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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.

PERBANDINGAN EFEKTIFITAS ASAM FOLAT DOSIS STANDAR DENGAN DOSIS TINGGI TERHADAP HIPERHOMOSISTEINEMIA PADA GAGAL GINJAL DENGAN HEMODIALISIS REGULER Darmaja, I Made Gede; Suwitra, Ketut
journal of internal medicine Vol. 7, No. 2 Mei 2006
Publisher : journal of internal medicine

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Prevalence of hyperhomocysteinemia(HHcy) in regularly hemodialysis chronic kidney disease (RHDCKD) is high.HHcy in RHD CKD related to atherosclerosis an increase risk of cardiovascular disease. Increasing 5 ?mol/L of Hcy level from10?mol/L correlate with increasing 60% cardiovascular risk in male and 80% in female and also increasing 50% risk of strokeboth in male and female. Folic acid, vitamin B 12 and vitamin B 6 is needed to decrease Hcy level according homocysteine trialystlowering collaboration (HTLC), folic acid may decrease the Hcy level by 25%, vitamin B 12 7% but no significance effect ofvitamin B 6. Standard dose of folic acid 2-5 mg/day may normalized HHcy in predialysis CKD but most of RHDCKD fail toreach normal level. Treatment result of RHDCKD before is varied and inconsistent. This study was randomized double blindcontrolled clinical trial aimed to know whether higher dose of folic acid decreased Hcy greater than standard dose, that using 15mg/day compare to 5 mg/day of folic acid treatment for 4 weeks RHDCKD with hyperhomocysteinemia. Thirty patients wererecruited base on exclusion and inclusion criteria and two weeks standardization using 1 mg/day folic acid was performed.Complete blood count, lipid profile, blood sugar, albumin and globulin, BUN, creatinine serum, SGPT/SGOT and Hcy wereexamined in the beginning of the study and after 4 weeks. Permuted block randomization was done among participant in order togrouping them into 15 mg/day and 5 mg/day folic acid group. Compare means of decreased Hcy in each group as primaryoutcome was analyzed using student t test, 95% confidence interval (CI) , p<0,05. During study, 15 patients were treated with 15mg/day folic acid and 13 patients with 5 mg/day folic acid. Increased of Hcy was 1,00±4,11 ?Mol/L among 15 mg/day folic acidgroup (20,67 ±6,69 ?Mol/L increased to 21,68±4,59 ?Mol/L ) and 1,93±3,40 ?Mol/L (18,77±5,38 increased to21,00±5,24?Mol/L) among 5 mg /day folic acid group, CI 95% -2,03 to 3,88, p = 0,53. ANCOVA analyzed of other variableseffect such as BMI, blood sugar, age and sex on Hcy level was not found. We conclude that 15 mg/day comparing to 5 mg/dayfolic acid is not more effective in decreasing Hcy level of regularly hemodialysed patient with hyperhomocysteinemia.

PENGARUH VITAMIN C TERHADAP KADAR SERUM FERITIN PADA PASIEN GAGAL GINJAL KRONIK DENGAN HEMODILISIS REGULER Wiryani, Cilik; Suwitra, Ketut
journal of internal medicine Vol. 11, No. 2 Mei 2010
Publisher : journal of internal medicine

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Hyperferitinemia in chronic kidney disease patients with regular hemodyalisis may caused by repeated transfusion,excessive iron supplementations, and also inß ammation. Increasing of serum feritin level doesn!t depend on iron reservecapacity. Hemodialysis patients with no supplementations may lead to several antioxidant components deÞ ciency. Qualitative andquantitative of vitamin C deÞ ciency may also occur, thus administration 1 " 1.5 gram/week or 300 mg of vitamin C parenterallyevery dialysis session was recommended in order to compensate subclinical deÞ ciency.This study determine whether administration of vitamin C (500 mg, in NaCl 0.9%, every session of hemodialysis in 8weeks) can decrease serum feritin level in chronic kidney disease patients with regular hemodialysis. Randomized clinical trial,single-blind of 38 chronic kidney disease patients with regular hemodialysis was recruited based on inclusion and exclusioncriteria. Randomization in group with treatment was done with permuted block randomization. Mean of serum feritin before andafter treatment in every group was compared and analysed with Man-Whitney U test. SigniÞ cancy level () was with p less than0.05 (p < 0.05).The result of median and mean for decreasing of serum feritin in group with treatment of 500 mg, vitamin C is 0.00(-227.00 " 218.00) and 77.85 ± 383.25, respectively. While the result of median and mean for decreasing of serum feritincontrol group is 32.00 (-14.00 " 108.00) and 65.85 ± 209.6, respectively. On the analysis indicates median of serum feritinin group with treatment of vitamin C had less 32 points depends with control group (p = 0.84), Thus, there was no signiÞ cantdifference (p > 0.05) between two groups. From Anova analysis for gender, there was signiÞ cant effect in decreasing of serumferitin level (p < 0.05).There was no decreasing of serum feritin level after administration of 500 mg, vitamin C in chronic kidney diseasepatients with regular hemodialysis, and sex had signiÞ cant effect in alteration of serum feritin level.

HUBUNGAN PENYAKIT GINJAL KRONIS PREDIALISIS DENGAN BEBERAPA PARAMETER PENYAKIT ATEROSKLEROSIS ARTERI KAROTIS Sutarka, Nyoma; Suwitra, Ketut; Loekman, Jodi S; Sudhana, Wayan; Kandarini, Yenny; Martadiani, Elysanti Dwi; Margian, Nyoman
journal of internal medicine Vol. 11, No. 3 September 2010
Publisher : journal of internal medicine

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Carotid artery intima media thickness (cIMT) is valid marker of subclinical atherosclerosis because it gives sign of earlyatherosclerosis process. We conduct this study to know the relationship between predialysis chronic kidney disease (CKD) withseveral parameters of carotid arterial atherosclerosis.A cross sectional study was done in patients with predialysis CKD who came to outpatient Clinic of Nephrology inSanglah General Hospital from May 2009. CKD criteria is based on KDQQI 2003. Estimated Glomerular Filtration Rate (eGFR)was calculated with Cockroft-Gault formula. Measurement of cIMT is done by USG B-Mode with USG Logig-5.There were 30 patients (20 with eGFR < 60 ml/mnt and 10 with eGFR 60 ml/mnt). Mean of cIMT in eGFR < 60ml/mnt: right/left cIMT1 0.24445 ± 0.3096/0.3210 ± 0.4006 mm; IMT2 0.2405 ± 0.3138/0.2825 ± 0.3971 mm; IMT3 0.2315 ±0.3026/0.2820 ± 0.3672 mm; bifurkatio IMT 0.3115 ± 0.4069/0.3515 ± 0.4991 mm; total IMT 0.6350 ± 0.1738/0.6938 ± 0.1912mm. For eGFR > 60 ml/mnt: right/left IMT1 0.1120 ± 0.1722/0.1030 ± 0.1398 mm; IMT2 0.0880 ± 0.1103/0.1130 ± 0.1718mm; IMT3 0.1010 ± 0.1408/0.1170 ± 0.1700 mm; bifurcatio IMT 0.1920 ± 0.3545/0.1980 ± 0.3527 mm, total IMT 0.6250 ±0.1269/0.6750 ± 0.1124 mm. There was signiÞ cant difference in eGFR < 60 ml/mnt the left IMT1 (MD: 0.21 CI95% 0.01 ! 0.42;p = 0.038). Five out of 20 patients with eGFR < 60 ml/mnt and 6 among 10 patients of eGFR 60 ml/mnt were found plaques.There are no signiÞ cant difference of plaque location, plaque width, and lumen diameter between carotid arterial with andwithout plaque. As a conclusion we found there is no signiÞ cant difference between predialysis CKD with several parameters ofcarotid arterial atherosclerosis but cIMT tends to be thicker on predialysis CKD patients with eGFR < 60 ml/mnt.

CHARACTERISTICS OF PILI HEMAGLUTININ PROTEIN AND ITS ROLE IN THE PATHOGENESIS OF URINARY TRACT INFECTION WITH UROPATHOGENIC ESCHERICHIA COLI Sudhana, I Wayan; Suwitra, Ketut; -, Sumarno
INDONESIAN JOURNAL OF BIOMEDICAL SCIENCES Vol. 3, No. 2 Juli 2009
Publisher : Udayana University

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Urinary tract infection (UTI) is one of the most common infectious diseasesencountered in the community. The bacteria most frequently implicated as the causes ofUTI are the Gram-negative bacteria, especially Escherechia coli. Early phase of thepathogenesis of the infection constitutes adhesion of bacteria onto the epithelial cells ofurinary tract. SDS-PAGE examination was carried out to investigate molecule ofhemagglutinin protein and hemagglutination (HA) test continued by adhesion andinhibited adhesion tests.The observation of molecular weight of pili E. coli protein molecule byexplorative examination using SDS-PAGE showed on E. coli strip that the mostprominent molecular weights (MW) of the proteins were 61 kDa, 37 kDa, 30 kDa, and 20kDa. Purification by electro-elusion was done to proteins of the MW of 20 kDa, 37 kDaand 61 kDa. The HA test results indicated the 61 kDa, 37 kDa, and 20 kDa werehemagglutinin proteins and one which subsequently applied as sub unit proteins ofUropathogenic E. coli (UPEC) was the 37 kDa. Adhesion test of UPEC bacteria carriedout on urinary bladder epithelial cells of rabbit showed a significant correlation betweenadhesion index and various doses of subunit proteins of UPEC 37 kDa as coat of urinarybladder epithelial cells. Spearman rank correlation test and regression/non regressionanalysis confirmed an exponential decrease of UPEC adhesion to urinary tract epithelialcells as a response to the increasing doses of coating protein. This finding points out thatpili hemagglutinin protein subunit of UPEC 37 kDa was an adhesive molecule. Pilihemagglutinin protein subunit of UPEC 37 kDa is an adhesive molecule, which plays arole in adherence of UPEC to epithelial cells of urinary bladder at the early pathogenesisof urinary tract infection.

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