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SEORANG PENDERITA SINDROM NEFRITIK AKUT PASCA INFEKSI STREPTOKOKUS Renny A Rena, Ni Made; Suwitra, Ketut
journal of internal medicine Vol. 10, No. 3 September 2009
Publisher : journal of internal medicine

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Acute nephritic syndrome is classically de! ned by symptoms of oliguria, oedem, hypertension and also urinalysisabnormality such as proteinuria less than 2 grams/day, hematuria, or ! nding of erytrocite silinder in the urine. The etiology ofacute nephritic syndrome are disorders of primary glomerulopathy (idiopathic), glomerulopathy after infection, DisseminatedLupus Erythomatosus (DLE), vasculitis and hereditary nephritis (Alport syndrome). Acute nephritic syndrome is one of clinicalmanifestation of acute glomerulonephritis after streptococcal infection, which is in" lamation occur on tubulus and glomerularof the kidney, after streptococcal infection of skin or upper respratory tract. The most frequent cause by particular strain ofhemolyticus streptococcus ß group A type 12. Herewith, we reported a case of acute glomerulonephritis after streptococcalinfection with clinical manifestation acute neph! tic syndrome. A fourteen years old Balinese male patient found with anasarcaoedem, oliguria and hematuria. Previous medical history with infection of throat 2 weeks before admitted to hospital. On physicalexamination, we found with Stage II hypertension, laboratory data shown urinalysis: hematuria and proteinuria, protein esbach3.25 gram/liter/day, ASTO 200 IU/ml, ANA test negative and throat swab isolated Streptococcus viridans, alpha hemoliticus.Imaging data showed right pleural effusion and bilateral nephritis of the kidney. Patient gives a good respon to corticosteroid(metilprednisolone), diuretic and also ACE inhibitor

PENGARUH VITAMIN C TERHADAP C-REACTIVE PROTEIN SEBAGAI PETANDA INFLAMASI PADA GAGAL GINJAL KRONIK DENGAN HEMODIALISIS REGULER Wulandari, Diah Catur; Suwitra, Ketut
journal of internal medicine Vol. 9, No. 3 September 2008
Publisher : journal of internal medicine

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One of possible treatment to diminish the inflammation in regularly hemodialysis chronic kidney disease (RHCKD) isantioxidant. Ascorbic acid can inhibit nuclear factor B (NF-B) activation, decrease C-reactive protein (CRP) levels. The objectiveis to determine whether ascorbic acid 1000 mg intravenously can decrease CRP levels in RHCKD. In this randomized singleblind controlled clinical trial, thirty two patients were recruited. CRP was examined at baseline and 4 weeks. Permutted blockrandomization was done to receive vitamin C 1000 mg or NaCL 0.9%. CRP levels were compared between the two groups asprimary outcome. During study 16 patients were received i.v. ascorbic acid 1000 mg and 16 patients were received NaCl 0.9%.One of patient in vitamin C 1000 mg group was dropped out due to infection. During follow-up, both groups showed increased ofCRP among ascorbic acid 1000 mg groups (from 1.77 ± 1.41 mg/L before to 1.83 ± 1.78 mg/L after study; increase by 0.06 ± 1.38mg/L; 95% CI -0.20 ? 0.28 P = 0.72) and among NaCl 0.9% group (from 2.83 ± 2.86 mg/L before to 2.98 ± 3.29 mg/L afterstudy increase by 0.15 ± 1.38 mg/L 95% CI -0.14 ? 0.11 P = 0.82 ). Although CRP levels were increased, no statistically differentof CRP increament in both groups. The conclusion of this study is ascorbic acid 1000 mg during 4 weeks can not decrease CRPlevels in RHCKD.

HUBUNGAN ANTARA PRODUK KALSIUM X FOSFAT SERUM DENGAN PENYAKIT ARTERI PERIFER PADA PASIEN HEMODIALISIS REGULER DI RSUP SANGLAH DENPASAR Wulandari, Dewi Catur; Raka Widiana, I G; SL, Jodi; Sudhana, I W; Suwitra, Ketut
journal of internal medicine Vol. 8, No. 2 Mei 2007
Publisher : journal of internal medicine

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Peripheral Arterial Occlusive Disease (PAOD) is common among patients undergoing hemodialysis (HD). In the generalpopulation, DM, male, cigarette smoking, advanced age, hypertension and dyslipidemia are the most important risk factorsfor PAOD. Recently, some studies in patients with regular HD found evidences that PAOD associated with increase of calciumand phosphate serum level and increase of Ca.P product due to secondary hyperparatiroidism. A cross-sectional study was doneon 46 regular HD patients to evaluate prevalence of PAOD among patients who are undergoing regular HD and their associationbetween Ca.P product. Morning fasting plasma were taken for lipid profile, blood sugar, blood urea nitrogen, serum creatinin,albumin level, Ca, inorganic P. Ankle-brachial index (ABI) of blood pressure as measured after dialysis session using Va-SeraVS-100. Fourty six (26 males, 20 females) regular HD patients, age 50.95 ± 9.90 years, duration of HD 27.7 ± 22 months wereincluded in this study. Using ABI < 0.9 as cut off value for the presence of PAOD, 15.2% had PAOD. Means of Ca serum levelwas 9.04 ± 0.76 mg/dl, phosphate serum level was 56.48 ± 23.90 mg/dl. Using 55 or more as cut off value for abnormal concentrationof Ca.P product, 47.7% patients had abnormal Ca.P product. Three of 21 patients with Ca.P 55 had PAOD and 4 of 23patients with Ca.P < 55 had PAOD ( OR 0.79 with 95% CI : 0.15 ? 4.04 for patients with Ca.P < 55 ). Using logistic regression tocontrol Ca and P levels, Ca.P 55 tend to associate with increased risk of PAOD (OR 6.22 ; 95% CI : 0.23 ? 167.71)More than fifteen percent of patients with regular HD had PAOD. More than fourty seven percent of patients had abnormal Ca.P.Patients with Ca.P 55 tend to associated with increased risk of PAOD (OR 6.22 ; 95% CI : 0.23 ? 167.71)

PERAN HIPOKSIA PADA PATOGENESIS PENYAKIT GINJAL Sastrawan, I Gede Pande; Suwitra, Ketut
journal of internal medicine Vol. 9, No. 1 Januari 2008
Publisher : journal of internal medicine

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Chronic kidney disease is a current major worldwide health problem with an increasing prevalency.Kidney is a sensitive organ with hypoxic condition relate to its high tubular epithelial cells and vascular oxygenconsumption. Chronic peritubular ischemia may occur through several interrelating mechanisms. The activationof local renin-angiotensin system, angiotensin II, could induce hypoxia by means of hemodinamic and nonhemodinamicmechanisms.Anemia in renal disease could accelerate the decline of renal function through the induction oftubulointerstitial hypoxia. Non Steroidal Anti Inflamatory Drugs (NSAID) could evoke renal medullar hypoxiaby its regional hypoperfusion mechanism and the escalation of tubular transport. The Outer region of renalmedulla and tubulus are main target of hypoxic renal damage. The mechanism of hypoxia induced AcuteKidney Disease involves renal vascular and tubulus through the reduction of blood flow and the increasing oftubular oxygen demands. The Patofisiology of hypoxia induced chronic kidney disease occurs bytubulointerstitial damage which induce fibrogenesis, causing interference of peritubular blood flow and oxygenconsumption.

HUBUNGAN ANTARA KADAR LEPTIN DAN ADIPONEKTIN PLASMA PADA PASIEN DENGAN DIALISIS RUTIN Raka Widiana, I Gde; Kandarini, Yenny; Suwitra, Ketut
journal of internal medicine Vol. 9, No. 2 Mei 2008
Publisher : journal of internal medicine

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Leptin and adiponectin (ADPN) are adipokines with respective pro-atherogenic and anti atherogenic properties. In nonrenalpatients, both hyperleptinemia and hypoadiponectinemia are associated with cardiovascular complication. Relationshipsbetween serum leptin and ADPN in patients with dialysis is not consistently reported.Objective of this study is evaluate relationships between serum ADPN and leptin in patients with dialysis. A cross sectionalstudy was performed in and 54 HD and 22 CAPD patients.Seventy six patients were enrolled this study, M/F 41/76, aged 48.4±11.4 year, BMI 21.4±2.7 kg/m2, haemoglobin (Hb)7.9±1.5 mg/dL, blood sugar 94.8±33.5 mg/dL, albumin 4.1±0.4 g/dL, total-cholesterol 177.9±46.3 mg/dL, triglyserida 164.4±104.8mg/dL, SC 14.3±3.8 mg/dL, TNF 14.40±7.43 pg/mL, ADPN 17.6±7.6 µg/mL, leptin 13068±23589 µg/mL (log leptin 3.7±0.59µg/ml). Using Spearmans rho analysis there were negative correlation between log-leptin and ADPN (r= -0.39, p= 0.00), andpositive correlation between log leptin and Hb (r= 0.25, p= 0.04), insulin(r= 0.44, p = 0.00), total-cholesterol (r= 0.34, p = 0.003),triglyserida (r= 0.41, p= 0.00), and BMI (r= 0.41, p= 0.00), but there was no correlation between log-leptin and albumin, bloodsugar, SC and TNF alfa. Using multiple regression to analyze relationship between ADPN and leptin, insulin, Hb, and dialysismodality, we found log leptin independently correlated with ADPN (B= -0.402, p= 0.01, 95%CI B: -1.24 to -0.32). Using multipleregression to analized relationship between ADPN with log-leptin, BMI, total cholesterol, and triglyserida, we found log leptin(beta= -0.3, p= 0.01, 95%CI B: -0.98 to -0.13) and triglyserida independently correlated with ADPN (beta= -0.5, p= 0.00, 95%CIB: -0.008 to -0.003).Serum leptin and triglyseride relate with ADPN. Some metabolic parameters such as insulin resistance, anemia, dialysismodality, nutritional status (BMI and total cholesterol) have indirect relationship with ADPN may be through leptin secretion.

KADAR ADIPONEKTIN PLASMA PADA PASIEN YANG MENJALANI HEMODIALISIS DI RUMAH SAKIT SANGLAH DENPASAR Sanjaya, Surya; Suwitra, Ketut
journal of internal medicine Vol. 11, No. 1 Januari 2010
Publisher : journal of internal medicine

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Adiponectin, a cytokine with anti-inß ammatory properties that is secreted from adipose tissue. Adiponectin has beenshown to be a predictor of cardiovascular events in the general population and patients who undergoing hemodialysis. The aimof this study is to evaluate serum adiponectin in patient undergoing regular hemodialysis.A cross sectional study involved 53 reguler hemodialysis patient at Sanglah hospital. Inclusion criteria was patientundergoing regular hemodialysis more than three month and twice a week. We exclude severe infections, abnormality of liverfunctions test, malignancies and diabetes mellitus.The mean of age and abdominal circumference was 48.01 ± 12.3 years old and 79.5 ± 9.99 cm. Systolic and diastolicblood pressure pre hemodyalisis was 140 ± 20.7 mmHg and 83.3 ± 10.7 mmHg. Systolic and diastolic blood pressure posthemodialysis was 148.6 ± 23.6 mmHg and 85.6 ± 11.5 mmHg, respectively. We found serum level of calcium 9.5 ± .97 mmol/l,inorganic phospat 6.4 ± 2.1 mmol/l, BUN 84.8 ± 19.9 mg/dl, serum creatinin 16.1 ± 3.9 mg/dl, hemoglobine levels 7.7 ± 1.4 g/dland blood glucose levels 92.9 ± 1.4 mg/dl. Serum levels of adiponectin was 15.4 ± 5.98 mg/l compare with normal levels 5.52mg/l. Levels of serum adiponectin in regular hemodialysis patients is three fold higher than normal population.

PATOFISIOLOGI DAN PENATALAKSANAAN NEFROPATI RADIOKONTRAS Sanjaya, Surya; Suwitra, Ketut
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Contrast induced nephropaty (CIN) was recognized as one of the leading causes of acute renal failure in patient withrenal insufficiency, diabetes mellitus, volume depletion and low cardiac out put. The incidence of CIN is estimated to be 1 Ð 2%in the general population, but the relative risk is greatly increased in diabetics, the elderly, and those with intrinsic renal disease,congestive heart failure, and dehydration. CIN is defined by an increase in creatinine 0.5 mg/dL or 25% from baseline that occurs2 Ð 3 days after contrast administration. A reduction in renal perfusion caused by a direct effect ofcontrastmedia on the kidneyand toxic effects on the tubularcells are generally accepted as the main factors in the pathophysiologyof contrastmedium inducednephropathy. Pathological changes induced by contrastmedium are epithelialcell vacuolization, interstitial inflammation andcellular necrosissuggest a direct toxic effect of contrastmedia on renal tubularepithelial cells. Several measures have beenrecommended to prevent contrastinduced nephropathy,which include: volume expansion, hydrationwith intravenous administrationof normal saline, infusion of mannitol, theophylline, dopamine,acetylcysteine, use of iso-osmolar non-ionic contrastmediainsteadof low-osmolarnon-ionic or high-osmolar ionic contrast,haemofiltration rapidly after contrast administration, injectionofsmall volume of contrast medium, gadolinium based contrastmedia

KEJADIAN PERITONITIS PADA PASIEN CONTINUOUS AMBULATORY PERITONEAL DIALYSIS: IDENTIFIKASI MIKROORGANISME DAN SENSITIFITAS ANTIBIOTIK Haryanti, Elizabeth; Kandarini, Yenny; Widiana, I Gde Raka; Sudhana, Wayan; Loekman, Jod; Suwitra, Ketut
journal of internal medicine Vol. 11, No. 2 Mei 2010
Publisher : journal of internal medicine

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Patients treated with Continuous Ambulatory Peritoneal Dialysis (CAPD) are constantly exposed to microbial invasionof the peritoneal cavity and rapid microbiological diagnosis of peritonitis is essential due to Hospitalization and imposes asignicant burden of morbidity. The aims of this study were to enumerate the association between microorganisms, sensitity,and resistence of antibiotic on CAPD patients with clinical peritonitis.We collected data through medical records by the number of CAPD patients with clinical peritonitis from June 2004 untilJune 2009. The study was analysis with one-way ANOVA. We found 23 patients clinical peritonitis out of 77 CAPD patients,with insidence was 14% per-year, aged 14 ? 65 y (15M; 8F). The chronic pyelonephritic was a leading (16/23) cause of endstages renal disease. Each patients underwent HD prior (5 ? 60 months) to CAPD, with survival time was 2 ? 51 months. Out of23 patients, 4 were returned to hemodialisis, 15 were died, due to cardiogenic shock 46.7%. Aseptic peritonitis was 31.3%, andthe common microorganism was staphylococcus 18.8%. Peritoneal !uid test showed mean score of sensitivity were tetracycline22.93, cipro!oxacin 19.36, piperacillin-tazobactam 17.36, thrimetropin/sulfamethoxazole 16.5, fosfomycin 15.78, consecutivelyand the rest were resistent. Staphylococus was strongly related to insidence peritonitis, and tetracycline was the most highlysensitive antibiotic in CAPD patients.

HUBUNGAN ANTARA PERUBAHAN VOLUME DARAH RELATIF DENGAN EPISODE HIPOTENSI INTRADIALITIK SELAMA HEMODIALISIS PADA GAGAL GINJAL KRONIK Agustriadi, Ommy; Suwitra, Ketut; Raka Widiana, Gde; Sudhana, Wayan; Sidharta Loekman, Jodi; Kandarini, Yenny
journal of internal medicine Vol. 10, No. 2 Mei 2009
Publisher : journal of internal medicine

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Intradialytic hypotension (IDH) is a common complication in chronic hemodialysis (HD) patients, in turn would increase morbidity and mortality. Relative blood volume changes during HD play a role in IDH episode. Those changes can be assessed by total plasma protein measurement before and after HD. To determine relationship between relative blood volume changes (assessed by percentage of total plasma protein changes during HD) and IDH episode during HD in chronic renal failure, an analytical cross-sectional study was perferomed in 51 patients (28 males and 23 females, age 47.8 ±11.6 years) underwent chronic HD at Hemodialysis Unit of Sanglah Hospital Denpasar. Data were collected during single HD session. Blood pressure was measured every 30 minutes and relative blood volume changes assessed by measuring percentage of total plasma protein changes during HD. Among them, IDH episode experienced in 10 (19.6%) patients. Logistic regression analysis revealed a strong and significant relationship between relative blood volume changes and IDH episode during HD in chronic renal failure (Beta = 0.29; OR = 1.35; CI 95%: 1.1 - 1.6; p < 0.01) and it was found that every 1% changes in relative blood volume, would increase risk of hypotension episode by 35%. This relationship was still strong and significant (Beta = 0.46; OR = 1.58; CI 95%: 1.11 -2.25; p = 0.01) after adjusted by hemoglobin levels, intradialytic body weight changes, use of antihypertensive medi¬cations and diabetes melitus. Using ROC curve, found that optimal cut of point of intradialytic total plasma protein changes to predict an IDH episode during HD was 5.56% with 90.0% sensitivity and 80.5% specificity (95% CI: 0.83-0.99; p < 0.01). Our data revealed a strong and significant relationship between intradialytic relative blood volume changes assessed by intradialytic total plasma protein changes and IDH episode during HD in chronic renal failure.

PREVALENSI, KARAKTERISTIK DAN FAKTOR-FAKTOR YANG TERKAIT DENGAN INFEKSI SALURAN KEMIH PADA PENDERITA DIABETES MELITUS YANG RAWAT INAP Ariwijaya, Made; Suwitra, Ketut
journal of internal medicine Vol. 8, No. 2 Mei 2007
Publisher : journal of internal medicine

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Diabetes Melitus (DM) is related with the increased risk of Urogenital Tract Infection (UTI). Prevalence and characteristicorganisms from urine suprapubic aspiration in DM patient who admitted to the hospital is rare. The aim of the study wasto now prevalence, characteristic and related factor with UTI in DM patient who admitted. We have done cross sectional analyticstudy in admitted DM patient more than 12 years old, less than 3 days admission. The patients who used antibiotic last 7 daybefore urine culture dan pregnancy were excluded. Urine specimen were taken via suprapubic aspiration. We had 100 respondenwith 53 men (53%), 47 women (47%), age 56 ± 11.9 yo., mean Body massa indeks (BMI) 23.99±2.56 Bw/ m2.SBP 130.7 ± 28.5mmHg. DBP 80 ± 14.65 mmHg. WBC 14.5 ± 11.9 K/ml . Hb 12.5± 3.1 mg/dl. BUN 32.2± 33 mg/dl. SC 2.2± 3.3 mg/dl. HbA1C13.8 ± 6.4 g%. Cholesterol 173.7 ± 61.6 mg/dl. HDL-cholesterol 39.06 ± 28.0 mg/dl. LDL-cholesterol 115.0 ± 55 mg/dl.trigliserida 138.8 ± 71.5 mg/dl, Fasting BS 196.6 ± 94 mg/dl, after meal BS 243.2 ± 110 mg/dl. We found 36 patient UTI (36%)with upper UTI 9 (25%). Lower UTI 27 (75%). Asymptomatic bacteriuria 25 (69.4%). Symptomatic bacteriuria 11 (30.6%).About 2.8% of recurrent UTI. Prevalence of UTI in patients less than 50 yo. were more than patient above 50 yo. UTI in womenwere higher than men. We found E. coli 30.5%, S. epidermidis 27.7% S. aureus 11.1%, E. zakazakii, and S. marcescens, C.albican respectly 5.5%, S. coagulase, S. liquyacians, E. cloaceae, E. hapniae, C. violaleum respectly 2.7%. as cause UTI thisstudy. We found Sensitivity test with antibiotic, imipenem 23%, amoxicillin-clavulamic acid 20%, ceftazidin 19%, gentamisin19%, cefoxitin 17%, piperacillin/ tazobactam 14%, sulphamethoxazol, ofloxasin, ceftriaxon 13% respectly, cefuroxime 12%,cifroploxasin 11%, ampicilin, linezolide 6% respectly. vancomisin 4%, cephazolin, cefoperazone-sulbactam 3% respectedly.meticilin, cefoperazone, erithromisin, amoxillin, oxacilin respectly 1%. We found E. coli 100% sensitive with imepenem,amoxicillin-clavulamic acid, piperasillin-tazobactam. 90.9% Sensitivity for ceftazidin, gentamycin. From six independen variabel(dyslipidemia, BMI catagori, hipertension, sex, age, blood sugar controled, stone in urinary tract, chronic renal disease, lungTB, pneumonia, cancer, user of chateterization) only BMI significant correlation (X2 = 13.8, p= 0.03 OR= 2.14) with prevalenceUTI in patient DM.

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