from the body in the form of urine.

Immune system — The complex system within the body which serves to fight off harmful invaders, such as bacteria, viruses, fungi.

Kidney failure — The inability of the kidney to excrete toxic substances from the body. 

Prognosis 

Prognosis depends on the underlying disorder. Minimal change disease has the best prognosis of all the kidney disorders, with 90% of all patients responding to treatment. Other types of kidney diseases have less favorable outcomes, with high rates of progression to kidney failure. When nephrotic syndrome is caused by another, treatable disorder (infection, allergic or drug reaction), the prognosis is very good.

References

Appel GB. Glomerular disorders and nephrotic syndromes. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 122.
Nachman PH, Jennette JC, Falk RJ. Primary glomerular disease. In: Brenner BM, ed. Brenner and Rector's the Kidney. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 30.
 
Agraharkar, Mahendra., 2006. Nephrotic syndrome.   http://www.emedicine.com/linkus.htm
Gunawan CA., 2006, Pathogenesis and Treatment of nephrotic syndrome. Mirror of the World of Medicine: 150: 50-54.
Sukandar, E., 2001, nephrotic syndrome, in Textbook of Medicine II, FK UI Hall Publishers, London.
Author
Dian M. Izzati. Panembahan Senopati Bantul District Hospital.