ASIDOSIS TU8ULUS

DISTAL 0IMJAL PADA
IEHAMILAM
Siti EIkunu NuuIi
PEMDAHULUAM
Definisi : qonqquon yonq menqokibofkon
kefidokmompuon qin¡oI unfuk mensekresi H+
ofou menohon HCO3-
Tondo kIosik :
osidosis hiperkIoremik
Io¡u fiIfrosi qIomeruIus normoI ofou berkuronq
sedikif
fidok difemukon odonyo refensi onion (fosfof &
suIfof)
#erofo produksi H+ dori mokonon :
I-I,b mmoI/kq88/hori, ferufomo
berosoI dori konsumsi profein
DoIom kondisi fidok fernefroIisir,
kondisi osom ini okon menqhosiIkon
pH~I unfuk I Iifer urin (pH minimoI urin
fisioIoqis odoIoh 4,Z)
Penqoruh kehomiIon ferhodop
onofomi & fisioIoqi qin¡oI
0in¡oI membesor ± I cm, koreno
penimbunon coiron di pembuIuh doroh
don coiron infersfisioI
DiIofosi koIiks, peIvis, don urefer
(ferufomo di boqion konon), muIoi
frimesfer II s/d Z buIon posko
persoIinon
IIinis qomboron qoqoI qin¡oI okuf podo
umumnyo disebobkon nekrosis fubuIor
okuf okibof hipovoIemio
Dibondinqkon denqon qoqoI qin¡oI okuf
diIuor kehomiIon, nekrosis korfikoI okuf
seboqoi penyebob qoqoI qin¡oI okuf
podo kehomiIon Iebih serinq difemui
ISIOLO0I 0IMJAL
0in¡oI mencopoi forqef keseimbonqon
osom boso meIoIui 3 mekonisme :
#eobsorbsi HCO3- di fubuIus proksimoI
Sinfesis & ekskresi MH4+ di fubuIus
proksimoI
Sekresi H+ di fubuIus disfoI
TU8ULUS P#OISIMAL
unqsi ufomo
reobsorbsi HCO3-
pembenfukon MH4+
menquronqi pH urin dori 7,I men¡odi o,7
reobsorbsi qIukoso, osom omino, onion orqonik
(fermosuk sifrof) & fosfof
Enzim yonq beker¡o :
Mo+/I+ATPose
enzim onhidrose korbonik di brush border
enzim qIufominose
fosfoenoIpiruvof korboksikinose
LOOP HEMLE
Merupokon fempof persinqqohon MH4+
sebeIum okhirnyo diobsorbsi di boqion
Iimb osenden feboI
TU8ULUS DISTAL & DUITUS
IOLEITI
unqsi :
rekIomosi Z07 dori fofoI HCO3-
sekresi H+
TubuIus disfoI memiIiki Z seI penfinq yonq
berperon doIom proses ini :
seI prinsipoI don seI inferkoIosi (oIfo don
befo)
SeI prinsipoI berfuqos unfuk reobsorbsi Mo+
don oir, don sekresi I+
SeI inferkoIosi oIfo : sekresi H+ (diofur oIeh
H+-ATPose)
SeI inferkoIosi befo : sekresi HCO3- yonq
okon difukor denqon CI-
Disfribusi : o07 seI prinsipoI, sisonyo odoIoh
seI inferkoIosi (seI inferkoIosi befo fidok
difemukon di dukfus koIekfif boqion meduIo)
PATOISIOLO0I
4 fipe osidosis fubuIus qin¡oI :
Tipe I : osidosis fubuIus disfoI (d#TA)
Tipe Z : osidosis fubuIus proksimoI
(p#TA)
Tipe 3 : fipe compuron proksimoI & disfoI
(soof ini fidok diqunokon Ioqi)
Tipe 4 : okibof sekunder dori defisiensi
ofou resisfensi oIdosferon
#TA Tipe I (d#TA)
AbnormoIifos primer : kefidokmompuon qin¡oI
unfuk menurunkon pH urin diserfoi osidosis
mefoboIik okibof qonqquon sekresi H+
Tondo :
Asidosis mefoboIik
HipokoIemio
MefrokoIsinosis
UroIifiosis
TIPE d#TA :
Secoro fisioIoqi diboqi men¡odi 3 fipe
berdosorkon pofoqenesis seIuIernyo :
Asidosis fubuIus disfoI fipe
sekreforik/kIosik
Asidosis fubuIus disfoI fipe bock-Ieok
Asidosis fubuIus disfoI fipe voIfoqe
dependenf
|a)l|po|a|er|a |l|pe ||as||)
P(|re(
0erel||
0|sp(ole|rer|a
0ardduar |a|s|ur
Perva||l d|rja|
Aulo|rur
0oal/(acur
|a)l|pe(|a|er|a |vo|raoe oeoenoenr)
0osl(u|s| l(a|lus u(|ra(|us
lerod|oo|ropal|
0oal
- le(ed|le(
- 3po(ad||
- 3|rd. Er|e( 0ar|os
- 3|rd. Va(lar
- Perv. Fao(v
- Perva||l w||sor
- l|pe(darad|oou||rer|a
- K(|od|oou||rer|a
- Ar||o|dos|s
- l|pe(|a|s|u(|a |d|opal||
- l|pe(pa(al|(o|d p(|re(
- lrlo|s||as| v|lar|r 0
- P|e|orel(|l|s |(or||
- Nel(opal| 8a||ar
- Pero|a|ar d|rja| l(arsp|ar
- 3|rd. 3jod(er
- T|(o|d|l|s
- A|veo||l|s l|o(osa
- lepal|l|s |(or|| a|l|l
- 3|(os|s o|||a(|s p(|re(
- Po||a(le(|l|s rodosa
- Arlole(|s|r
- L|l|ur
- Ara|del||
- To|uer
- Perva||l se| sao|l
- Ar||o(|d
- T(|arle(er
ASIDOSIS TU8ULUS
P#OISIMAL
AbnormoIifos ufomo :
keqoqoIon reobsorbsi HCO3-
Podo semuo fipe osidosis fubuIus proksimoI, ombonq
bofos reobsorbsi HCO3- furun dori ZZ mmoI/L men¡odi
sekifor Ib mmoI/L
Iefiko HCO3- serum furun dibowoh kodor ini ekskresi
HCO3- okon furun denqon cepof don urin okon men¡odi
osom sefeIoh meIoIui fubuIus disfoI denqon pH urin
mencopoi dibowoh b,b
Asidosis fubuIus proksimoI merupokon keIoinon yonq
dopof sembuh sendiri.
Penyebob ferserinq keIoinon ini odoIoh mefoboIic bone
diseose
|a) Te(|so|as| |larpa s|rd.Farcor|)
P(|re(
Arr|d(ase |a(oor||
|o) 0ere(a| |derdar s|rd.Farcor|)
P(|re(
8e(ruourdar derdar derel||
0|sp(ole|rer|a
l|po|a|ser|a
8e(ruourdar derdar |e|a|rar d|rja|
Aulo|rur
Lodar oe(al
0oal/(acur
-le(ed|le(
-3po(ad||
-Perdraroalar |le(ap| aselazo|ar|d)
-0el|s|ers| ||solo(r ll derdar osleopo(os|s)
-le(ed|le(
-3po(ad||
-3|sl|ros|s
-0a|a|loser|a
-Perva||l d|o|oder l|pe l
-lrlo|e(ars| l(u|losa re(ed|le(
-3|rd. LoWe
-Leu|od|sl(ol| rela|(oral||
-T|(os|rer|a
-Perva||l w||sor
-V|e|ora ru|l|pe|
-onr onan o8ea8e
-Ar||o|dos|s
-0el|s|ers| v|lar|r 0
-Res|slers| v|lar|r 0
-T(oroos|s vera (era||s
-Pero|a|ar l(arsp|ar
-3|rd. 3jod(er
-T|roa|
-Cadr|ur
-Ve(|u(|
-Arl|o|ol|| ar|rod|||os|da
-Tel(as||||r |ada|ua(sa
-Coura(|r
-3l(eplozolos|r
ASIDOSIS TU8ULUS
0IMJAL TIPE 4
Difondoi denqon keqoqoIon sekresi H+
don I+ di dukfus koIekfif okibof
defisiensi oIdosferon ofou resisfensi
0el|s|ers| r|re(a|o|o(l||o|d p(|re(
0el|s|ers|r le(|so|as|
Koro|ras| derdar del|s|ers| d|u|o|o(l||o|d
l|poa|dosle(or-r|po(er|r
0el|s|ers|/(es|sler ard|olers|r ll
Res|slers| a|dosle(or
0oal
-0el|s|ers| rel||o|s|dase lar|||a|
-0el|s|ers| r|re(a|o|o(l||o|d l(ars|er
-l|pe(p|as| ad(era|
-Perva||l Add|sor
-Nel(opal| 0V
-Perva||l luou|o|rle(sl|s|a|
-Nel(opal| oosl(u|l|l
-T(arsp|arlas| d|rja|
-Nel(|l|s |upus
-ACE |rr|o|lo(s
-lrsers|l|v|las ad(era|
-Pseudor|poa|dosle(or
-3p|(oro|a|lor
-Ar||o(|d
-T(|arle(er
-Te(ap| repa(|r jard|a |ara
ILUST#ASI IASUS
Momo : My #
Usio : Z7 fh
Peker¡oon : I#T
Aqomo : IsIom
Pendidikon : SMP
Sfofus : menikoh denqon I onok
AMAMMESIS
IeIuhon Ufomo : munfoh se¡ok I minqqu SM#S
#iwoyof Penyokif Sekoronq :
- munfoh-munfoh se¡ok I minqqu SM#S.
- munfoh berisi mokonon don minumon yonq mosuk
- muoI, sokif kepoIo seperfi difusuk ¡orum, bodon Iemos,
nofsu mokon menurun
Posien soof ini sedonq homiI 4 minqqu (HPHT 8 ebruori
Z008).
SeIomo Z hori ferokhir posien suIif dio¡ok berkomunikosi don
menqeIuh keduo funqkoi bowohnyo suIif diqerokkon.
8uonq oir keciI men¡odi Iebih ¡oronq don oqok qeIop wornonyo.
#iwoyof Penyokif DohuIu :
Porfus sponfon b fohun yonq IoIu
Juni Z00o posien serinq menqeIuh Iemos
seIuruh eksfremifos yonq fimbuI biIo
posien keIeIohon
#iwoyof Penyokif doIom IeIuorqo :
fidok odo keIuorqo posien yonq memiIiki
keIuhon seperfi ini
PEME#IISAAM ISII
Ieodoon umum : Iemoh, Iidoh kerinq
Iesodoron : kompos menfis
Tondo vifoI
TD : 90/o0 Modi : 7b x/mnf ## : ZZ
T : 37,Z
Mofo : kon¡unqfivo pucof, skIero fidok ikferik
Leher : I08 fidok ferobo membesor, firoid fidok
membesor
Jonfunq : 8J I-II normoI, murmur (-), qoIIop (-)
Poru : vesikuIer, ronki (-), menqi (-)
Abdomen : Iemos, nyeri fekon (-)
Eksfremifos : porese (-)
EI0 : Sinus rifme, Io¡u ¡onfunq 80
bpm, oxis normoI, qeIombonq P (+), P#
infervoI 0,IZ C#S durofion 0,08 ST-T
chonqes (-)
Hemoglobin
Hematokrit
Leukosit
Trombosit
MCV
MCH
MCHC
Ureum
Kreatinin
Natrium
Kalium
Klorida
Gula darah sewaktu
Hitung jenis :
Basofil
Eosinofil
Batang
Segmen
Limfosit
Monosit
Sediaan apus darah tepi
SÌ/TÌBC
TSH
Free T4
8,1
26
8100
238000
77
24
32
50
1,5
135
2,1
115
114
0
2
1
85
11
1
Anemia
mikrositik
hipokrom
41/300
1,5
5,3
Protein total
Albumin
Globulin
Cholesterol
Bilirubin total
SGPT
SGOT
Gamma GT
Alkalin fosfatase
Urinalisa :
pH
Protein
Glukosa
Bilirubin
Eritrosit
Leukosit
Toraks
Kristal
Epitel
Lain-lain
Keton
Kalium
Natrium
Klorida
Kalsium
7,0
3,6
3,4
105
1,0
14
19
18
173
5,6
+
-
-
2-1-2
3-4-5
-
Ca oxalat
+
-
+
250
36,6
226
7,2
MosoIoh :
Hiperemesis qrovidorum podo 0ZPI H 4
minqqu denqon dehidrosi
HipokoIemio ec hiperemesis qrovidorum
Anemio ec defisiensi besi
I. Hiperemesis qrovidorum podo 0ZPI H 4 minqqu denqon
dehidrosi
#encono Dioqnosis :
US0 obdomen unfuk meniIoi kese¡ohferoon ¡onin
#encono Teropi :
IVD Aserinq + ICI Zb mEq/ koIf diberikon Z0
fefes/menif
Anfosido 3xCI
MefocIopromid 3xI ompuI
Z. HipokoIemio ec hiperemesis
qrovidorum
#encono Dioqnosis :
- Cek IoIium fiop hori
#encono Teropi :
- Ioreksi ICI Zb mEq doIom Z ¡om
3. Anemio ec defisiensi besi
#encono dioqnosis :
-sedioon opus doroh fepi, refikuIosif
-SI, TI8C
-feses Ienqkop
#encono feropi :
-Hemobion IxI fob
HASIL IOMSUL
IPD (8 ApriI Z008)
MosoIoh : dehidrosi, infoke kuronq,
hiperemesis qrovidorum, onemio
Soron : koreksi ICI b0 mEq doIom IZ ¡om
IVD Aserinq/#L : Db ~ Z:Z ~ 30 fefes/menif
8oIons coiron
#oboronfio Asom foIof 3xI fobIef
IonsuI psikiofri
OLLOW UP
7 ApriI Z008 posien dioIih rowof ke boqion kebidonon
8 ApriI Z008 : IoIium Z,I diIokukon koreksi ICI b0 mEq
seIomo IZ ¡om
9 ApriI Z008 : posien kesodoron somnoIen, fondo vifoI sfobiI.
Munfoh (-), muoI (-)
IoIium I,8 diIokukon koreksi uIonq IoIium b0 mEq/b00cc
#L/IZ ¡om
A0D : pH 7,Z34/pOZ I34,3/pCOZ Ib,7/HCO3 o,b/
8E -I8,3/Sof 98
Sikop : koreksi 8icnof I00 mEq doIom 8 ¡om,OZ o Ifr/menif
I0 ApriI Z008 posien kemboIi dioIih rowof ke
penyokif doIom
IoIium I,8 diIokukon koreksi cepof ICI Z0
mEq doIom Z¡om don koreksi Iombof Zb mEq +
MoCI 0,97 Z0 fefes/menif
Ioreksi 8icnof I00 mEq
IonsuI 0in¡oI Hiperfensi (I0 ApriI Z008) :
MosoIoh : suspek disfoI #enoI TubuIor
Acidosis
Sikop : fronsfusi P#C Zb0 cc
Ioreksi IoIium don 8icnof diferuskon
K
a
l
i
u
m

d
a
r
a
h
0 1 2 3 4 5
2 3 /0 3 /2 0 0 8
3 0 /0 3 /2 0 0 8
0 6 /0 4 /2 0 0 8
1 3 /0 4 /2 0 0 8
2 0 /0 4 /2 0 0 8
2 7 /0 4 /2 0 0 8
0 4 /0 5 /2 0 0 8
T
a
n
g
g
a
I
m E q
K
a
l
i
u
m

d
a
r
a
h
arbonat darah
0
2
4
6
8
10
12
14
16
2
3
/
0
3
/
2
0
0
8
3
0
/
0
3
/
2
0
0
8
0
6
/
0
4
/
2
0
0
8
1
3
/
0
4
/
2
0
0
8
2
0
/
0
4
/
2
0
0
8
2
7
/
0
4
/
2
0
0
8
0
4
/
0
5
/
2
0
0
8
TanggaI
m
E
q
Series1
Series2
Series3
MosoIoh :
HipokoIemio beruIonq ec osidosis
fubuIus qin¡oI disfoI
Asidosis mefoboIik beruIonq ec
osidosis fubuIus qin¡oI disfoI
0Z PI homiI IZ minqqu ¡onin funqqoI
HipokoIsemio
Teropi ferokhir :
IS# 3xZ fobIef
8icnof 3x3 fobIef
Asom foIof IxI fobIef
SuIfos ferosus IxI fobIef
Ioreksi 8icMof don ICL fefop diferuskon
Dief TITP Io00 kkoI denqon exfro koIdu don
buoh
Exfro ¡eruk nipis 8 buoh
Lorufon SOHL 3 x CI
Ieson Umum :
Seoronq wonifo Z7 fohun denqon mosoIoh
osidosis mefoboIik don hipokoIemio beruIonq
koreno osidosis fubuIus qin¡oI disfoI podo
kehomiIon IZ minqqu. Posien denqon keIuhon
porese keempof eksfremifos se¡ok I fohun
yonq IoIu yonq dicefuskon oIeh keIeIohon fisik.
DiIokukon pemberion Iorufon SOHL don
koreksi ferhodop hipokoIemio, osidosis
mefoboIik don hipokoIsemio. Posien mosih
doIom perowofon koreno mosoIoh hipokoIemio
yonq beruIonq don osidosis mefoboIik yonq
beruIonq meskipun sudoh diberikon koreksi.
DISIUSI
Dioqnosis osidosis fubuIor qin¡oI disfoI
difeqokkon ofos kriferio dioqnosis :
HipokoIemio
Asidosis mefoboIik
HiperkIoremio
Anion qop urin posifif
pH urin
Moniforinq :
onoIiso qos doroh
eIekfroIif doroh
koIsium urin dopof diIokukon unfuk
memperfohonkon kodor koIsium urin
dibowoh 0-0,b mmoI/kq88/Z4 ¡om
moniforinq ¡uqo diIokukon ferhodop
ke¡odion nefrokoIsinosis don
osfeoporosis
P#O0MOSIS
PerIu pemonfouon berkoIo ferhodop
kehomiIon
8eIum odo dofo peneIifion efek #TA
podo kehomiIon
Moniforinq ferhodop nefroIifiosis don
osfeoporosis horus diIokukon secoro
berkoIo
Teropi kosus ini merupokon feropi
¡onqko pon¡onq
IESIMPULAM
TeIoh diIoporkon kosus seoronq wonifo Z7
fohun denqon mosoIoh osidosis mefoboIik don
hipokoIemio beruIonq koreno osidosis fubuIus
qin¡oI disfoI podo kehomiIon IZ minqqu. Posien
denqon keIuhon porese keempof eksfremifos
se¡ok I fohun yonq IoIu yonq dicefuskon oIeh
keIeIohon fisik. DiIokukon pemberion Iorufon
SOHL don koreksi ferhodop hipokoIemio,
osi dosi s mefoboI i k don hi pokoI semi o.

!&& 
0138,3:,3,3203,-,9,3 09/,2,25:,33,:39:20380708  ,9,:203,,3 
%,3/,,8
,8/4885074702 ,:197,84207::83472,,9,:-07:7,3 80/9 9/,/902:,3,/,3,709038,343 1481,9  8:1,9

#07,9,574/:8 /,72,,3,3  
224



,7 907:9,2, -07,8,/,7438:28574903 ,,243/89/,9073097,87  43/8,8,23,,3203,8,3 5:39:907:73 5232,:73 18448,/,, 

3:70907 907:9.33907898.3.. 3./-.5 .7.7.3.2.3 2:.703. .7:0..2.7] . 5032-:3.9..8 /.2 .!03.7.3.202-08. 972089078./.3/502-::/.8 50.942 18443.3907.3.8. /.3.

8. 5078.35.3 ./-:.3.

30-8073/902: ..:9 /:. -.7 .-../.3.2.70.3/03.38.3 307488479.3.:9 80-..2-.:9 5.-.33074889:-:./80-.5030-...3/3.7.:9.-.402.:95. :2:23../.954..3.3.0..2.3.

$   3..20.8.3820 #0.-847-8  /9:-::857482. $0708 /9:-::8/89.3 . .203.3.9.7090802-. $39088 08708 /9:-::8 57482.8.:20.2-.5.

8:897. .2.234 .9 32.-847-8:48.35:73/.9  1481. .3 203:7.2.-847-8  502-039:. 70.3 9072.3-007.8.7 203.34347./  70.%&&&$!# $ :38:9. .

 %!.80.3/7.80 032.7-483.9.23.80 1481403457:.80 .7-43/-7:8-47/07 032:9..

.

3 2-..3  80-0:2.803/0390-../.-847-8/-. ! 07:5.73.950783.. .39025.

.

  80708  %:-::8/89./.8 /.8:39:70.7 /.25748083 8057385.3 -09..-847-8.2.1.3 -07507.  /.-079:..380708 .3803907./.7949.3/.%&&&$$% &%&$  % :38 70. $057385.2028050393.8 .3.

 803907.1.3.. /902:.7/03..9/..3 .$03907..8-09.8-09.../.8.8 803907.3//:9:84091-.320/:.3/9:. 88..3 897-:8 8057385.80708  /.80  $03907. .9:740  %!..80708  .

.

.

.

/:3.9.25:7. 5#% %50950.7/018038 . /#% %50... 8.-.8/4889:-::857482. %50.939/.357482.3..!% $   950. /89.8/4889:-::8/89.980:3/07/.:70889038./4890743 .8/4889:-::83. %50.

3/.8/488 209.380708  %.. 0174.2.#%%50 /#% -3472.9. :39:203:7:3.25:.83488 &749.-4.-.35:73/8079.85720709/.9.33.02.-4 54. 8/488209.3:.88 .

940308880:073.8.7.%!/#% $0.950 8070947. 8/4889:-::8/89.1844/-.203.35.7../950 -07/.

 0.0 /0503/039 .. 8/4889:-::8/89.950-.8 8/4889:-::8/89.950.49..

8:2 !03.3.9. 54.. :942:3 -.02. 950.3:.8 !7207 0309 857490302. .93.

49.998743. .-9 247/ %7.91 $7488-.8:7. 24/488 507.348 $3/ .9. 744-:302.3 $3/ $4703 %74/98 .33.3 !03 .3 !034.71.9:8:73.290703 . 05.09 %4:03 .9843 507.4-:302.7857207 !4.2.7./45.8..385.9 5075.23 !04301798743 01745.04981-748.9 -.7.79079834/48./ $3/ 07.. 507.9 !03.9808.:3 070/907 $547.02.97.-7 !03..0/0503/039 -897:897.7:8 0244-345.9.974/57207 3948. 21490783 9:2 3.

.3 -./.870. 0.7224.370.802:.-847-8  9:7:3/..$ $$%&&&$ !# $ -3472. .-847-8  !.2-.8:9.2.8/4889:-::857482.9.950.9.

7224./ 809.203.

/.8./...80 .3:73./ .20.-430 /80.  8/4889:-::857482. 09.9802-:803/7  !030-.39:7:3/03.3 /..207:5.28090.30.33..:9:-::8/89.35:73 203.3.  807:29:7:3/-.3./-.3.-4.7308708   .05.209..9/..5.-90780730./03...3.3203.5.

4.23 #0889038.802.3/03.23448/.30. 07:-:3. 54.3 907.3. 4:2. /03.9 %748302.809.83./. :942:3 4.03./2:2 07:7 39-49.9.9 -.7-43 ..30309 070/907 $547. %097.2-07. .2:950 9.80.9.:.23 %742-488.8 !034.0307..8 9.9.5.703.9.78.94802.385.33..73 $97059449483 857490302.43 !7207 3/7.070/907 $3/ 40 0:4/89741209.3/03. !03..2/ 018038 841472/03.3.397.3817:948. !03.3/80.80 24/488 018038.348904547488 070/907 $547.9843 042.383/ .35.3.83/ .2-. %0784.43 !7207 07:-:3./ !03./ $893488 .94403950 39407.742.3 $3/ $4703 %2-.

.:3 .7.

.3/.-.9 /018038./4890743.:70889038 .30.9..$ $$%&&&$ %! 9.3 //:9:84091.380708  /./03.

8/03.0180382307.44794/57207 018038390784./4890743 547033 018038.3/018038:44794/ 54.8 42-3.

505.8.99:-:43907898.9 !03.2./703.385.7088903.73.3490383 #0889038.94-897:91 %7./4890743 -./4890743 $57434.943 247/ %7./703. !03.2..3.8.39. 0180382307.290703 %07.44794/97. 01745.9. .3803 5075.801. !80:/454.9//843 01745. 01798:5:8 3-9478 380389.9 01803820948/.83.

&$%#$$&$ .3 $! $9. ..2. # &8.3 #% .2.9:8 203. 8.3.3.2 !03//. 9 !007./03.

7.3.3.302..8:9/07.70..32./0-.7.3.7:2 -.3 2:39.3 :.9$0.-0782.-.9:3.8038.8038:9/.223: !%0-7:. 2:39.73.8  3.  .3203:7:3 !.8/.3.9!03.7    $0.5.2.2..3 2030:0/:.80.3.3/.3.18:2.7907.....$$ 0:.. 8.9380/.80.75.905.2:39.8: 2:.-0742:3.0.23:$#$ #..805079/9:8:.323:2..23:$#$ 2:39.3.203./.3/.3&9.

38050793 . 9/.5.80300.: :3 5...8 80:7:0897029.3.:3..8.9!03.392-:-.80380732030:02.39.9. 5.79:885439.7.9/.3 #.803.9!03.20:.7.:: !.#..3202 0:.0:./..

34254820398 %../.3:2:202. /.9.!#$$ 0..3/./. % .073 08.7.

/. .

202-08.39:3 3472.9/.-.7: .907.9 807.3 897029.7080 .239 ## %  .7 .5:. 202-08.9.85. 2:72:7 ..08:07 743 203 -/420302.45 !.7 974/9/.43:39.8 30790..907 0079/.

.83472. "#$/:7.3! !# 3907.$3:87920 .39:3  -52 .. 042-.943 $% % .:.308 .

7.:2 47/.9.5:8/.7. :.905                   302..933 .3 $0203 21489 43489 $0/.80./.9479 0:489 %742-489 '   &70:2 70.97:2 .0244-3 02.9: 9:3038 .3. 27489 54742 .841 48341 .

9.8 789.% .9      $.31481.22.8. $!% $ % .4.3 0943 . 7:-3 797489 0:489 %47.3 .:2 .   !74903949.8:2                  .80 &73. 590 . -:23 4-:3 4089074 7:-3949..97:2 47/. 5 !74903 :48. .

% %$ 700% .

../.507020887./.0.3/0/7.! 23:/03./.7:25.02../018038-08 .7:2 302.8 54.0.8. 507020887..

080.3./..5 '8073 26.3./.3 /0/7.-/4203:39:203...8 #03. 507020887..33 #03.3488 &$.!23:/03.7:25.907.3..%07.

41/-07.3  90908.

 094.457.25: .8/.2/.2039 39.

:29..50702088 7.7 #03..5 470826/..5.3488 0.7:2 #03.3.2 .. 54.2.%07./..02.0.3.

/.- ./018038-08 #03..3.5 024-439.3..5:8/..3.3488 80/. 302.5 #03.907.7.0.905 709:489 $ % 1080803.

8.0:7..7:2 .3  507020887.$ $& ! 57  ../0/7.2. $.7..2 '8073./.302.34708 26/.8 39.

# 90908.

8.2039 ..214.3 #4-47.99.39.7.-09 438:58.97 .38..

3/..3..34708 26 80.80308.. ./.:.9.2.90-.:2 26.803/.7.3 57 .:.3. 2:.:2  /.-  :39.2 57 5.  &! 57 5.30-/.89.34708:.7..38423403 9.:2  /.

 #.. .

2 5 ..

5  .

5  .

  .

   .

3.54708.$..2 97.2.9 $.9 26/.

2039 .

.926  . 57 5.:2  /..7.9/.90 503.2-.34708.  90908.:..2/.80302-.9  26/.34708.05.2./.2 .

3.3 .381:8!# . 4708.8.7 .5079038  57   .:2/..8:850/89..3.#03./488 $.9 26 438:3.2039 4708.597.%:-:.3.9/907:8.

2 6        .

 .

   .

 .

   .

 .

3.:2/.  %.7.   . .

 .

   .

 .

    .

 .

   .

 .

7.:2/. .  .

2 6  .

 .

      .

 .

 .

 .

  .

  .

     .

  .

  .

  .

 .

 .

%. $0708 $0708 $0708 .9/.7.3.         .7-43.

. .02.8/4889:-::83..30.30.223:. 8/488209./89..339:3./89. . 54. !.-4-07:.8.802. 54.8/488 9:-::83.-07:.

5907.3$  .214.3 09%%! .5/907:8.3909.-09 $:1.3097.-09 4708.9/.7:9.3 -:.-09 8..%07. 97./:/. .3./03.99.-09 .99..07:358-:.810748:89.7 $#9.

2507..318  . .02.3 4708907.8./.802.02./89./..9.:3 .354.3&2:2 $047.8 /.8032.02.34708 .:.09:8.-4/.3.3.3502-07.2.3.8.2.3 5.8/488 209.3/.323: !.3.:.3-07:.30:.3 -07:..880.8/4889:-::83.3 ...5.9. .54.703. .-07:.703./-07. !.:3/03.3/.34000.8/488209..803/03.-4.70800025.32085:38:/.39.9.7:9.3.8/488209.08.3$ /.32.90897029.354.-4/.554. 0.

/.3488..02.87907.5:7354891 5:73 .9.73. /90.8/4889:-:.-4 5074702.$&$ .3. 8/488209. 343./89.3488 54.

.

.

.

.3.8/. 009749/.7. 224.439473 ..5. .3:39: 2025079.3.:.7.3.8..8:2:73 /-./.9/.8:2:73/.7.

.

/.2 2439473:.5 0.3907././.330174.3 48904547488 ..:.83488/.

3 439473907.88/.5.3 48904547488.3907./.!#  $$ !07:502.5 0.3 0:2././.3 .:.3.3.2.380.0.8:83207:5. -07.3-07.5.7:8/..5 .5301749.3010#% 5.:.9./.39. %07.50309.7.2.907./....

/.3 2.3 .39.-4 /.$!& %0.8..3 0:.9 0897029.3 54.8 80./.3  23: !.09:8.3 /. .8/488 209.:3 /03.3 40 00.3 5.2.: . . /.:. -07:. .:3 . 0.-4 /. . 5.  9.3 .3 54.3 .3 502-07.3 $  /.8/488 9:-::8 3.5 54.803 /03.7:9.3 .3 .02. /89.3 18 .02.3 4708 907.7080 0025.  9..8:8 8047.547.8/488 209.802.703.