8/12/2019 Gab. Kuliah Nefro
1/75
Prof. Dr. dr.Syarifuddin Rauf, SpAK
Bagian Ilmu Kesehatan Anak FK - UNHAS
RS Dr. Wahidin Sudirohusodo Makassar
8/12/2019 Gab. Kuliah Nefro
2/75
GLOMERULONEFRITIS AKUTGNA)
8/12/2019 Gab. Kuliah Nefro
3/75
Proliferasi dan inflamasi glomeruli
Sekunder oleh mekanisme imunologik
Antigen: bakteri, virus, parasit & zat lain.
8/12/2019 Gab. Kuliah Nefro
4/75
GLOMERULONEFRITIS AKUTPASCA STREPTOKOKKUS
GNAPS)
8/12/2019 Gab. Kuliah Nefro
5/75
1. Angka kejadian
Lebih sering umur 6-7 thn, jarang < 3 thn
Lakilaki > perempuan (2:1)
10- 12 % kasus infeksi strept. hemolitikus
grup A
Kaplan: 50% kasus asimtomatik pd epidemi
GNAPS didahului ISPA atau piodermi
8/12/2019 Gab. Kuliah Nefro
6/75
2. Etiologi
Streptokokus hemolitikus grup A (tipe M)
NEFRITOGENIK
Faringitis (serotipe tersering 12, lalu 1,3,4,6,25)
Piodermi (serotipe tersering 49, lalu 2,53,55,
56,57,58,60
8/12/2019 Gab. Kuliah Nefro
7/75
a. Periode latent: 13 minggu
b. Edema
c. Hematuri
d. Hipertensi
e. Oligouria
f. Gejala-gejala lain: lelah, malaise, letargi
& anoreksia
g. Kelainan laboratorium
MANIFESTASI KLINIK
8/12/2019 Gab. Kuliah Nefro
8/75
URIN:
Hematuri, warna kemerah-merahan atau
seperti air daging
Proteinuri : kualitatif dan kuantitatif
> 6 bulan proteinuri persisten
biopsi ginjal
8/12/2019 Gab. Kuliah Nefro
9/75
DARAH:
Titer ASTO meningkat
Menurunnya kadar C3
LED meninggi
Hipoproteinemi ringan
Pemeriksaan bakteriologik
8/12/2019 Gab. Kuliah Nefro
10/75
Bila memenuhi 4 gejala berikut
Hematuri makroskopik atau mikroskopik
Edema
Hipertensi
ASTO meningkat
C3 menurun
Diagnosis GNAPS
8/12/2019 Gab. Kuliah Nefro
11/75
SINDROM NEFROTIK SN)
8/12/2019 Gab. Kuliah Nefro
12/75
1. Edema Masif
2. Proteinuri Masif
3. Hipoproteinemi (< 2,5 g/dl)
4. Hiperkolesterolemi
(>250 mg/dl)
8/12/2019 Gab. Kuliah Nefro
13/75
ANGKA KEJADIAN
Anak > dewasa
Anak: 13 tahun
> 5 tahun
Wila Wirya (1992): 6 kasus/100.000 penduduk
< 14 thn/thn
Jumlah kasus di Indonesia (210 juta pend.) :
5040 SN
8/12/2019 Gab. Kuliah Nefro
14/75
ETIOLOGI
Tidak diketahui: SN idiopatik
Genetik : SN kongenital
HLA-B12, HLA B8
Pencetus : Infeksi virus/bakteri
Alergi
8/12/2019 Gab. Kuliah Nefro
15/75
PATOMEKANISME
Soluble antigen- antibody complex
Teori elektrokemik
8/12/2019 Gab. Kuliah Nefro
16/75
8/12/2019 Gab. Kuliah Nefro
17/75
KOMPLIKASI YANG TERJADI PADA
GNAPS DAN SN:
1.HIPERTENSI ENSEFALOPATI
2. EDEMA PARU
3. SYOK HIPOALUMINEMI
4. GAGAL GINJAL
8/12/2019 Gab. Kuliah Nefro
18/75
URINARY TRACT INFECTIONUTI)
8/12/2019 Gab. Kuliah Nefro
19/75
Infection from renal parenchyme
orificium urethrae externa
Significant bacteriuria
With or without symptoms
DEFINITION
8/12/2019 Gab. Kuliah Nefro
20/75
2
Pathogenic bacteria
Colony count : > 100.000/ml urine
> 1x lab. examinations
Significant bacteriuria
8/12/2019 Gab. Kuliah Nefro
21/75
3
Relapsing UTI :
Recurrent UTI
Same microorganism
Reinfection UTI :
Recurrent UTI
Different microrganism
8/12/2019 Gab. Kuliah Nefro
22/75
ETIOLOGY
Bacteria :
E. Coli
Klebsiella
Proteus
Pseudomonas
Other microorganisms :
Protozoa
Virus
8/12/2019 Gab. Kuliah Nefro
23/75
CLASSIFICATION
Clinically : 1. Symptomatic UTI
2. Asymptomatic UTI
Complication :A. Simple UTI
B. Complication UTI
Localization : 1. Upper UTI
2. Lower UTI
8/12/2019 Gab. Kuliah Nefro
24/75
PATHOGENESIS
1. Hematogenic
2. Percontinuitatum
3. Lymphogenic
8/12/2019 Gab. Kuliah Nefro
25/75
Clinically :
1. Upper UTI (Pyelonephritis) :
Fever, back/flank pain & with or
without lower UTI symptoms
2. Lower UTI (Cystitis) :
Suprapubic punction, dysuria,
frequent voiding etc.
DIAGNOSIS
8/12/2019 Gab. Kuliah Nefro
26/75
PATHOGENESIS
Neonates Baby & Child
(>1 month)
Hematogen
(Septicemia)
Percontinuitatum
(Ascending)
Bacteria enter to
Urinary tract
Symptomatic UTI Asymptomatic UTI
Colonization on GIT
Certain focus
: Periurethra/Perineum
: Subpreputium
?
8/12/2019 Gab. Kuliah Nefro
27/75
LAB. EXAMINATIONS
URINE:
1. Urinalysis : Leukocyte > 5-10/HPF
Erythrocyte : +/-
2. Urine culture :
a. Mid : stream urine :
C.C. : > 100.000/ml urine
b. Catheterization :C.C. : > 10.000/ml urine
c. Suprapubic punction :
C.C. : > 1000/ml urine
8/12/2019 Gab. Kuliah Nefro
28/75
BLOOD:
Leucocytosis
Increased BSR (> 30 mm/hour)
Increased CRP (> 30 ug/ml)
8/12/2019 Gab. Kuliah Nefro
29/75
1. Eradicate acute infection
2. Detection, prevention, & treatment
recurrent infection
3. Detection & surgical correction
abnormality of anatomical structure
MANAGEMENT
8/12/2019 Gab. Kuliah Nefro
30/75
8/12/2019 Gab. Kuliah Nefro
31/75
Sudden loss or decreased of kidneys
function
Imbalance of water & electrolyte blood
Increased of waste products (Ureum &
Creatinin)
8/12/2019 Gab. Kuliah Nefro
32/75
A. Prerenal: Decrased blood flow
Diarrhea dehydration
Hemorrhage
Burns
Septic shock
ETIOLOGY:
8/12/2019 Gab. Kuliah Nefro
33/75
B. Renal:
Acute Tubular Necrosis
Acute Nephritic Syndrome
Nephrotic syndrome
Acute Pyelonephritis
8/12/2019 Gab. Kuliah Nefro
34/75
C. Postrenal: Urinary tract obstruction
Tumors
Kidneystones
Nephrocalcinosis
8/12/2019 Gab. Kuliah Nefro
35/75
1. Prerenal:
Perinatal hemorrhage (birth trauma, placenta
abruption)
Neonatal hemorrhage (severe intraventricular
hemorrhage, adrenal hemorrhage)
Perinatal asphyxia
Hyaline membrane disease
Etiology of ARF in Newborn:
8/12/2019 Gab. Kuliah Nefro
36/75
2. Renal :
Acute Tubular Necrosis (perinatal asphyxia)
Maternal-fetal transfer:
Antibodies
Infections: syphilis, Cytomegalovirus
3. Postrenal :Congenital malformations of urinary
collecting system
8/12/2019 Gab. Kuliah Nefro
37/75
CLINICAL MANIFESTATIONS:
1. Decreased urine volume (Oligouria Anuria)2. Generalized swelling
3. Changes in mental status:
UnconsciousDelirium/confusion
Coma
4. Seizures5. Nausea, vomiting
6. Anemia
7. Kusmaul respiration
8/12/2019 Gab. Kuliah Nefro
38/75
DIAGNOSISClinical Manifestations
Lab. Examination:
Serum Ureum increased
Serum Creatinin increased
Creatinin Clearance
Serrum Potasium
8/12/2019 Gab. Kuliah Nefro
39/75
TREATMENT1. The goal of the treatment is to identify & treat
reversible causes like prerenal causes
(diarrhea dehydration) & post renal causes
(e.g. obstructive uropathy by surgeon
procedure)
2. Medical drugs:
Antibiotics: To prevent infection
Diuretics: to treat oligouria or anuria
Diazepam: To handle convulsion
8/12/2019 Gab. Kuliah Nefro
40/75
3. Emergency condition:
Hyperkalemia:
Ca Glukonas
Potassium exchange resin
(Kayexalate) Oral/rectal
Metabolic acidosis: Bicarbonate Natricus
8/12/2019 Gab. Kuliah Nefro
41/75
8/12/2019 Gab. Kuliah Nefro
42/75
Renal function progresses to decrease
slowly
Imbalance of water & electrolyte
Increased of waste products (Blood
ureum & creatinin)
8/12/2019 Gab. Kuliah Nefro
43/75
< 5 years old:
Hypoplasia / Dysplasia kidney
Congenital structure of urinary tract
Vesicoureteral reflux
Congenital Nephrotic Syndrome
ETIOLOGY:
8/12/2019 Gab. Kuliah Nefro
44/75
515 years old :
Hereditary diseases: Alports syndrome,
sistinuri
Primary glomerulonephritis: Nephritic
Syndrome
Secondary glomerulonephritis : SLE,SHS
8/12/2019 Gab. Kuliah Nefro
45/75
TREATMENT1. Conservative Treatment:
The aims of this treatment:
Preparing the child & family for the
treatment of CRF
Slowly progression to End Stage RF
8/12/2019 Gab. Kuliah Nefro
46/75
2. Replacement therapy:
The aims is to replace the function of the
unfunction kidney by:
Dialysis:
Peritoneal dialysis (PD)
Hemodialysis
Transplantation
8/12/2019 Gab. Kuliah Nefro
47/75
8/12/2019 Gab. Kuliah Nefro
48/75
Complication of SLE
Damage to glomerulus
Progressive loss of kidney function
8/12/2019 Gab. Kuliah Nefro
49/75
1. Unknown
2. Genetic factor :
HLA Antigen (HLA-DR2, HLA-DR3)
High incidence in monozygotic twin
High incidence in family
ETIOLOGY:
8/12/2019 Gab. Kuliah Nefro
50/75
3. Nongenetic factor:
Longterm treatment of certain drugs
(>6 months) hydralazine
Sex hormone: estrogen SLE (>)
Viral infection
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
8/12/2019 Gab. Kuliah Nefro
51/75
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Autoimune disorder
Damage to: Joints
Heart
Lungs
Blood vessels
Kidneys
Skin
PATHOGENESIS
8/12/2019 Gab. Kuliah Nefro
52/75
PATHOGENESIS
Autoimune process
Antinuclear Antibody (ANA)
+ Ds-DNA (Antigen)
Soluble Ag-Ab Complex
MBG
Deposition of: ANA + Ds-DNA + C3
Renal symptoms
GENERAL SYMPTOMS
8/12/2019 Gab. Kuliah Nefro
53/75
GENERAL SYMPTOMS
Fever
Malar rash: A rash shaped like butterfly
Usually found on the bridge
of the nose & cheeks
Inflammation of the joints (arthritis)
Anorexia
Weight loss
Anemia
CLINICAL MANIFESTATIONS
8/12/2019 Gab. Kuliah Nefro
54/75
CLINICAL MANIFESTATIONS:RENAL SYMTOMPS
1. PROTEINURIA:
(+)(++) (30-100 mg/dl)
Haematuria (+)/(-)
2. ACUTE NEPHRITIC SYNDROME
3. NEPHROTIC SYNDROME
DIAGNOSIS
8/12/2019 Gab. Kuliah Nefro
55/75
DIAGNOSIS
Clinical Manifestations
Lab. Examination:
Blood: Anti Nuclear Antibody (+)
LE cell (+)
Ds-DNA (+)
C3 & C4
CLASIFICATION HISTOPATHOLOGIC
8/12/2019 Gab. Kuliah Nefro
56/75
CLASIFICATION HISTOPATHOLOGIC
I. Normal histopathologic feature
II. Mesangial Glomerulonephritis
III. Focal Segmental Proliferative Glomerulonephritis
IV. Diffuse Proliferative Glomerulonephritis
V. Membranous Glomerulonephritis
TREATMENT
8/12/2019 Gab. Kuliah Nefro
57/75
TREATMENT
Class I & II : Symptomatic treatment
No specific treatment
Class III,IV&V: Symptomatic treatment
Specific treatment
Corticosteroid
Immunosuppressive
8/12/2019 Gab. Kuliah Nefro
58/75
KIDNEY :
8/12/2019 Gab. Kuliah Nefro
59/75
KIDNEY :
1. AGENESIS: BILATERAL RENAL AGENESIS
= Potters Syndrome
Oligohydramnion
Pulmonary hypoplasia
Low-set ears
2. RENAL HYPOPLASIA : The kidney is small
Normal nephron
8/12/2019 Gab. Kuliah Nefro
60/75
3. Horseshoe kidney :
Fusion of the renal parenchyma
Joined at the lower pole
4. Polycystic kidney :
a. Infantile Polycystic Kidney (IPCK)
b. Adults Polycystic Kidney (APCK)
I P C K
8/12/2019 Gab. Kuliah Nefro
61/75
I P C K
Autosomal Recessive Polycystic Kidney
Enlargement of distal tubulus & colligents
ductus
Glomerulus & proximal tubulus normal
Liver enlargement
URETER
8/12/2019 Gab. Kuliah Nefro
62/75
URETER
Duplication of ureter
Ureterocele
Ectopic ureter
VESICO URETERAL REFLUX
8/12/2019 Gab. Kuliah Nefro
63/75
VESICO URETERAL REFLUX
Reflux of urine from the bladder into ureter
Damage the upper urinary tract by bacterial
Infection
Causes : Congenital anomalous development
of the ureterovesical junction
Bladder outlet obstruction
8/12/2019 Gab. Kuliah Nefro
64/75
BLADDER (VESICA URINARIA)
Agnesia
Bladder neck obstruction
Agnesia / atresia urethra
Congenital posterior urethral valves
URETHRA
8/12/2019 Gab. Kuliah Nefro
65/75
8/12/2019 Gab. Kuliah Nefro
66/75
SHS : Systemic disease
Vasculitis on :
Skin purpura
Joint arthritis
Digestive tract abdominal pain
Kidney glomerulonephritis
INCIDENCE
8/12/2019 Gab. Kuliah Nefro
67/75
Age incidence :
All ages
75% of cases : 2-11 years
Sex incidence : : = 2 : 1
50% of cases : preceded by upper respiratory
infection group A streptococci
INCIDENCE
CLINICAL MANIFESTATIONS
8/12/2019 Gab. Kuliah Nefro
68/75
1. PURPURA :
Erythematous macular palpable purpura
Ecchymotic
Associated with subcutaneous edema
(extremities, scalp, periorbital region,
hands, feet, scrotal area)
Lower legs, ankles, dorsal foot ( symmetric)
CLINICAL MANIFESTATIONS
8/12/2019 Gab. Kuliah Nefro
69/75
2. Gastrointestinal Symptoms:
Abdominal pain : 35-85% of cases
Gastrointestinal bleeding: melena,
hematemesis, bloody stool
Invagination, intestinal perforation
8/12/2019 Gab. Kuliah Nefro
70/75
3. Joint Symptoms:
Arthritis
Arthralgia
Ankles & knees: most commonly
affected
The three signs: Classic triad of SHS
RENAL INVOLVEMENT (SHS NEPHRITIS)
8/12/2019 Gab. Kuliah Nefro
71/75
Haematuria associated with proteinuria
Acute Nephritic Syndrome
Nephrotic Syndrome
Renal Failure
RENAL INVOLVEMENT (SHS NEPHRITIS)
PATHOPHYSIOLOGY
8/12/2019 Gab. Kuliah Nefro
72/75
INCITING FACTOR (URIStreptococcus)
IgA complexes (IgA1 & IgA2)
Deposite in glom. basement membrane (gbm)
Activate complement
Immune complexes in gbm (IgA,IgG+C3)
Renal symptoms
MANAGEMENT
8/12/2019 Gab. Kuliah Nefro
73/75
1. Self Limiting Disease
2. Supportive & symptomatic Treatment:
Fluid intake
Antihypertensive Hypertensive patient
Diuretic Oligouria
Antibiotic Infection
Analgesics Arthralgia
MANAGEMENT
8/12/2019 Gab. Kuliah Nefro
74/75
3. Specific treatment:
Corticosteroid (Prednison 1-2 mg/kgBW)
Severe Abdominal pain
GI bleeding
Renal treatment
R/ Acute Nephritic syndrome
Nephrotic Syndrome
Renal Failure
8/12/2019 Gab. Kuliah Nefro
75/75