CASE REPORTACUTE KIDNEY INJURY IN 7

YEARS OLDPresented By :

Agnes Thasia Parhusip (110100284)Cennikon Pakpahan (110100299)

Supervised by :dr. Johannes Harlan Saing M.Ked (Ped) SpA (K)

CHILD HEALTH DEPARTMENTH.ADAM MALIK HOSPITAL

UNIVERSITY OF NORTH SUMATERA

ACUTE KIDNEY INJURY

Definition •characterized by a reversible increase in the blood concentration of creatinine and nitrogenous waste product•has a uniqueness that is fast growing azotemia or oliguri

Epidemiology•The incidence of AKI in children appears to be increasing •But the incidence is not clear in Children

Etiology•Pre-Renal•Renal•Post-Renal

Depressed Renal Blood Flow

Acute Tubular Necrosis

Apoptosis and Inflamatory Process

Vasoconstriction

Isothenuria,Restoration and Associated Complication

Pathophysiology

Clinical Manifestations

Skin :Macupapular

Rash, Patechie

Ears and Eyes : Keratitis,Iritis,Uv

eitis,Jaundice

Cardiovascular System : Irregular Rhytmhs,

Murmur, VJ Distention

Abdomen : Pelvic, rectal masses, prostatic

hypertrophy,distended bladder – Urinary

obstruction

Pulmonary : Rales,Hemopth

ysis

Differential Diagnosis

• Dehydration • Gastrointestinal (GI) bleeding • Heart failure • Chronic renal failure • Urinary obstruction • Urinary tract infection• Diabetic ketoacidosis

Diagnostic

Treatment• Correction of fluid overload with furosemide • Correction of severe acidosis with bicarbonate

administration, which can be important as a bridge to dialysis • Correction of hyperkalemia• Correction of hematologic abnormalities• Avoid Nephrotoxic agents• Dopamine infusion • Type of fluid administration • Fluid administration • Diuretics• Nutritional Support• Renal Replacement Therapy (RRT)

Prognosis

The prognosis for patients with AKI is directly related to the cause of renal failure and, to a great extent, to the presence or absence of preexisting kidney disease (estimated GFR [eGFR] < 60 mL/min), as well as to the duration of renal dysfunction prior to therapeutic intervention. In the past, AKI was thought to be completely reversible, but long-term follow-up of patients with this condition has shown otherwise.

Case Review

• Name : N• Age : 7 years• Sex : Male• RM : 00.63.82.74• Address : Dusun IX Purwosari• Date of Admission : April,5 2015

HistoryMain Complaint : Fever

• It has happened for 10 days before admit to hospital. It is high Fever and responds with Anti-Pyretic drug. He also had dyspnea since 10 days before His Parents admit him to hospital and this dyspnea not related with His Activities,Weather. Cyantoic Appereance is Rejected. Cough is found for 1 week. Mucous was’nt found. Edema (+) in all of his Body happen for 10 days. Edema started from palpebra and eyelid continue to hand and foot. Edema could not seen when patient admit to hospital.

• History of Gross Hematuria (+) happened at for one week. Dysuria (-).• History of Vomitting (+) happened for 3 days. Frequency 3-4 times for one

day. He vomitted what he ate and drunk with volume ± 62,5 cc. • He was referred from R.S Insana Stabat with Nefrotik Syndroma,

Glomerunephritis Post Streptococci Infection and Congestive Heart Failure. • He was Given Lasix Injection, Ranitidine injection, and Ondansentron

Injection.

• History of Previous IllnessThe patient previously went to RS Insani Stabat with same complaints.

• History of birthPatient was born spontaneously and immediately cried. The birth was helped by midwife. Birth weight 3600 grams. Family HistoryThe age of patient’s father is 33 years old whereas the age of her mother is 30 years old. Patient was the first child in his family.

• Feeding History

The patient got exclusive breast milk until 4 months, continue with MP-ASI (Promina) from 6 until 8 Months. From 8 Months-2 Years, He Got Poured Rice.

• History of Immunization

The patient immunization was completed

Physical Examination

Generalized status• Body weight : 17 kg • Body length : 122 cm • Body weight in 50th percentile according to age : 24 kg• Body length in 50th percentile according to age : 123cm• Body weight in 50th percentile according to• body length : 24 kg

• BW/Age : 17/24 = 70%• BL/Age : 122/123 = 99%• BB/TB : 17/24 = 70 %

Presence Status• Sensorium: Compos Mentis, HR = 120 bpm,

RR= 40 x/min, temperature: 38,5oC. Anemic (+), dyspnea (+), cyanotic (-), edema (-), icteric (-). Body weight (BW): 17 kg. Body length (BL): 122 cm. CDC: BW/Age = 70 %%, BL/Age = 99%, BW/BL = 70%

Localized Status

• Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (+/+). Ear/ Nose/ Mouth: within normal limit/ O2 nasal canule / within normal limit.

• Neck : Lymph NodeEnlrgement (-)• Thorax :Symmetric fusiform, retraction (+) Epigastric Retraction, HR:

120 bpm, regular, murmur (+),gallop,RR: 40 x/minute, regular, ronchi (-/-)• Abdomen : Ascites (+), Smily Umbilical (-), peristaltic (+) normal.

Liver : not palpable Spleen : not palpable

• Extremities : Pulse 120 bpm, regular, adequate pressure/volume, Warm Extremity, CRT < 3, TD : 110/80 mmHg

• Genitalia: Male, within normal limit.

Lab Report

• Hb/Ht/Leukosit/Trom : 10,7/37,8/10.390/171.000• Peripheral Blood Gas,

Ph/PCO2/PO2/PHCO3/TCO2/BE/SaO2 : 7,417/25.7/128,7/16,2/16,9/-7,3/98,9 %

• Albumin : 2,9 mg/dl• Blood Glucose : 145 mg/dl• Ureum/Creatine : 58,6/0,91• GFR :73,7• Ca/Na/K/Cl : 7,9/134/3,3/105• PCT : 133,47 mg/ml

Differential Diagnostic• Acute Glomerunephritis • Congestive Heart Failue e.c Acyanotic CHD• Nephrotic Syndrome

Working Diagnosis• Acute Glomerunephritis + CHF e.c Acyanotic

CHD

Therapi

• O2 Nasal Canule ½-1 l/min• IVFD D5% NaCl 0,45 % 15 gtt/min, Macro• Cefoperazone inj 800 mg/12 Hours/ IV • Furosemide oral 3 x 20 mg• Spirinolactone 2 x 12,5 mg• Fluid Balance / 6 Hours• Diet MB RD 1350 kkal with 17 gr Protein• Plan : Urinalisa, Echocardiography

FOLLOW-UP

S Fever (+), Dyspnea (+)

O Sensorium : Compos Mentis

Temperature : 37,8 C

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (+/+). Ear/ Nose/ Mouth: within normal limit/ O2 nasal canule /

within normal limit.

Thorax :Symmetric fusiform, retraction (-), HR: 112 bpm, regular,

murmur (+),gallop,RR: 36 x/minute, regular, ronchi (-/-)

Abdomen : Soepel, peristaltic (+) normal.

Liver : not palpable

Spleen : not palpable

Extremities : Pulse 112 bpm, regular, adequate pressure/volume, Warm

Extremity, CRT < 3, TD : 80/50 mmHg

A Acute Kidney Injury e.c Acute Glomerunephritis, Nephrotic Syndrome

P - O2 Nasal Canule ½-1 l/min

- IVFD D5% NaCl 0,45 % 15 gtt/min, Macro

- Cefoperazone inj 800 mg/12 Hours/ IV

- Furosemide oral 3 x 20 mg

- Spirinolactone 2 x 12,5 mg

- Fluid Balance / 6 Hours

- Diet MB RD 1350 kkal with 17 gr Protein

Urinalisis Hasil Rujukan

Warna Kuning Keruh Kuning

Glukosa Negatif Negatif

Bilirubin Negatif Negatif

Keton Negatif Negatif

Berat Jenis 1.010 1.005-1.030

Ph 5 5-8

Protein Negatif Negatif

Urobilinogen Negatif

Nitrit Negatif Negatif

Leukosit Negatif

Darah Positif Negatif

Eritrosit 30-40 <3

Leukosit 0-1 <6

Epitel 0-1

Casts Negatif Negatif

Kristal Negatif

• Asto : 200• CRP Kualitatif : positif• PCT : Menyusul

S Fever (-), Dyspnea (+)

O Sensorium : Compos Mentis

Temperature : 36,8 C

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (+/+). Ear/ Nose/ Mouth: within normal limit/ O2 nasal canule /

within normal limit.

Thorax :Symmetric fusiform, retraction (-), HR: 108 bpm, regular,

murmur (+),gallop,RR: 32 x/minute, regular, ronchi (-/-)

Abdomen : Soepel, peristaltic (+) normal.

Liver : palpable 3 cm under arcus costae

Spleen : not palpable

Extremities : Pulse 108 bpm, regular, adequate pressure/volume, Warm

Extremity, CRT < 3, TD : 90/60 mmHg

A Acute Kidney Injury stad Risk E.c GNAPS + CHF NYHA II

P - O2 Nasal Canule ½-1 l/min

- IVFD D5% NaCl 0,45 % 15 gtt/min, Macro

- Cefoperazone inj 800 mg/12 Hours/ IV on 3rd days stopped and

change in to Cefriazxon inj 800 mg/12 Hours/IV

- Furosemide oral 3 x 20 mg

- Spirinolactone 2 x 12,5 mg

- Fluid Balance / 6 Hours

- Diet MB RD 1350 kkal with 17 gr Protein

Jenis Pemeriksaan Hasil Rujukan Keterangan

ANA test 4,13 <20 Moderate – 20-

60

Strong : >60

Anti ds DNA 16,6 0-200 Moderate :

301-801

Strong : >=

801

S Fever (-), Dyspnea (+)

O Sensorium : Compos Mentis

Temperature : 36,7 C

Head : Eye: light reflex (+/+), isochoric pupil, pale inferior conjunctiva

palpebra (+/+). Ear/ Nose/ Mouth: within normal limit/ within normal /

within normal limit.

Thorax :Symmetric fusiform, retraction (-), HR: 108 bpm, regular,

murmur (+),gallop (-),RR: 32 x/minute, regular, ronchi (-/-)

Abdomen : Soepel, peristaltic (+) normal.

Liver : palpable 3 cm under arcus costae

Spleen : not palpable

Extremities : Pulse 108 bpm, regular, adequate pressure/volume, Warm

Extremity, CRT < 3, TD : 100/50 mmHg, MAP : 65 mmHg

A Acute Kidney Injury stad Risk E.c GNAPS + CHF NYHA II

P - Bed Rest

- O2 Nasal Canule ½-1 l/min

- IVFD D5% NaCl 0,45 % 15 gtt/min, Macro

- Cefoperazone inj 800 mg/12 Hours/ IV on 3rd days stopped and

change in to Cefriazxon inj 800 mg/12 Hours/IV

- Furosemide oral 3 x 20 mg

- Spirinolactone 2 x 12,5 mg

- Fluid Balance / 6 Hours

- Diet MB RD 1350 kkal with 17 gr Protein

Discussion Theory Observation in Reportmarked decline in renal function with azotemia and reduced glomerular filtration rate

In this patient there is a decrease of 0.25% filtration rate and urine output <0.5 ml / kg / h for 8 hours

The Classification based pRIFLE The Clinist use Prifle to Clasifycaused by factors such as pre-renal, renal and post-renal

cause of acute kidney injury is suspected Glomerunephritis Post Sterptococci

can be found symptoms such as hypertension, edema, prutitus, it could be an increase in heart rate

patients suspected failure Congestive herat, on arrival at the first sound Gallop suspected as a sign of good circulation of fluid in the body. But signs such as hypertension, edama, pruritus is not clearly visible.

Treatment based symptomatic etiology and also depend on the cause. Congestive heart failure due to acute kidney injury are given furosemide as a diuretic and can be combined with potassium-sparing diuretics such as Sprinolacton

Patients also get a combination of both the administration and Sprinolacton Furosemide.

Giving Antibiotics can be performed in patients with suspected AKI caused by Glomerunephritis with ampicillin as antibiotic selection option

antibiotics are given no antibiotics group peniciline group.

Giving dopamine and said fluid is not recommended to be given to patients with Acute Kidney Injury as well as dopamine

patients are not given as a treatment fluid.

Nutrition must be tightened first protein nutrition

In these patients the granting of nutrients is limited based on the calculation of proteins according to RDA

Treatment developed at this time leads to renal replacement therapy.

patients is not done it could be due to the patient's renal function can still be restored to normal function.

monitor the amount of liquid or fluid balanc

It this patients, it is done

Complications of Acute Kidney Injury can be Congestive Heart Failure. Prognosis depends disease stage

In these patients Congestive Heart Failure has occurred.Glomeruly Filtration rate can return to normal in

Summary

This patient was diagnosed with Acute Kidney Injury caused Glomerunephritis post streptococci. Diagnosis is by history taking, clinical symptoms, and laboratory tests. Patients were treated according etiologic cause, in this case the cause is GNPs. Symptomatic treatment also depends symptoms appear.