PBL WEEK 4 KIDNEY

Tutorial 1

Page 1

Mr. F., 55 years, came to see his doctor in the hospital which is located in the town where he is
living. He complains that he had nauseous filling for three weeks. His appetite was less than
usual and sometime he vomits twice a day. He also complains of weakness of his body and
feeling shortness of breath when doing fast walk or going upstairs of his house. He has history of
Diabetes Mellitus for 14 years and during these times his blood sugar not well controlled. His
doctor told him that he had kidney disease.

1. What are the problems of this patient?

● Nauseous filling for 3 weeks
● Appetite less than usual
● Vomits 2x a day
● Weakness of the body
● SoB when walking fast or climbing stairs
● History of DM for 14 years → during this times blood sugar is not controlled
● Kidney disease

2. How do these problems appear?

Kayaknya buat ini boleh langsung kaitin aja dari kidney diseasenya sama dia kenapa
soalnya udah frontal dibilang dia ada kidney disease
- Nausea, loss of appetite, vomit (uremia) → retention of metabolic acids and other
metabolic waste products → krn kidney function nya rusak jadi proses sekresi &
reabsorpsi normal terhambat → sehingga waste products yg harusnya di sekresi
gak bisa keluar → numpuk di tubuh → nausea, loss of appetite, vomit
- SoB → Pulmonary edema karena fluid overload to extracellular space
- Kidney disease → dari riwayat diabetes 14 tahun + lately uncontrolled → high
blood sugar from diabetes can damage blood vessels in the kidneys as well as
nephrons so they don't work as well as they should.
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From physical examination findings conjunctivas of the eyes was pale, blood pressure 170/110
mmHg, pulse rate 84 times per minute, respiratory rate 16 times per minute and no fever.

Jugular Venous Pressure was normal, the right and the left borders of his heart were wider than
normal but his lung was clear. Liver and spleen were not enlarged and there was slight edema of
the both of the legs. The urine volume was about 1200 ml per 24 hour

1. What are the positive signs from the physical examination?

● Conjunctiva anemis
● BP → Hypertension
● Batas jantung kiri dan kanan lebih lebar
● Edema di kedua kaki

2. Please make the conclusion from all of these sign?

Ini keliatan sih dia ada history of DM selama 14 tahun, belakangan ini gak kekontrol juga
terus udah kena ke ginjal karena dokternya juga udah bilang dia ada kidney disease
● Anemia → komplikasi CKD, bisa juga karena dia emang ilang nafsu makan,
lemes, muntah 2x sehari juga
● Edema kaki → komplikasi CKD, kidney damage, excretion of salt and water
decrease causing fluid overload in extracellular space → systemic fluid overload
● Hypertension → komplikasi CKD -> Elevated renin → stimulates the secretion of
aldosterone → increasing sodium reabsorption → excess sodium and fluid volume
→ hypertension
● Cardiomegaly → bisa jadi komplikasi dari masalah ginjal yang sudah lama
(kronis) trus komplikasi ke jantung -> Endothelial cell dysfunction and calcium
deposits lead to a loss of vessel elasticity and vascular calcification → increases
the risk for ischemic heart disease, left ventricular hypertrophy, congestive heart
failure, stroke, and peripheral vascular disease in individuals with uremia.
 ●

Staging CKD:

TUTORIAL 2
Page One

From laboratory examinations were findings hemoglobin : 8 gram/dl; WBC : 7000/mm3;

Platelets 200000/mm3; ESR : 20 /hour; Non fasting Blood Sugar 220 mg/dl; Urea 100 mg/dl;
Creatinine 4.2 mg/dl; Sodium 125 meq/L; Potassium 5.5 meq/L; chloride 97 meq/L; HCO3 18

1. What are the positive signs from the laboratory examination?

- Hb 8 gram/dl → rendah (hemoglobin is: For men, 13.2 to 16.6 grams per
deciliter. For women, 11.6 to 15 grams per deciliter) → anemia
- WBC, platelets → normal
- Non fasting blood sugar 220 mg/dl → tinggi (Regardless of when you last ate, a
level of 200 mg/dL (11.1 mmol/L) or higher suggests diabetes)
- Urea 100 mg/dl → tinggi (6-24 mg/dL) → diabetes
- Creatinine 4.2 mg/dl → tinggi (A normal result is 0.7 to 1.3 mg/dL (61.9 to 114.9
µmol/L) for men and 0.6 to 1.1 mg/dL (53 to 97.2 µmol/L) for women) →
impaired kidney function
- Sodium 125 meq/ L → rendah (135-145) mEq/L
- Potassium 5.5 meq/ L → tinggi (3.5-4.5) mEq/L
- Chloride 97 meq/ L → normal (95-105) mEq/L
- HCO3 18 → rendah (22 to 28 (mEq/L)

2. Please make the conclusion from all of these sign?

 - Stage 4 CKD
- Kidney damage → ureum creatinine tinggi
- Hyponatremia
- Hyperkalemia
- Metabolic acidosis

TUTORIAL 2

Page Two

From urinalysis there is protein with scale +3, red blood cell +1, white blood cell +3 and no
sign of glucose.

1. What is the final diagnosis of this case?

Proteinuria, Inflammation
Stage 4 ckd
2. How should you treat this patient?
Hemodialysis, peritoneal dialysis

TUTORIAL 2

Page Three

Tomorrow, Mr. F. was referral to nephrologist and he discussed to choosing the optimal renal
replacement therapy and to manage the many issues associated with chronic renal failure and
after the counseling the patient was referral to vascular surgeon before do the choice treatment.

1. What is Mr. F choice for his therapy?

2. What is the other option for renal replacement therapy?

3. What is the complication for the chosen therapy?
 Sci-Hub | Complications associated with continuous renal replacement therapy.
Seminars in Dialysis | 10.1111/sdi.12970 (mksa.top)

TUTORIAL 3
Page One
After few therapy session Mr. F. become paler and feel itchy on his skin. His legs also
start to get edema for 3 days due to lots of drinking water. He loves to eat meats, legumes
and eggs.

1. What are the nutritional problems that we deal with this case?
Kolestrol, jantung koroner -> Adult kidney transplant patients should be treated with
a statin because of an increased risk for coronary events

Protein tinggi dia → mengandung banyak purin

Phosphorus juga tinggi → ini juga kenapa dia bisa itchy skinnya
Kebanyakan airnya → edema
Legumes apa ya? Kacang

2. How you manage the nutritional problems?

Intinya semua dibatesin sesuai dosis rekomendasi