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SEORANG PENDERITA SINDROM NEFRITIK AKUT PASCA INFEKSI STREPTOKOKUS

Ni Ma d eRe n n yA Re n a , Ke t u t S u wi t r a Ba g i a n / S M FI l muP e n y a k i t Da l a mF K Un u d / RS UPS a n g l a hDe n p a s a r e ma i l : r e n n y _ a n g @y a h o o . c o m
ABS TRACT Ac u t en e p h r i t i cs y n d r o me i sc l a s s i c a l l yd e n e db ys y mp t o ms o fo l i g u r i a ,o e d e m,h y p e r t e n s i o na n da l s ou r i n a l y s i s a b n o r ma l i t ys u c ha sp r o t e i n u r i al e s st h a n2 g r a ms / d a y , h e ma t u r i a , o rn d i n go fe r y t r o c i t es i l i n d e ri nt h eu r i n e . Th ee t i o l o g yo f a c u t en e p h r i t i cs y n d r o mea r ed i s o r d e r so fp r i ma r yg l o me r u l o p a t h y( i d i o p a t h i c ) , g l o me r u l o p a t h ya f t e ri n f e c t i o n , Di s s e mi n a t e d Lu p u sEr y t h o ma t o s u s( DLE) , v a s c u l i t i sa n dh e r e d i t a r yn e p h r i t i s( Al p o r t s y n d r o me ) . Ac u t en e p h r i t i cs y n d r o mei so n eo fc l i n i c a l ma n i f e s t a t i o no fa c u t eg l o me r u l o n e p h r i t i sa f t e rs t r e p t o c o c c a l i n f e c t i o n , wh i c hi si n l a ma t i o no c c u ro nt u b u l u sa n dg l o me r u l a r o ft h ek i d n e y ,a f t e rs t r e p t o c o c c a li n f e c t i o no fs k i no ru p p e rr e s p r a t o r yt r a c t .Th emo s tf r e q u e n tc a u s eb yp a r t i c u l a rs t r a i no f h e mo l y t i c u ss t r e p t o c o c c u s g r o u pA t y p e 12.He r e wi t h ,we r e p o r t e d ac a s eo fa c u t eg l o me r u l o n e p h r i t i sa f t e rs t r e p t o c o c c a l i n f e c t i o nwi t hc l i n i c a l ma n i f e s t a t i o na c u t en e p h t i cs y n d r o me . Af o u r t e e ny e a r so l dBa l i n e s ema l ep a t i e n t f o u n dwi t ha n a s a r c a o e d e m, o l i g u r i aa n dh e ma t u r i a . P r e v i o u sme d i c a l h i s t o r ywi t hi n f e c t i o no f t h r o a t 2 we e k sb e f o r ea d mi t t e dt oh o s p i t a l . Onp h y s i c a l e x a mi n a t i o n , wef o u n dwi t hS t a g eI Ih y p e r t e n s i o n , l a b o r a t o r yd a t as h o wnu r i n a l y s i s : h e ma t u r i aa n dp r o t e i n u r i a , p r o t e i ne s b a c h 3. 25 g r a m/ l i t e r / d a y , AS TO 200 I U/ ml , ANA t e s tn e g a t i v ea n dt h r o a ts wa bi s o l a t e dS t r e p t o c o c c u sv i r i d a n s , a l p h ah e mo l i t i c u s . I ma g i n gd a t as h o we dr i g h tp l e u r a le f f u s i o na n db i l a t e r a ln e p h r i t i so ft h ek i d n e y . P a t i e n tg i v e sag o o dr e s p o nt oc o r t i c o s t e r o i d ( me t i l p r e d n i s o l o n e ) , d i u r e t i ca n da l s oACE i n h i b i t o r . Ke y wo r d s : n e p h r i t i c , g l o me r u l o n e p h r i t i s , s t r e p t o c o c c a l

P ENDAHULUAN S i n d r o m Ne f r i t i k Ak u t ( S NA) me r u p a k a n k u mp u l a ng a mb a r a nk l i n i sb e r u p ao l i g u r i a ,e d e ma , h i p e r t e n s iy a n gd i s e r t a ia d a n y ak e l a i n a nu r i n a l i s i s ( p r o t e i n u r ik u r a n gd a r i2 g r a m/ h a r id a nh e ma t u r i 13 s e r t as i l i n d e re r i t r o s i t ) . Et i o l o g iS NA s a n g a tb a n y a k , d i a n t a r a n y ak e l a i n a ng l o me r u l o p a t ip r i me r( i d i o p a t i ) , g l o me r u l o p a t ip a s c ai n f e k s i , DLE, v a s k u l i t i sd a n 3 n e f r i t i sh e r e d i t e r( s i n d r o maAl p o r t ) . S NA me r u p a k a ns a l a hs a t u ma n i f e s t a s ik l i n i s Gl o me r u l o n e f r i t i sAk u t P a s c aS t r e p t o k o k u s( GNAP S ) , d i ma n at e r j a d is u a t up r o s e si n a ma s ip a d at u b u l u s

S e o r a n gP e n d e r i t aS i n d r o m Ne f r i t i kAk u t P a s c aI n f e k s i S t r e p t o k o k u s Ni Made Renny A Rena, Ketut Suwitra

d a ng l o me r u l u sg i n j a ly a n gt e r j a d is e t e l a ha d a n y a s u a t ui n f e k s is t r e p t o k o k u sp a d as e s e o r a n g .GNAP S b e r k e mb a n gs e t e l a hs t r a i ns t r e p t o k o k u st e r t e n t uy a i t u s t r e p t o k o k u s h e mo l i t i k u sg r o u pA t e r s e r i n gt i p e 12 me n g i n f e k s ik u l i ta t a us a l u r a nn a f a s .T e r j a d ip e r i o d e l a t e nb e r k i s a r a n t a r a1 2 mi n g g uu n t u ki n f e k s i s a l u r a n 46 n a f a sd a n1 3 mi n g g uu n t u ki n f e k s i k u l i t . Me k a n i s me y a n gt e r j a d ip a d a GNAP Sa d a l a h s u t up r o s e sk o mp l e k si mu nd i ma n aa n t i b o d i d a r i t u b u h a k a nb e r e a k s i d e n g a na n t i g e ny a n gb e r e d a r d a l a md a r a h d a nk o mp l e me nu n t u k me mb e n t u ks u a t uk o mp l e k s i mu n . Ko mp l e k si mu ny a n gb e r e d a r d a l a md a r a hd a l a m j u ml a hy a n gb a n y a kd a n wa k t uy a n gs i n g k a tme l e k a t 201

p a d ak a p i l e r k a p i l e rg l o me r u l u sd a nt e r j a d ip e r u s a k a n me k a n i s me l a l u ia k t i v a s is i s t e m k o mp l e me n ,r e a k s i 5 7 p e r a d a n g a nd a nmi k r o k o a g u l a s i . GNAP S t e r c a t a ts e b a g a ip e n y e b a b p e n t i n g t e r j a d i n y ag a g a lg i n j a l ,y a i t ut e r h i t u n g 10 15 %d a r i k a s u sg a g a lg i n j a ld iAme r i k aS e r i k a t .GNAP Sd a p a t mu n c u ls e c a r as p o r a d i k ma u p u ne p i d e mi kt e r u t a ma me n y e r a n ga n a k a n a ka t a ud e wa s a mu d ap a d au s i a s e k i t a r4 12 t a h u nd e n g a np u n c a ku s i a5 6 t a h u n . Le b i hs e r i n gp a d al a k i l a k id a r i p a d a wa n i t ad e n g a n r a s i o1, 72 : 1. T i d a ka d ap r e d i l e k s i k h u s u sp a d ar a s 45 a t a u p u ng o l o n g a nt e r t e n t u . GNAP S me r u p a k a np e n y a k i tg i n j a ls u p u r a t i f t e r s e r i n gd e n g a n ma n i f e s t a s ik l i n i sb e r u p ap e n y a k i t y a n gr i n g a nh i n g g aa s i mt o ma t i s ,h a n y as e d i k i ts e k a l i d e n g a n ma n i f e s t a s ik l i n i sy a n gb e r a t ,d e n g a nr a s i o3 :1.M e n g i n g a ti n s i d e n GNAP Sd e n g a n ma n i f e s t a s i k l i n i sy a n gj e l a sj a r a n gd i t e mu k a n ,ma k a d i a g n o s i s 4 d a nt e r a p i me r u p a k a nma s a l a hp e n t i n gu n t u kd i b a h a s . Be r i k u td i l a p o r k a n s e b u a h k a s u s p e n d e r i t a g l o me r u l o n e f r i t i s a k u tp a s c a i n f e k s is t r e p t o k o k u s d e n g a nma n i f e s t a s i k l i n i ss i n d r o mn e f r i t i ka k u t . KAS US S e o r a n gl a k i l a k i ,14 t a h u n ,S u k u Ba l i .M a s u k r u ma hs a k i t ( M RS ) t a n g g a l7S e p t e mb e r 2004, d e n g a n k e l u h a n b e n g k a k p a d a wa j a h n y at e r u t a ma s e k i t a r ma t a .Be n g k a kd i r a s a k a ns e j a k3 h a r is e b e l u m M RS , d i r a s a k a nt e b a ld a nt a n p an y e r i .Be n g k a kp a d a mu k a me l u a sh i n g g ak ek a k id a nd a e r a hp e r u td a nt e r u t a ma b e n g k a kl e b i ht e r l i h a t j e l a s s a a t p a g i h a r i . P e n d e r i t aj u g a me n g e l u hs e s a ks e j a k3 h a r is e b e l u m M RS , d i r a s a k a n b e b e r a p aj a ms e t e l a ht i mb u l b e n g k a kp a d ama t a , t i d a k me mb e r a td a n t i d a k me mb a i k d e n g a n p e r u b a h a n p o s i s i . S e l a i ni t up e n d e r i t ame n g e l u hk e n c i n gb e r wa r n a k e me r a h a n ,t e t a p it i d a kn y e r is a a tBAK d a nd e ma m. Ri wa y a tp e n y a k i ts e b e l u mn y a ,2 mi n g g uy a n gl a l u p e n d e r i t ame n g e l u hp a n a s , b a t u k , p i l e kd a nn y e r i p a d a t e n g g o r o k a n n y a .P e n d e r i t at e l a hb e r o b a tk ed o k t e r d a nd i b e r i k a nt i g ama c a mo b a t , d a nk e l u h a n n y as u d a h me mb a i ks e j a ks e b e l u mb e n g k a k . 202

P a d ap e me r i k s a a n s i kd i t e mu k a nk e s a d a r a n c o mp o s me n t i s ,t e n s i 17 0/ 100 mmHg ,n a d i8 0 x / 0 e r a t me n i t ,p e r n a f a s a n 20 x / me n i t ,t e mp e r a t u r37C,b b a d a n 47 k g ,d a nt i n g g ib a d a n 15 7c m,s t a t u sg i z i c u k u p .Di t e mu k a ne d e mak e l o p a k ma t a ,n a mu nt i d a k d i t e mu k a nt a n d a a n e mi ma u p u ni k t e r u s . THTd i t e mu k a n p e mb e s a r a nt o n s i lT2/ T2,t i d a ka d ah i p e r e mif a r i n g . J VP P R +0 c mH20. S u a r aj a n t u n gp e r t a mad a nk e d u a n o r ma lt a n p a mu r mu r ,s u a r ad a s a rp a r uv e s i k u l e r , t i d a kd i t e mu k a nr h o n k id a n wh e e z i n g . P a d aa b d o me n d i t e mu k a na s i t e ss e d a n g ,h a t id a nl i mp at a kt e r a b a , e k s t r e mi t a st a mp a ke d e map a d ak e d u ak a k id a na k r a l t e r a b ah a n g a t . P e me r i k s a a nl a b o r a t o r i u m,me n u n j u k k a n W BC 6 , 7 . 103/ u l ; h e mo g l o b i n12 g / d l p l a t e l e t 213. 103 / u l ; LED 16 ; BUN 6 0 mg / d l ; S C 0, 8 9mg / d l ; AS T 17I U/ l ; AL T 23 I U/ l ; Na144, 4 mmo l / l ; K 4, 38mmo l / l ; a l b u mi n3, 2 g / d l ; k o l e s t e r o l 17 8mg / d l . P a d ap e me r i k s a a nu r i n a l i s i s me n u n j u k k a nk e k e r u h a n( + ) ; p H5 , 5 ; BJ 1, 030; l e u k o s i t ( + ) 7 0; n i t r i t ( + ) ; b a k t e r i ( + ) ; b i l i r u b i n( + + ) ; s e l l e u k o s i t 3 4/ l a pp a n d a n g ; e r i t r o s i t 22 24/ l a pp a n d a n g . P a d a p e me r i k s a a n EKG i r a ma s i n u sn o r ma l8 4k a l i / me n i t ; f o t ot h o r a k st a mp a kk a r d i o me g a l i d e n g a nCTR 5 4, 23% d a ne f u s i p l e r ak a n a n . Be r d a s a r k a nd a t ak l i n i kd i a t a s , p a s i e nd i d i a g n o s as i n d r o man e f r i t i ka k u t . P a d ah a r ip e r t a ma p e r a wa t a n ,d i b e r i k a nc a i r a n i n t r a v e n a Na Cl0, 9 % 8t e t e s / me n i t ,d i e t25 00 Kk a l d a n 35 g r a m p r o t e i n .P e n g o b a t a n d e n g a n i n j e k s i me t i l p r e d n i s o l o n2 x6 2, 5 mg ,i n j e k s if u r o s e mi d3 x 20 mgd a nc a p t o p r i l 2 x25mg . Di l a k u k a nmo n i t o r i n g k e s e i mb a n g a nc a i r a n , e l e k t r o l i ts e r t at a n d av i t a l . P a d a h a r ik e t i g ap e r a wa t a n ,k e l u h a nb e n g k a kb e r k u r a n g f u r o s e mi d 40 mg d i b e r i k a ns e c a r ao r a l1 k a l is e h a r i . Di k o n s u l k a nd i v i s i k a r d i o l o g i , d i s a r a n k a np e me r i k s a a n e k o k a r d i o g r a d e n g a nh a s i l t r i k u s p i dr e g u r g i t a s i t r i v i a l , d a nd i b e r i k a nt e r a p i me t i l d i g o x i n1 k a l i s e h a r i . Ha s i lp e me r i k s a a ns e r o ma r k e rHBs Ag d a na n t i HCV n e g a t i f .AS TO 200 I U/ ml ,h s CRP 2, 32 mg / l . P r o t e i n Es b a c h me n u n j u k k a n a d a n y a p r o t e i n u r i a s e b e s a r 3, 25g r a m/ l i t e r / h a r i . US Ga b d o me nd i d a p a t k a n n e f r i t i sg i n j a l k a n a nd a nk i r i , s p l e n o me g a l i , a s i t e sd a n
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e f u s i p l e r a . Ha s i l p e me r i k s a a nANA t e s t n e g a t i f , s wa b t e n g g o r o kd i t e mu k a nh a s i l p o s i t i f a d a n y aS t r e p t o c o c c u s v i r i d a n s , a l p h a h e mo l i t i k u s , s e n s i t i f t e r h a d a p a n t i mi k r o b a a mp i c i l l i n ,a mo x i c i l l i n ,e r y t h r o my c i n , s u l b a c t a m/ c e f o p e r a z o ns e r t ai mi p e n e m.Be r d a s a r k a n d a t ap e n u n j a n gb e r i k u td ia t a s ,p a s i e nd i d i a g n o s a s i n d r o man e f r i t i ka k u t p a s c ai n f e k s i s t r e p t o k o k u s . P a d ah a r ik ed e l a p a np e r a wa t a n ,t e r a p ia n t i h i p e r t e n s ic a p t o p r i ld i t i n g k a t k a nd o s i s n y a me n j a d i2 x5 0 mg , k a r e n at a r g e tt e k a n a nd a r a hd i b a wa h140/ 8 0 mmHg b e l u m t e r c a p a i .Ke l u h a nb e n g k a k me mb a i k p a d ap e r a wa t a nh a r ik es e p u l u h ,t e r a p if u r o s e mi d d a n me t i l p r e d n i s o l o n d i h e n t i k a n . Ha r ik e d u a b e l a s p e r a wa t a n ,k e l u h a np e n d e r i t ame mb a i k ,d i r e n c a n a k a n r a wa tj a l a nd e n g a np e mb e r i a nt e r a p ic a p t o p r i l2 x 5 0 mgd a nme t i l d i g o x i n0, 1 mg1 k a l i s e h a r i . Di s a r a n k a n k o n t r o l p o l i k l i n i sn e f r o l o g i d a nk a r d i o l o g i . P EM BAHAS AN S i n d r o mn e f r i t i ka k u t p a s c ai n f e k s i s t r e p t o k o k u s d e n g a ng e j a l ak l i n i sy a n gj e l a s t e r ma s u kp e n y a k i t d e n g a n i n s i d e n y a n g t i d a k t e r l a l u t i n g g i ,s e k i t a r 1 : 10. 000. S i n d r o m n e f r i t i k a k u tp a s c ai n f e k s i s t r e p t o k o k u st a n p ag e j a l ai n s i d e n n y ame n c a p a i j u ml a h 4 5k a l il e b i hb a n y a k . Umu mn y ame n y e r a n gs e mu a u s i a , n a mu nt e r u t a mal a k i l a k i u s i a3 7t a h u n . Di a g n o s i s s i n d r o ma n e f r i t i k a k u t d i b u a t b e r d a s a r k a na d a n y a : ( i ) o l i g u r i ( i i ) e d e ma( i i i ) h i p e r t e n s i s e r t a( i v )k e l a i n a nu r i n a l i s i sb e r u p ap r o t e i n u r i k u r a n g d a r i2 g r a m/ h a r id a nh e ma t u r is e r t as i l i n d e re r i t r o s i t . Na mu n p a d a b e b e r a p a k e p u s t a k a a n d i s e b u t k a n p r o t e i n u r ima s i fd a p a tt e r j a d ip a d a2 5 % p e n d e r i t a GNAP Su s i a mu d a ,b a h k a nd a p a tme n y e r u p a is u a t u g a mb a r a n p r o t e i n u r ip a d as i n d r o m n e f r o t i k .P a d a p e n d e r i t a( k a s u s )t e r s e b u td i a t a s , d i t e mu k a nt i g ad a r i e mp a tk r i t e r i ay a n gt e r p e n u h iy a i t ua d a n y ae d e ma p a d as e l u r u ht u b u h , h i p e r t e n s i g r a d eI I , s e r t ak e l a i n a n u r i n a l i s i sb e r u p ah e ma t u r i a 22 24/ l a p a n gp a n d a n g d a np r o t e i n u r i a3, 25g r a m/ l i t e r / h a r i .

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Et i o l o g i Hi s t o p a t o l o g i P a t o g e n e s i s Gl o me r u l o n e Gl o me r u l o n e f r i t i sS t r e p t o k o k u s , Ko mp l e k s f r i t i sp r o l i f e r a a k u t ( p o s t i n f e k s i ) b a k t e r i l a i n i mu n t i fd i f u s Ne f r o p a t i I g A( p e n y a k i t Be r g e r , HS P ) I S P A( v i r a l ) , i n - Gl o me r u l o n e T i d a kd i k e t a r i t i sme s a n f e k s i t r a k t u sGI ,f h u i i o p r o l i f e r a t i f u l ik es yndro me g

Lu p u se r y t h e ma t o s u s , k r i o g l o b u l i n e mi ac a mGl o me r u l o n e - Ko mp l e k s p u r a n , i n f e k s i f r i t i sc res entic i mu n e n d o k a r d i t i s u b a k u t , i n f e k s i Rap idl yp ro g res -s i r a i s iv eg l o merul o - p S i n d r o ma nef ritis Gl o me r u l o n e - An t i b o d i a n t i Go o d p a s t u r e s f r i t i sc res entic GBM a t a ui d i o p a t i k Gr a n u l o ma t o s i s Gl o me r u l o n e -T i d a kd i k e t a We g e n e r , p o l i a r f r i t i sc res entic h u i t e r i t i s , i d i o p a t i k

Ad a n y ap e r i o d el a t e na n t a r ai n f e k s i s t r e p t o k o k u s d e n g a n g a mb a r a n k l i n i s k e r u s a k a n g l o me r u l u s me n u n j u k k a nb a h wa p r o s e si mu n o l o g i s me me g a n g p e r a n a np e n t i n gd a l a mp a t o g e n e s i sg l o me r u l o n e f r i t i s . Me k a n i s me d a s a rt e r j a d i n y as i n d r o m n e f r i t i ka k u t p a s c ai n f e k s i s t r e p t o k o k u sa d a l a ha d a n y as u a t up r o s e s i mu n o l o g i sy a n gt e r j a d i a n t a r aa n t i b o d i s p e s i kd e n g a n a n t i g e ns t r e p t o k o k u s .P r o s e si n it e r j a d id id i n d i n g k a p i l e r g l o me r u l u s d a n me n g a k i b a t k a n a k t i v a s i 203

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s i s t e m k o mp l e me n .S e l a n j u t n y as i s t e m k o mp l e me n me mp r o d u k s ia k t i v a t o rk o mp l e me n 5 a( C5 a )d a n me d i a t o r me d i a t o r i n a ma s i l a i n n y a . S i t o k i nd a nf a k t o r p e mi c ui mu n i t a ss e l u l e rl a i n n y aa k a n me n i mb u l k a n r e s p o ni n a ma s i d e n g a nma n i f e s t a s i p r o l i f e r a s i s e l d a n 3, 8 11 e d e mag l o me r u l a r . P e n u r u n a nl a j u l t r a s ig l o me r u l u sb e r h u b u n g a n d e n g a np e n u r u n a nk o e s i e nu l t r a l t r a s ig l o me r u l u s . P e n u r u n a nl a j u l t r a s ig l o me r u l u sd i i k u t ip e n u r u n a n e k s k r e s ia t a uk e n a i k a nr e a b s o r b s in a t r i u m s e h i n g g a t e r d a p a tp e n i mb u n a nn a t r i u m d e n g a na i rs e l a n j u t n y a a k a nd i i k u t i k e n a i k a nv o l u mep l a s mad a nv o l u mec a i r a n 204

e k s t r a s e l u l a rs e h i n g g aa k a nt i mb u lg a mb a r a nk l i n i s o l i g u r i a , h i p e r t e n s i , e d e mad a nb e n d u n g a ns i r k u l a s i . Ed e ma t e r j a d ip a d a8 5 % p a s i e nS NA p a s c a i n f e k s is t r e p t o k o k u s ,b i a s a n y at e r j a d ime n d a d a kd a n p e r t a mak a l i t e r j a d i d i d a e r a hp e r i o r b i t a l d a ns e l a n j u t n y a d a p a t me n j a d i e d e maa n a s a r k a . De r a j a t b e r a t r i n g a n n y a e d e ma y a n gt e r j a d it e r g a n t u n gp a d ab e b e r a p af a k t o r y a i t u l u a s n y ak e r u s a k a n g l o mo r e l u sy a n g t e r j a d i , a s u p a nc a i r a n , d a nd e r a j a t h i p o a l b u mi n e mi a . He ma t u r ima k r o k o s p i st e r j a d is e k i t a r30 5 0% p a d ap e n d e r i t aS NA p a s c as t r e p t o k o k u s .M a n i f e s t a s i y a n gt i mb u lu r i n ed a p a tb e r wa r n as e p e r t ic o l a ,t e h a t a u p u nk e r u hd a ns e r i n gd e n g a no l i g u r i . Hi p e r t e n s i me r u p a k a nt a n d ak a r d i n a l k e t i g ab a g i S NA p a s c ai n f e k s i s t r e p t o k o k u s , d i l a p o r k a n5 0 9 0% d a r ip e n d e r i t ay a n gd i r a wa td e n g a ng l o me l u r o n e f r i t i s a k u t . Le d i n g h a m3 me n g u n g k a p k a nh i p o t e s i st e r j a d i n y a h i p e r t e n s imu n g k i na k i b a td a r id u aa t a ut i g af a k t o r b e r i k u t y a i t u , g a n g g u a nk e s e i mb a n g a nn a t r i u m, p e r a n a n s i s t e m r e n i n a n g i o t e n s i n o g e n d a n s u b s t a n s ir e n a l medul l ary h yp o tens iv ef ac to rs , d i d u g ap r o s t a g l a n d i n . Be n d u n g a n s i r k u l a s i b a n y a k t e r j a d i p a d a p e n d e r i t ay a n gd i r a wa td ir u ma hs a k i t .M a n i f e s t a s i k l i n i sy a n gt a mp a kd a p a tb e r u p ad y s p n e u ,o r t h o p n e u , b a t u kd a ne d e map a r u . P a d a p e me r i k s a a n l a b o r a t o r i u m, d i t e mu k a n k e l a i n a nu r i n a l i s i sb e r u p ap r o t e i n u r ib e r k i s a ra n t a r a 2 4 g r a mp e rh a r i ,t e r d i r id a r ip r o t e i nd e n g a nb e r a t mo l e k u l b e s a r t e r u t a maa l b u mi n . He ma t u r i , d e n g a na t a u t a n p as i l i n d e re r i t r o s i td i t e mu k a np a d ak i r a k i r a 40% p a s i e n .S i l i n d e re r i t r o s i tme r u p a k a nt a n d ak e r u s a k a n p a r e n k i m ma s i ha k t i f . Ko n s e n t r a s i Fib rin Deg radatio n Pro duc t ( F DP ) me n i n g k a t ,p a d ap a s i e n p a s i e nb e r a t t e r u t a ma y a n gb e r u b a h me n j a d irap idl y p ro g res s iv e g l o merul o nep h ritis . P e n e n t u a nk o n s e n t r a s i F DPd a l a m u r i n s a n g a tp e n t i n g u n t u k me n e n t u k a n p r o g n o s i s s i n d r o mn e f r i t i ka k u t p a s c ai n f e k s i s t r e p t o k o k u s . Bi a k a n u r i np a d as e t i a pp e n y a k i tg i n j a la p a p u nj u g a ,k a r e n a i n f e k s i s a l u r a nk e mi hs e r i n gk a l i t e r s e mb u n y i d a nt i d a k me mb e r i k a nk e l u h a n . P a d as i n d r o mn e f r i t i ka k u t p a s c a i n f e k s i s t r e p t o k o k u s t i d a kj a r a n gd i j u mp a i k e l a i n a nu r i n
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y a n gme n y e r u p a i i n f e k s i : l e k o s i t u r i d a ns i l i n d e r l e k o s i t wa l a u p u nt i d a kt e r b u k t i s e c a r ab a k t e r i o l o g i sme n d e r i t a i n f e k s is e k u n d e r . Be b e r a p a s u mb e r me n y e b u t k a n 38 k a d a n g k a d a n gt e r j a d i g l u k o s u r i . P a d ap e me r i k s a a nf a a lg i n j a ls e r i n gd i g u n a k a n u r e u m, k r e a t i n i ns e r u m, d a np e n j e r n i h a nk r e a t i n i n me n e n t u k a n d e r a j a tf a a l La j u F i l t r a s i Gl o me r u l u s ( LF G) .Ko mb i n a s id a r ik e t i g ap a r a me t e ri n is a n g a t p e n t i n g .S e p e r t id i k e t a h u i ,u r e u m s e r u m t i d a kt e p a t u n t u k me mp e r k i r a k a nf a a l LF G k a r e n a :( a )u r e u m t i d a kh a n y ad i l t r a s io l e hg l o me r u l u st e t a p ia k a n d i r e b s o r p s ij u g ao l e ht u b u l u sg i n j a l ,( b )k o n s e n t r a s i u r e u m t e r g a n t u n gd a r id i e tp r o t e i nd a nk a t a b o l i s me p r o t e i n .Wa l a u p u nd e mi k i a np e n e n t u a nu r e u ms e r u m p e n t i n gu n t u kme n e n t u k a nd e r a j a t k a t a b o l i s mep r o t e i n . S e r u m k r e a t i n i nl e b i ht e p a td a r iu r e u m s e r u m u n t u k me mp e r k i r a k a nf a a lLF G k a r e n ak o n s e n t r a s is e r u m k r e t i n i ns e ma t a ma t at e r g a n t u n gd a r ima s ao t o t o t o t d a nf a a lLF G. Ma s ao t o t o t o tr e l a t i fk o n s t a ns e h i n g g a s e r u mk r e a t i n i ns e ma t a ma t at e r g a n t u n gd a r i f a a l LF G. Be b e r a p ak e r u g i a nd a r in i l a ip e n j e r n i h a nk r e a t i n i n : ( a )s e r i n gd i t e mu k a nk e n a i k a ns e mu d a r ip a s i e n( b ) s e r i n gt e r d a p a tk e s a l a h a ns e l a ma p e n a mp u n g a nu r i n 24 j a m. P a d ag a n g g u a nf a a lt u b u l u st e r u t a mae k s k r e s i e l e k t r o l i t . P a d ap a s i e nd e n g a no l i g u r ia t a ua n u r it i d a k j a r a n gd i t e mu k a nh i p e r k a l e mi . P a d a p e me r i k s a a n d a r a h d i t e mu k a n a n e mi a r i n g a n n o r mo k o r m d a n n o r mo s i t e rk a r e n ar e t e n s i n a t r i u m d a nh e mo d i l u s i .P a d as e d i a a nd a r a ht e p i d i j u mp a is i s t o s i t ,f r a g me n t a s ie r i t r o s i td i s e r t a it a n d a t a n d a mi k r o a n g i o p a t i .La j ue n d a p a nd a r a h me n i n g g i wa l a u p u nt i d a k me mp u n y a ia r t id i a g n o s i s ma u p u n p r o g n o s i s .J u ml a hl e k o s i td a nt r o mb o s i tma s i hd a l a m b a t a sn o r ma l . P a d ap a s i e nb e r a t t e r u t a maRP GN s e r i n g d i j u mp a ig a n g g u a n p e r d a r a h a n y a n g me mp u n y a i h u b u n g a nd e n g a nt r o mb o s i t o p e n i aa t a ug a n g g u a nf a a l t r o mb o s i t ( t r o mb o p a t i ) . P a d ab e b e r a p ap a s i e nmu n g k i n t e r d a p a tp e n u r u n a np r o t e i ns e r u m t e r u t a ma a l b u mi n a k i b a tr e t e n s in a t r i u m d a ne k s p a n s iv o l u me c a i r a n e k s t r a s e l u l e r . Hi p e r l i p i d e mi r i n g a n d a n s e me n t a r a , me k a n i s me n y a t i d a k d i k e t a h u i . Hi p e r l i p i d e mi i n i
S e o r a n gP e n d e r i t aS i n d r o m Ne f r i t i kAk u t P a s c aI n f e k s i S t r e p t o k o k u s Ni Made Renny A Rena, Ketut Suwitra

t i d a kme mp u n y a i h u b u n g a nd e n g a nd e r a j a t p e n u r u n a n a l b u mi ns e p e r t i p a d as i n d r o mn e f r o t i k . P a d a p e me r i k s a a n b a k t e r i o l o g i s d i t e mu k a n p e n g e c a t a ng r a m/ me t h y l i n eb l u ed a nb i a k a nd a r i b a h a n p e me r i k s a a nh a p u st e n g g o r o k a na t a up u s( i mp e t i g o ) u n t u ki s o l a s i d a ni d e n t i k a s i s t r e p t o k o k u s . Ha s i l b i a k a n p o s i t i fd i t e mu k a nh a n y a25 %d a r ip a s i e n p a s i e ny a n g t i d a k me n d a p a ta n t i b i o t i ks e l a ma i n f e k s ia k u to l e h s t r e p t o k o k u s . P e r l ud i c a t a t , b a h wah a s i l b i a k a np o s i t i f b e l u md a p a t me ma s t i k a ne t i o l o g i g l o me r u l o n e f r i t i s a k u t mu n g k i nh a n y ame r u p a k a ni n f e k s i s e k u n d e r . Ke n a i k a n t i t e ra n t is t r e p t o l i s i nO ( AS O)h a n y ad i t e mu k a np a d a 8 0% p a s i e n p a s i e ny a n gt i d a k me n d a p a ta n t i b i o t i k s e l a ma f a s ed a r ii n f e k s is t r e p t o k o k u s .Ke n a i k a nt i t e r AS O d a p a td i j u mp a ip a d ab e b e r a p ak e a d a a ns e p e r t i p e mb a wa k u ma n ( k a r i e r ) ,h i p e r k o l e s t e r o l e mi ,d a n i n f e k s is t r e p t o k o k u sy a n gb a r ut e t a p ib u k a nb e r s i f a t 35 n e f r i t o g e n i k . P e me r i k s a a n p e n u n j a n g p e n c i t r a a n d e n g a n u l t r a s o n o g r a d i p e r o l e h a d a n y a p e mb e s a r a n r i n g a ng i n j a lb i l a t e r a ld e n g a nb e b e r a p ak a s u sy a n g me n u n j u k k a na d a n y ap e n i n g k a t a ne k o g e n e s i t a s .F o t o t o r a k ss e r i n g d i t e mu k a n g a mb a r a n k o n g e s t iv e n a s e n t r a l d i a r e ah i l u ss e s u a i d e n g a np e n i n g k a t a nv o l u me 47 e k s t r a s e l u l e r . P a d ak a s u s ,g e j a l ak l i n i sy a n gt i mb u la d a l a h a d a n y ae d e ma a n a s a r k a ,h i p e r t e n s ig r a d ed u a ,s e r t a k e l a i n a nu r i n a l i s i sb e r u p ah e ma t u r id a np r o t e i n u r i . S e b e l u mn y at e r d a p a tp e r i o d el a t e ns e k i t a r2 mi n g g u s e t e l a hp e n d e r i t at e r s e r a n gs u a t ui n f e k s is a l u r a nn a f a s a t a s . Ha s i lp e me r i k s a a nl a b o r a t o r i u m me n u n j u k k a n h e ma t u r id a np r o t e i n u r ip a d au r i n a l i s i s ,p e me r i k s a a n b a k t e r i o l o g i ss wa bt e n g g o r o kd i t e mu k a nSt r e p t o c o c c u s v i r i d a n sa l p h ah e mo l i t i c u s ,s e r t as e r o l o g iAS TO 200 I U/ mld a n ANA t e sn e g a t i f .P e me r i k s a a np e n c i t r a a n US G me n u n j u k k a na d a n y an e f r i t i sg i n j a ld e x t r ad a n s i n i s t r a . P e n a t a l a k s a n a a n y a n g d i r e k o me n d a s i p a d a p e n d e r i t a S NA p o s t s t r e p t o k o k u s a d a l a h t e r a p i s i mt o ma t i ky a n gb e r d a s a rp a d ad e r a j a tk e p a r a h a n p e n y a k i ts e c a r ak l i n i s .T u j u a nu t a mad a r ip e n g o b a t a n 205

a d a l a h me n g e n d a l i k a nh i p e r t e n s id a ne d e ma .S e l a ma f a s e a k u t ,p e n d e r i t a d i b a t a s ia k t i v i t a s n y a d e n g a n p e mb e r i a n d i e t 35 k a l / k g b e r a tb a d a n p e r h a r i , p e mb a t a s a nd i e tp r o t e i nh e wa n i0, 5 0, 7g r a m/ k g b e r a t b a d a np e r h a r i , l e ma kt a kj e n u h , d a nr e n d a hg a r a m y a i t u2 g r a m n a t r i u m p e r h a r i .As u p a ne l e k t r o l i tp u n h a r u sd i b a t a s i . Na t r i u m 20 me qp e r h a r i , r e n d a hk a l i u m y a i t uk u r a n gd a r i7 0 9 0 me qp e r h a r is e r t ak a l s i u m 6 00 1000 mg p e r h a r i .Re s t r i k s ic a i r a ns e c a r ak e t a t d e n g a np e mb a t a s a nc a i r a nma s u k1 l i t e rp e r h a r i , g u n a 3, 9 14 me n g a t a s i h i p e r t e n s i . P e n g o b a t a n h i p e r t e n s id a p a td e n g a n me n g g u n a k a nd i u r e t i kk u a t ,a t a ub i l ah i p e r t e n s it e t a pt i d a k t e r a t a s ip i l i h a n o b a ts e l a n j u t n y aa d a l a h g o l o n g a n c al c ium c h annelb l o c k er, ACE inh ib ito r a t a ub a h k a n n i t r o p r u s i di n t r a v e n ab a g ih i p e r t e n s i ma l i g n a .P a d a b e b e r a p ak a s u sb e r a td e n g a n k o n d i s ih i p e r k a l e mi d a ns i n d r o m u r e mi ay a n gb e r a td i i n d i k a s i k a nu n t u k h e mo d i a l i s a . T e r a p is t e r o i di n t r a v e n at e r u t a ma d i i n d i k a s i k a n u n t u kg l o me r u l o n e f r i t i st i p ek r e s e n t i kd e n g a nl u a sl e s i l e b i hd a r i 30% g l o me r u l u st o t a l . Me t i l p r e d n i s o l o n5 00 mg i n t r a v e n ap e r h a r it e r b a g id a l a m4d o s i ss e l a ma 3 5h a r i . Na mu nb e b e r a p ar e f e r e n s i me n y e b u t k a nt i d a k d i i n d i k a s i k a nu n t u kp e mb e r i a nt e r a p is t e r o i dd a l a m 45 j a n g k ap a n j a n g . An t i b i o t i k a d i i n d i k a s i k a n u n t u k p e n g o b a t a n i n f e k s is t r e p t o k o k u s .P i l i h a no b a ty a n gd i r e k o me n d a s i k a na d a l a hp e n i c i l l i nG o r a l4 x 25 0 mg s e l a ma7 10 h a r i . P e n d e r i t ap a d ak a s u s i n i d i b e r i k a nd i e t 25 00 Kk a l d a nt i n g g i p r o t e i n . P e n g o b a t a nd e n g a ni n j e k s i p h e n o x y me t i l p r e d n i s o l o n2 x6 2, 5 mg ,i n j e k s if u r o s e mi d3 x 20 mgd a nk a p t o p r i l 2 x25mg . Di l a k u k a nmo n i t o r i n g k e s e i mb a n g a nc a i r a n , e l e k t r o l i t s e r t at a n d av i t a l s e c a r a k e t a t . P a d a u mu mn y a t e r d a p a t 4 k e mu n g k i n a n p e r j a l a n a np e n y a k i td a r is i n d r o m n e f r i t i sa k u tp a s c a i n f e k s i s t r e p t o k o k u s , y a i t uk e ma t i a ns e l a mama s aa k u t d a p a td i s e b a b k a ni n f e k s is e k u n d e rt e r u t a ma i n f e k s i p a r u( p n e u mo n i a ) ,b e n d u n g a np a r ua k u t ,e n s e f a l o p a t i 206

h i p e r t e n s i f , d a nh i p e r k a l e mi . An g k ak e ma t i a nb i a s a n y a k u r a n gd a r i5 % b e r k a tk e ma j u a nt e r a p i mi s a l n y a p e mb e r i a no b a t o b a ta n t i h i p e r t e n s iy a n gp o t e n / k u a t , h e mo d i a l i s i s / p e r i t o n e a l d i a l i s i s , d a n t r a n s p l a n t a s i 3, 15 g i n j a l . S e b a g i a n p a s i e n g l o me r u l o n e p h r i t i sa k u t( 5 10%) me mp e r l i h a t k a n t i p ep e r j a l a n a n p e n y a k i t y a n gc e p a td a np r o g r e s i fd i s e r t a io l i g u r id a na n u r i , d a p a t me n i n g g a ld a l a m wa k t u2 3 b u l a n ,y a n g d i s e b u tj u g ad e n g a ns i n d r o m Rap idl y Pro g res s iv e Gl o merul o nep h ritis( RP GN) . T i p ep e r j a l a n a np e n y a k i t i n it e r u t a ma me n g e n a ip a s i e n p a s i e nd e wa s a .Ge j a l a k l i n i so l i g u r id a n a n u r iy a n g t i mb u ls e me n t a r a , t i d a k s e l a l u me n u n j u k a n p r o g n o s i s y a n g b u r u k . P a d au mu mn y ap r o g n o s i sd a p a td i r a ma l k a nh a n y a b e r d a s a r k a nk e l a i n a n k e l a i n a nh i s t o p a t o l o g i sb e r u p a p r o l i f e r a s i e k s t r ak a p i l e ry a n ge k s t e n s i fme l i p u t i l e b i h d a r i7 5 % g l o me r u l i . Ke l a i n a n l a b o r a t o r i u m y a n g me n c u r i g a k a n p e r j a l a n a n p e n y a k i ty a n g p r o g r e s i f s e p e r t ik e n a i k a nc irc ul ating b rino g en d a na t a uF DP u r i n ,d i s a mp i n go l i g u r id a na n u r iy a n gb e r l a n g s u n g l a ma , s e l a mab e b e r a p ami n g g u . T e r j a d ig l o me r u l o n e f r i t i sk r o n i s ,b i l as e l a ma p e r j a l a n a np e n y a k i td i t e mu k a ns a t ua t a ul e b i ht a n d a k l i n i s ,a t a up r o t e i n u r id e n g a na t a ut a n p ah e ma t u r i a s i mt o ma t i k y a n g me n e t a p s e l a ma b e r t a h u n t a h u n a k a nb e r u b a h me n j a d ik r o n i s ,d a na k h i r n y ag a g a l g i n j a l k r o n i s . F r e k u e n s i p e r j a l a n a np e n y a k i t i n i r e n d a h , a n t a r a 5 10%.S e b a g i a nd a r ip a s i e n p a s i e n ma s i h me mp u n y a ik e l a i n a n k e l a i n a n h i s t o p a t o l o g i st a n p a g e j a l ak l i n i sd a nd a p a t h i d u pn o r ma l . P e n y e mb u h a n k l i n i s d i s e r t a i p e n y e mb u h a n l a b o r a t o r i u mb i a s a n y ab e r a n g s u r a n g s u rd a na k h i r n y a t e r j a d ip e n y e mb u h a ns e mp u r n a . Be n t u kp e r j a l a n a n p e n y a k i ti n ip a l i n gs e r i n gd i t e mu k a nt e r u t a ma p a d a p a s i e na n a k a n a k( 8 0 8 5 %) . Ge j a l a g e j a l ak l i n i s s e p e r t i e d e map a r ua k u t , h i p e r t e n s i , e d e mad a no l i g u r i , s e g e r ah i l a n gs e t e l a ht e r j a d id i u r e s i s , b i a s a n y as e t e l a h b e b e r a p ah a r i / mi n g g u . Ke l a i n a ns e d i me nu r i nt e r u t a ma h e ma t u r i mi k r o s k o p i sb a r uh i l a n gs e t e l a hb e b e r a p a b u l a n , b a h k a nh i n g g ab e b e r a p at a h u n .
JPeny Dal am, V o l ume 1 0No mo r 3Sep temb er 2 0 1 0

RI NGKAS AN T e l a hd i l a p o r k a nk a s u ss e o r a n gl a k i l a k i , 14 t a h u n ,s u k u Ba l iy a n gd i d i a g n o s i sd e n g a ns i n d r o ma n e f r i t i ka k u tp a s c ai n f e k s is t r e p t o k o k u s . Di a g n o s i s d i t e g a k k a nb e r d a s a ra n a mn e s ab e n g k a ks e l u r u ht u b u h , k e n c i n gb e r wa r n ak e me r a h a nd a ns e d i k i t ,r i wa y a t s a k i t t e n g g o r o k a n 2 mi n g g us e b e l u m M RS .P e me r i k s a a n s i kd i d a p a t k a np e n d e r i t ad e n g a nh i p e r t e n s ig r a d e I I ,e d e ma a n a s a r k ad e n g a np e me r i k s a a np e n u n j a n g l a b o r a t o r i u m d i d a p a t k a ng r o s sh e ma t u r i ,p r o t e i n u r i , AS TO 200 I U/ ml , p r o t e i ne s b a c h3, 25g r a m/ l i t e r / h a r i , ANA t e s tn e g a t i fd a ns wa bt e n g g o r o kd i d a p a t k a n S t r e p t o c o c c u sv i r i d a n s ,a l p h ah e mo l i t i c u s . Ra d i o l o g i s d i p e r o l e h CTR 5 4, 23%, e f u s ip l e u r ad e x t r a . US G g i n j a lme n u n j u k k a na d a n y an e f r i t i sg i n j a ld e x t r ad a n s i n i s t r a . Ek o k a r d i o g r a me n u n j u k k a na d a n y at r i k u s p i d r e g u r g i t a s it r i v i a l .P e n d e r i t a me mb e r i k a n r e s p o n y a n g b a i k t e r h a d a p k o r t i k o s t e r o i d ,y a i t u p h e n o x y me t i l p r e d n i s o l o n , d i u r e t i k as e r t aACE i n h i b i t o r . DAF T AR RUJ UKAN 1. Me s s i n a LM , P a k LK, T i e r n e y LM . Gl o me r u l o n e p h r o p a t h i e s .I n : T i e r n e y LM , Mc P h e eS J ,P a p a d a k i s M A, e d i t o r s . La n g e r d c u r r e n tme d i c a ld i a g n o s i s& t r e a t me n t .43 e d . P h i l a d e l p h i a : La n g e Me d i c a l Bo o k s / Mc Gr a w Hi l l ; 2004. p . 8 8 29 0. Br a d y HR, O Me a r a YM , Br e n n e r BM . Gl o me r u l a rd i s e a s e .I n :De n n i sLK,F a u c iAS , Br a n wa l d E,Ha u s e rS L,Lo n g o DL,J a me s o n J L, e d i t o r s . Ha r r i s o n sp r i n c i p l e so fi n t e r n a l t h me d i c i n e ,16 e d .Ne w Yo r k :M c Gr a w Hi l l ; 2005 . p . 16 7 48 8 . En d a yS .Ne f r o l o g ik l i n i k ,e d i s iI I .Ba n d u n g : I TB; 19 9 7 . p . 145 6 3. T r a v i s L. Ac u t e p o s t s t r e p t o c o c c a l g l o me r u l o n e p h r i t i s . Av a i l a b l e f r o m: h t t p : / / www. e Me d i c i n e a c u t e p o s t s t r e p t o c o c c a l g l o me r u l o n e p h r i t i s . Ac e s s e do n : 12t hJ u n2005 .

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Ge e t h a D. Gl o me r u l o n e p h r i t i s , p o s t s t r e p t o c o c c a l . Av a i l a b l e f r o m: h t t p : / / www. e Me d i c i n e g l o me r u l o n e p h r i t i s ,p o s t s t r e p t o c o c c a l .Ac e s s e d o n : 12t hJ u n2005 . Ma u r e e n H. Ac u t e p o s t s t r e p t o c o c c a l g l o me r u l o n e p h r i t i s . Av a i l a b l e f r o m: h t t p : / / www. l i f e s t e ps . c om/ gm/ a t oz / e nc y/ a c ut e _ p o s t s t r e p t o c o c c a l _ g l o me r u l o n e p h r i t i s . j s p . Ac e s s e do n : 12t hJ u n2005 Vi n e n CS , Ol i v e i r a DBG. Ac u t e g l o me r u l o n e p h r i t i s . P o s t g r a d u a t e d Me d i c a l J o u r n a l 2003; 7 9 : 206 13. S mi t h J F . Ac u t e p o s t s t r e p t o c o c c a l g l o me r u l o n e p h r i t i s . Av a i l a b l ef r o m: h t t p : / / www. c h c l i b r a r y . o r g / . Ac e s s e do n : 12t hJ u n2005 d F r a n s i s c oL. P a p p e r sc l i n i c a l n e p h r o l o g y . 3r e d . Bo s t o n :Li t t l e , Br o wn a n d Co mp a n yI n c ;19 9 3. p . 1425 0. T o ms o n CRV.Ke yt o p i c si nr e n a l me d i c i n e . Ox f o r d : BI OS S c i e n t i c P u b l i s h e r Li mi t e d ; 19 9 7 . p . 139 43. Gl a s s o c k RJ ,Co h e n AH,Ad l e rS G.P r i ma r y g l o me r u l a rd i s e a s e s .I n :Br e n n e rB,Re c t o rF , t h e d i t o r s .Th ek i d n e y .6 e d .P h i l a d e l p h i a :W B S a u n d e r sCo ; 2000. p . 139 2402. Ro d r i g u e z I t u r b e B. P o s t i n f e c t i u sg l o me r u l o n e p h r i t i s . Am JKi d n e yDi s2000; 35 ( 1) : 46 8 . Ge d d e s C. Th e t r e a t me n t o f i d i o p a t h i c me mb r a n o u s n e p h r o p a t h y . S e mi n Ne p h r o l 2000; 20; 29 9 . Xi me n a B,Ed d a L,Er i cS ,Gl o r i aS ,Be a t r i z G, I n g r i d R. P o s t s t r e p t o c o c c a l a c u t e g l o me r u l o n e p h r i t i s . I n : Xi me n a B, e d i t o r . P e d i a t r i c Ne p h r o l o g y . P h i l a d e l p h i a : WB S a u n d e r sCo ; 2000. p . 45 6 6 7 . P o n t i c e l l iC.Ca np r o l o n g e dt r e a t me n ti mp r o v e t h ep r o g n o s i si na d u l t s wi t hf o c a ls e g me n t a l g l o me r u l o s c l e r o s i s ? Am J Ki d n e y Di s 19 9 9 ; 34: 6 18 .

S e o r a n gP e n d e r i t aS i n d r o m Ne f r i t i kAk u t P a s c aI n f e k s i S t r e p t o k o k u s Ni Made Renny A Rena, Ketut Suwitra

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