Felix Hansen (1015101)

Amanda Padma (1015058)

Indra Josua (0715092)
Case Presentation
Identity of Patient
Name : Tn. R
Age : 35 years old
Gender : Male
Occupation : Not working
Status : Single
Room/Bed : Gideon/4
Date : 09-06-2014
Diagnose : CKD Stage 5 on Hemodialysis
+ Acites

Resume
A male 35 years old came with pain in all parts
of abdomen. The pain wasnt radiate and patient
also complained having breathless because of
fluid in abdomen that press the chest. Patient
confessed having treatment with the kidney
disease and had hemodialysis for almost a
year. Patient also complained having swolen in
pair of feet.
Past medical history : UTI on 2010 => progress
to renal disease on 2012 => having
hemodialysis since then, asthma (-), diabetes
mellitus (-), hypertension (-)
Family medical history : -
Allergic history : -
Physical Examination

Vital Signs
BP : 120/80 mmHg
Heart rate : 120 x/minute
Respiration : 32x/minute
Temperature : 36,9C
Skin : cyanosis (-), jaundice (-)
Head
Eye : Conjunctiva anemic (+/+), sclera jaundice (-/-)
ENT : secretions (-)
Neck : lymph node not palpable, trachea
central
Thorax
Heart : heart sound S1S2 regular, murmur (-)
Pulmo : move symetric, vbs (+/+), ronchi (-/-),
wheezing (-/-)
Abdomen : raised, soepel, gut sound (-), palpable pain
(-), shifting dullness (+), fluid wave (+)
Extremities : swolen in pair of feet, non pitting,
muscle atrophy in pair of feet.


Lab Result (09-06-2014)
Hb : 9,4 gr/dl (<<)
Ht : 28,5 % (<<)
Leucocyte : 6.560 / mm3
Thrombocyte : 340.000 / mm3
Erythrocyte : 3.8 million / mm3 (<<)
MCV : 75 fl (<<)
MCH : 25 pg/ml
MCHC : 33 gr/dl
USG (03-06-2014)
R-Kidney
Smaller with length around 70mm, uneven
surfaces, thin parenchym, higher echogenesity
L-Kidney
Smaller with length around 77mm, thin
parenchym, higher echogenesity
Intraperitoneal free fluid
Minimal pleural effusion
Diagnose
Chronic Kidney Disease Stage 5 + Acites +
Anemia
Follow up
09-06-2014
BP: 120/80 mmHg
HR: 120x/minute
RR: 32x/minute
T : 36,9C
Breathless (+), fluid
intraperitoneal (+),
abdominal pain (+)
Bed rest, nasal cannule
O2 5 litres/minute,
prepare for ascites
punction
10-06-2014
BP: 110/80 mmHg
HR: 100x/minute
RR: 22x/minute
T : 36,4C
Breathless (-), fluid
intraperitoneal minimal,
abdominal pain (-)
Ascites punction +- 2-
2,5 litres
Chronic Kidney Disease
Is define as abnormalities of kidney structure or
function, present for more than 3 months with
implication for help
Staging of CKD

Why CKD??
Because the patient having abnormalities
structure (from the USG imaging)
The patient having history of hemodialysis for 2
years so we assume he had abnormality of renal
function more than 3 months
Why stage 5??
We assume he had CKD stage 5 because
dialysis is typically initiated when eGFR falls
bellow 10mL/minute/1,73 m2 but in this patient
we didnt have the last result of eGFR but he had
hemodialysis twice a week for 2 years

Why Ascites??
The etiology of ascites is still uncertain. The
pathogenesis seems to be multifactorial:

1. Chronic fluid overload with hepatic congestion resulting
in increased hepatic vein hydrostatic pressure is usual
2. Change in the permeability of the peritoneal membrane
have been shown in patients receiving CAPD
3. Impaired lymphatic peritoneal reabsorption was
proposed as a pathogenic mechanism and confirm by
lymphatic flow rate studies. The fact that the rate of
removal is much slower in ureamic patients compare to
non ureamic
4. Contributing causes include hypoproteinemia,
congestive heart failure, or liver cirrhosis with portal
hypertension
Why Anemia??
CKD leads to normocytic anemia due to
inadequate renal production of erythropoietin.
3.2.1: Diagnose anemia in adult and children > 15
years with CKD when Hb Concentration is < 13
g/dl in males and <12 g /dl
In Patient Hb is 9,4 g/dl
Management CKD
Hemodialysis 5 hours three times a week
If possible to doing renal transplant procedure
Refer to nephrologist
Management of anemia
In general, erythropoiesis stimulating agents are
used to maintain a hemoglobin level of 11 to 12
g/dl.
In patient receiving this treatment, iron stores
should be assessed and replenished as needed
to avoid apparent erythropoietin resistance.

Complication
Prognosis
Daftar Pustaka
http://www.pathophys.org/ckd/#Pathophysiology
http://emedicine.medscape.com/article/170907-
treatment
KDIGO 2012 Clinical Pratice Guideline for the
Evaluation and Management of Chronic Kidney
Disease. Kidney Disease Improving Global
Outcomes. 1, January 2013, Vol. 3.
Nephrology Dialysis Transplantation. Franz, M.
and Horl, W.H. 1997.