scenario 5

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.. Pielonefritis akutDefinisi: Infeksi pada ginjal. Ikhtisar: Lebih sering terjadi pada wanita dibandingkan pria. Infeksi pada ginjal dapat terjadi karena organisme menyebar ke ginjal dari kandung kemih (infeksi menaik) atau dari aliran darah. Infeksi Ascending lebih umum. E. Coli adalah organisme yang paling umum. Kelainan katup jantung bisa menjadi sumber organisme yang menyebar melalui aliran darah. Jenis: bakteri jamur Gejala: Biasanya pasien mengalami nyeri panggul (nyeri di bagian belakang tepat di bawah tulang rusuk), demam dan sering mual dan muntah. Rasa sakit dapat ditemukan di perut bagian kanan atas juga. Infeksi ginjal mungkin atau mungkin tidak disertai dengan gejala infeksi kandung kemih (sistitis melihat akut) dan pada kesempatan urin akan memiliki darah yang terlihat.

-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.
Komplikasi: Jika tidak ditangani sepenuhnya dan pada waktu yang tepat abses dapat terbentuk dalam ginjal atau dalam kasus yang jarang infeksi dapat masuk ke aliran darah dan membuat satu rumah sakit yang membutuhkan sangat sakit. Jika pielonefritis berkembang sebagai seorang pasien melewati batu ginjal, segera melakukan intervensi mungkin diperlukan untuk dekompresi ginjal dan memungkinkan drainase yang tepat dari ginjal untuk membersihkan infeksi.

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.
Temuan klinis / tanda: Pielonefritis tetap merupakan diagnosis klinis. Temuan pada pemeriksaan panggul atau atas termasuk nyeri demam, perut dan biasanya analisis urin positif dan budaya untuk bakteri. Mual dan muntah sering ditemukan. Jika kandung kemih terinfeksi mungkin ada kelembutan perut bagian bawah atasnya kandung kemih juga. Pencitraan dengan USG, CT atau modalitas lainnya dapat digunakan bila ada kecurigaan dari sebuah batu atau faktor rumit lainnya. Pasien dapat memiliki berbagai gejala termasuk septik fisiologi (kritis rendah tekanan darah dan tanda-tanda vital tidak stabil) jika infeksi telah menyebar ke aliran darah

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. Terapi: Gaya hidup - ada modifikasi gaya hidup tidak untuk mengurangi kemungkinan pielonefritis kecuali satu adalah rentan terhadap infeksi kandung kemih berulang. Treatment: Lifestyle there are no lifestyle modifications to decrease the chances of pyelonephritis unless one is prone to recurrent bladder infections. Obat - Antibiotik biasanya digunakan untuk mengobati infeksi. Lamanya waktu pasien pada antibiotik tergantung pada antibiotik tertentu dan situasi klinis. Meskipun episode pielonefritis paling dapat diobati secara rawat jalan, masuk ke rumah sakit dapat dibenarkan untuk antibiotik IV 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.
Pembedahan: Intervensi bedah mungkin diperlukan jika pielonefritis dipersulit oleh abses ginjal atau batu kemih. Jenis pembedahan atau intervensi tergantung pada situasi klinis. Kadang-kadang intervensi dapat dilakukan oleh ahli radiologi tanpa di bawah obat bius.

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: Prognosis untuk pielonefritis akut bakteri yang baik dengan asumsi bahwa tidak ada faktor rumit seperti abcess, sepsis atau batu. Pada anak-anak, ginjal yang masih berkembang, pielonefritis bakteri dapat menyebabkan jaringan parut dari jaringan ginjal dan, jika berulang, dapat menyebabkan fungsi ginjal secara keseluruhan menurun di kemudian hari.

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. Sindrom nefrotik adalah gambaran klinis penyakit
glomerulus ditandai dengan proteinuria masif> 3,5 gram/24 jam / 1,73 m 2 dengan hipoalbuminemia, edema anasarka, hiperlipidemia, lipiduria, dan hiperkoaguabilitas. Nephrotic syndrome can be caused

by glomerulonephritis (GN) due to primary and secondary infection, malignancy, drugs or toxins, connective tissue disease, systemic disease. Sindrom nefrotik dapat disebabkan oleh
glomerulonefritis (GN) karena infeksi primer dan sekunder, keganasan, obat-obatan atau racun,

penyakit jaringan ikat, penyakit sistemik. 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

terapi Apakah pembatasan asupan cairan intravena dengan flabot/24 jam administrasi RL 1 dan kateter kemih. Untuk mengurangi edema, furosemid diberikan sekali sehari di pagi hari. Untuk menurunkan tekanan darah dan kontrol proteinuria, diberikan captopril 6,25 mg oral tiga kali sehari. Untuk mengontrol hiperglikemia, mengingat insulin reguler geser skala mulai dari 10 iu pada kulit sub. 500mg pirantel pamoat diberikan sekali sehari untuk mengatasi kecacingan. Untuk infeksi saluran kemih, siprofloksasin 500 mg diberikan dua kali sehari. 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 steroiddependent 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. Angiotensinconverting 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.

Nephrotic syndrome
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. nefrotik sindrom definisi Sindrom nefrotik adalah kumpulan gejala yang terjadi karena pembuluh darah kecil (glomeruli) di ginjal menjadi bocor. Hal ini memungkinkan protein (biasanya tidak pernah pingsan dalam urin) untuk meninggalkan tubuh dalam jumlah besar. 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.
deskripsi Glomeruli (satu pun disebut glomerulus) adalah jumbai kecil kapiler (jenis terkecil dari pembuluh darah). Glomeruli terletak di ginjal, di mana mereka mengizinkan sejumlah produk air dan limbah meninggalkan darah, akhirnya harus berpindah dari dalam tubuh dalam bentuk urin. Biasanya, protein tidak dapat melewati saringan glomerulus. Sindrom nefrotik, bagaimanapun, terjadi ketika filter ini menjadi rusak, memungkinkan jumlah besar protein untuk meninggalkan sirkulasi darah, dan pingsan atau tubuh dalam urin. Pasien dengan sindrom nefrotik adalah dari semua kelompok umur, meskipun pada anak-anak ada peningkatan risiko gangguan antara usia 18 bulan dan empat tahun. Pada anak-anak, anak laki-laki lebih sering terkena dampak; pada orang dewasa, rasio laki-laki dengan perempuan adalah lebih dekat untuk sama.

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. Penyebab dan gejala Sindrom nefrotik dapat disebabkan oleh sejumlah penyakit yang berbeda. Mekanisme umum yang tampaknya menyebabkan kerusakan melibatkan sistem kekebalan tubuh. Untuk beberapa alasan, sistem kekebalan tubuh tampaknya menjadi ditujukan terhadap ginjal sendiri seseorang. Glomeruli menjadi semakin bocor sebagai berbagai zat dari sistem kekebalan tubuh disimpan dalam ginjal. 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 Sejumlah gangguan ginjal yang berbeda terkait dengan sindrom nefrotik, termasuk: perubahan penyakit minimal atau MCD (bertanggung jawab untuk sekitar 80% dari sindrom nefrotik pada anak, dan sekitar 20% pada orang dewasa) MCD adalah gangguan pada glomeruli fokus glomerulosklerosis membran glomerulopathy membranoproliferatif 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. Jenis lain dari penyakit juga dapat mengakibatkan sindrom nefrotik. Ini termasuk diabetes, anemia sel sabit, amiloidosis, lupus eritematosus sistemik, sarkoidosis, leukemia, limfoma, kanker, usus perut payudara, dan, reaksi terhadap obat (termasuk obat anti-inflamasi, lithium, dan pahlawan jalan), alergi reaksi (untuk sengatan serangga, racun ular, dan poison ivy), infeksi (malaria, berbagai bakteri, hepatitis B, herpes zoster, dan virus yang menyebabkan AIDS), dan tekanan darah tinggi berat. 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. Gejala pertama dari sindrom nefrotik sering urin berbusa. Sebagai sindrom berlangsung, pembengkakan (edema) adalah melihat di kelopak mata, tangan, kaki, lutut, skrotum, dan perut. Pasien merasa semakin lemah dan lelah. Nafsu makan sangat menurun. Seiring waktu, kehilangan protein menyebabkan otot menjadi lemah dan kecil (disebut otot). Pasien dapat mencatat nyeri perut dan sulit bernafas. Karena ginjal terlibat dalam regulasi tekanan darah, tekanan darah rendah yang tidak normal atau abnormal tinggi bisa terjadi. Seiring waktu, kehilangan protein yang terjadi pada sindrom nefrotik akan menghasilkan keadaan umumnya kurang gizi. Rambut dan kuku menjadi rapuh, dan pertumbuhan terhambat. Tulang menjadi lemah, dan tubuh mulai kehilangan nutrisi penting lainnya (gula, kalium, kalsium). Infeksi merupakan komplikasi serius dan sering, seperti juga gangguan pembekuan darah. Gagal ginjal akut dapat berkembang. 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. diagnosa Diagnosa didasarkan pertama pada pemeriksaan laboratorium urin dan darah. Sementara urin akan mengungkapkan jumlah yang signifikan protein, darah akan mengungkapkan jumlah abnormal rendah beredar protein. Tes darah juga akan mengungkapkan tingkat tinggi kolesterol. Untuk mendiagnosa salah satu gangguan ginjal yang menyebabkan sindrom nefrotik, sebuah contoh kecil dari ginjal (biopsi) akan perlu dihapus untuk diperiksa. Ini biopsi dapat dilakukan dengan jarum, panjang sangat tipis yang dimasukkan melalui kulit di bawah tulang rusuk. 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.
pengobatan Pengobatan tergantung pada gangguan yang mendasari yang menyebabkan sindrom nefrotik. Obat yang meredam sistem kekebalan tubuh adalah andalan pengobatan. Pilihan pertama biasanya merupakan obat steroid (misalnya prednison). Beberapa kondisi mungkin memerlukan obat bahkan lebih kuat, seperti siklofosfamid atau siklosporin. Mengobati kondisi yang mendasari (limfoma, kanker, penggunaan pahlawan, infeksi) yang telah menyebabkan sindrom nefrotik akan sering meningkatkan gejala sindrom nefrotik juga. Beberapa pasien akan memerlukan penggunaan obat spesifik untuk mengontrol tekanan darah tinggi. Kadang-kadang, jumlah cairan pasien diperbolehkan minum dibatasi. Beberapa pasien

manfaat dari penggunaan diuretik (yang memungkinkan ginjal untuk menghasilkan lebih banyak urin) untuk mengurangi pembengkakan

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. istilah kunci -Glomeruli - jumbai Tiny kapiler yang membawa darah dalam ginjal. Darah disaring oleh glomeruli. Darah kemudian berlanjut melalui sistem peredaran darah, namun sejumlah produk limbah cairan dan spesifik yang disaring dari darah, untuk dihapus dari tubuh dalam bentuk urin. Sistem kekebalan - Sistem kompleks dalam tubuh yang berfungsi untuk melawan penjajah berbahaya, seperti bakteri, virus, jamur. Gagal ginjal - Ketidakmampuan ginjal untuk mengeluarkan zat beracun dari tubuh. 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. prognosa Prognosis tergantung pada kelainan yang mendasarinya. Penyakit perubahan minimal memiliki prognosis yang terbaik dari semua gangguan ginjal, dengan 90% dari semua pasien merespon pengobatan. Jenis lain dari penyakit ginjal memiliki hasil yang kurang menguntungkan, dengan tingginya tingkat pengembangan menjadi gagal ginjal. Ketika sindrom nefrotik disebabkan oleh gangguan lain, dapat diobati (infeksi, reaksi alergi atau obat), prognosis sangat baik.

Nefropati Diabetik
komplikasi mikroangiopati dibetik 16,1% penyebab GGT yg memerlukan dialisis atau transplantasi Ditandai dg makroalbuminuri > 300mg/hr, persisten pada 2-3 pem. dlm 6 bulan Mikroalbuminuri 30-300mg/hr DM tipe I

-microangiopathic complications dibetik 16.1% the cause of GGT which requires dialysis or transplantation Accomplished by using makroalbuminuri> 300mg/hr, persistent at 2-3 pem. within 6 months Mikroalbuminuri 30-300mg/hr Type I diabetes

Perjalanan penyakit
DM tipe I 1.stad.hipertrofi-hiperfungsi 2.stad.sepi (silent stage) 3.stad.awal nefropati (incipient) 4.stad.klinik nefropati (overt DM nephropathy)

5.stad.GGT (end stage renal failure)

DM tipe II Stadium tak jelas: 3-16% nefropati diabetik Diperngaruhi faktor non-diabetes Tahap akhir perjalanan spt DM tipe I Type I diabetes 1.stad.hipertrofi-hiperfungsi 2.stad. "Quiet" (silent stage) 3.stad.awal nephropathy (incipient) 4.stad.klinik nephropathy (overt DM nephropathy) 5.stad.GGT (end stage renal failure) Type II DM Stadium is not clear: 3-16% diabetic nephropathy On the non-diabetic Diperngaruhi The final stage of the journey such as diabetes mellitus type I

Patogenesis:
1. Metabolic-pathway: glukosa a.amino bebasAGEs merusak glomerulus 2. Polyol pathway: reduksi gluk.meningkat sorbitol jar. Meningkatmioinositol berkurang ggn.osmol.membr.basal Faktor lain: Ggn. Hemodinamik sistemik Glukotoksisitas kel.sel endotel vaskuler 1.Metabolic-pathway: glucose-free a.amino damage the glomerular AGE's 2.Polyol pathway: sorbitol reduction gluk.meningkat jar. Increases reduced mioinositol

ggn.osmol.membr.basal Other factors: GGN. systemic hemodynamics Glukotoksisitas kel.sel vascular endothelial

Diagnosis
Klinis : - manifestasi DM -G/ nefropati stad.1-5 - G/ uremi: lemah badan, anoreksi,mual,muntah, asidosis, anemia, edema,hipertensi, koma. - G/ komplikasi organ lain: neuropati, retinopati Laboratorik: kadar gula darah, proteinuri, ggn. Profil lemak ok ggn.sensitifitas thd. Insulin peningkatan kolesterol total, koles.LDL, trigliserid apoprotein B, penurunan kolesterol HDL Dx.dini: mikroalbuminuri, enzim2 tubuler spt NAG (n-asetil glukosaminidase, gamaGT,retinol binding protein, alfa 1 mikroglobulin, transferin, leucine-aminopeptidase,, alkali fosfatase.

Clinical: - manifestations of DM -G / nephropathy stad.1-5 - G / uremi: low loss, anorexia, nausea, vomiting, acidosis, anemia, edema, hypertension, coma. - G / other organ complications: neuropathy, retinopathy Laboratory: blood sugar levels, proteinuri, GGN. Lipid profile ggn.sensitifitas eye out ok. Insulin increased total cholesterol, koles.LDL, triglycerides, apoprotein B, HDL cholesterol decreased Dx.dini: mikroalbuminuri, tubular enzim2 like NAG (N-acetyl glukosaminidase, gamaGT, retinol binding protein, alpha-1 microglobulin, transferrin, leucine-aminopeptidase,, alkaline phosphatase.

Pengobatan
1. Pengendalian intensif kadar gula darah 2. Pengendalian intensif tekanan darah 3. Pengendalian lemak darah 4. Pengendalian faktor2 yg memperberat seperti rokok, alkohol, stres dll 5. Bila nefropati : diet rendah protein 0,5-1g perKgBB perhari dg protein hewani GGT: dialisis(HD,CAPD) atau cangkok ginjal

Intensive control of blood sugar levels Intensive control of blood pressure Control of blood lipids Faktor2 control which aggravate such as cigarettes, alcohol, stress, etc. When nephropathy: low-protein diet perKgBB 0.5-1g of protein per day dg GGT: dialysis (HD, CAPD) or renal transplant

Pencegahan
A. Mencegah mikroalbuminuri B. Mencegah mikro makroalbuminuri Menunda makroalb. GGT
prevent mikroalbuminuri Prevent micro makroalbuminuri Makroalb delay. GGT