A 7 years old boy had increasing lethargy for a week. On physical examination, he had periorbital and pitting edema at the ankles, but is normotensive and afebrile. Laboratory studies smarked albuminuria. He was given a thiazide diuretic and his urine output increases and his edema resolves

1. PANEL
MODUL “KAKI BENGKAK”
BLOCK BASIC MECHANISM DISEASE
MEDICAL FACULTY
MUSLIM UNIVERSITY OF INDONESIA
2016
GROUP 15th
BY:

2. GROUP
15
Muh. Asy Shidiq 110 2015 0003
A. Muh.Yasser Mukti 110 2015 0022
Andira Ratu Nurrasyid 110 2015 0030
Andi Aisya Zealand 110 2015 0051
Nur Zamzam Azizah 110 2015 0059
Amaliah Hakim 110 2015 0070
Rifqy Aditya 110 2015 0078
Rindang Cahyani Putri H Abas 110 2015 0101
Elsa Shafira Prasetyati 110 2015 0117
Cindy Purnamasari 110 2015 0136
Atika Rahmah Mustapa 110 2015 0147

3. S C E N A R I O
3
A 7 years old boy had increasing lethargy for a week. On
physical examination, he had periorbital and pitting
edema at the ankles, but is normotensive and afebrile.
Laboratory studies smarked albuminuria. He was given a
thiazide diuretic and his urine output increases and his
edema resolves.

4. DIFFICULT WORDS
Edema
periorbital
Normotensive Lethargy
Afebrile
Albuminuria
Pitting
edema

5.  Edema periorbital : the appearance of swelling in the tissues around the eyes
 Normotensive : normal blood pressure
 Lethargy : a patological state of sleepiness or deep unresposiveness and in activity
 Afebrile : having a normal body temperature
 Albuminuria : having too much protein in urine
 Pitting edema : observable sweliing of body tissues due to fluid accumulation that
maybe demostrated by applying pressure to the swollen area
Editor David S. Strayer, MD, PhD. 2012.Robin’s Pathology seventh edition: Clinicopathologic Foundation of Medicine. Philadelphia: Wolters Kluwer Health. Page 829
www.merriam-webster.com. Medical Dictionary: Definition of CT scan. Access on April 29th 2016
Kamus Saku Kedokteran Dorland Edisi 29. Singapura:Elsevier

6. QUESTIONS
What is the anatomic structure of renal?
What is the histology structure of renal?
What is the physiology of the fluid balance
?
What is the function albumin related to the
balance of fluid ?
What is the definition of edema ?

7. QUESTIONS
How is the pathomechanism of edema
and desease related to edema ?
How is the pathomechanism of
nephrotic syndrome?
How is the pathomechanism of
albuminuria?
What cause periorbital and pitting
edema in the ankle?
How is the patient’s urine output
increase?

8. WHAT ISTHE STRUCTURE ANATOMIC OF
RENAL?
Rohen, W. Johannes, et.all.Color Atlas Of Anatomy : a photographic study of the human body 4th edition.
Location
The kidneys occupy the epigastric, hypochondriac, lumbar
and umbilical regions. Vertically they extend from the
upper border of twelfth thoracic vertebra to the centre of
the body of third lumbar vertebra. The right kidney is
slightly lower than the left, and the left kidney is a little
nearer to the median plane than the right.
1.

9. Chaurasia, L. 2005.HUMAN ANATOMY Regional and Applied : Dissection and Clinical Volume 24th edition. New Delhi: CBS publisher and distribution. Page 194

10. ANATOMY OF RENAL :
Rohen, W. Johannes, et.all.Color Atlas Of Anatomy : a photographic study of the human body 4th edition.

11. RELATIONS COMMONTOTHETWO KIDNEYS
1. The upper pole of each kidney is related to
the corresponding suprarenal gland. The lower
poles lie about 2.5 cm above the iliac crests.
2. The medial border of each kidney is related to the
suprarenal gland, above the hilus, and to the ureter
below the hilus

12. 3. Posterior relations:The posterior surfaces of both kidneys are related to the following:
(1) The diaphragm; (5) the transversus abdominis;
(2) the medial and lateral arcuate ligaments; (6) the subcostal vessels;
(3) the psoas major; (7) the subcostal, iliohypogastric and
ilioinguinal nerves).
(4) the quadratus lumborum;
In addition, the right kidney is related to twelfth
rib, and the left kidney to eleventh and twelfth rib.

13. Other Relations of the Right Kidney
Anterior Relations
(1)Right suprarenal gland,
(2)liver,
(3)second part of duodenum,
(4)hepatic flexure of colon, and
(5)small intestine.
Out of these the hepatic and intestinal surfaces are covered by peritoneum.
The lateral border of the right kidney is related to the right lobe of the liver and to the
hepatic flexure of the colon.

14. Other Relations of the Left Kidney
Anterior Relations
(1) Left suprarenal gland,
(2) spleen,
(3) stomach,
(4) pancreas,
(5) splenic vessels,
(6) splenic flexure and descending colon, and
(7) jejunum.
Out of these the gastric, splenic and jejunal surfaces are covered by
peritoneum.
The lateral border of the left kidney is related to the spleen and to the
descending colon.

15. WHAT ISTHE STRUCTURE HISTOLOGY OF
RENAL?
The cortex contains both distal and proximal convoluted tubules, glomeruli, and
medullary rays. Present also in the cortex are the interlobular arteries and
interlobular veins. The medullary rays are formed by the straight portions of
nephrons, blood vessels, and collecting tubules that join in the medulla to form
the larger collecting ducts. The medullary rays do not extend to the kidney
capsule because of the subcapsular convoluted tubules.
2.

16. CONT…
The medulla comprises the renal pyramids. The base of each pyramid is adjacent to the
cortex and its apex forms the pointed renal papilla that projects into the surrounding,
funnellike structure, the minor calyx, which represents the dilated portion of the ureter.
The area cribrosa is pierced by small holes, which are the openings of the collecting ducts
into the minor calyx. The tip of the renal papilla is usually covered with a simple columnar
epithelium. As the columnar epithelium of the renal papilla reflects onto the outer wall of
the minor calyx, it becomes a transitional epithelium.

18. JUSTAKGROMERULAR APPARATUS
The renal corpuscle exhibits the glomerular capillaries, parietal and visceral
epithelium of the glomerular (Bowman’s) capsule, and the capsular space. The brush
borders and acidophilic cells distinguish the proximal convoluted tubules from the
distal convoluted tubules, whose smaller, less intensely stained cells lack the brush
borders. The cuboidal cells of the collecting tubules exhibit cell outlines and pale
cytoplasm. Distinct basement membranes surround these tubules.
At the vascular pole, modified epithelioid cells with cytoplasmic granules replace the
smooth muscle cells in the tunica media of the afferent glomerular arteriole. These cells
are the juxtaglomerular cells. This area of darker, more compact cell arrangement is
called the macula densa.

20. PAPILLARY REGION (TRANSVERSE REGION)
The papilla in the kidney faces the minor calyx and contains the terminal portions
of the collecting tubules, now called the papillary ducts. The papillary ducts exhibit
large diameters and wide lumina, and are lined by tall, pale-staining columnar cells.
Also present in the papilla are the straight (ascending) segments of the distal
tubules and the straight (descending) segments of the proximal tubules.
Interspersed among the ascending and descending straight tubules are the transverse
sections of the thin segments of the loop of Henle that resemble the capillaries or
small venules.

22. 3. WHAT ISTHE PHYSIOLOGY OF
THE FLUID BALANCE ?

23. BODY FLUID COMPARTMENT

24. RENIN-ANGIOTENSIN-ALDOSTERON SYSTEM

25. WHAT ISTHE FUNCTION ALBUMIN
RELATEDTOTHE BALANCE OF FLUID ?
 Albumin as a binder and carrier albumin will bind weakly and reversible particles
positively and negatively charged, and serves as a carrier and the carrier
metabolite and drug molecules. Although many theories about the importance of albumin as
a carrier and binding proteins, but still slightly about the changes that occur in patients with
hypoalbuminemia.
 Anticoagulant effect of albumin
Albumin has effects on blood coagulation. works like heparin, because it has a molecular
structure similarities. heparin charged negative on sulfate group bonded antithrombin III
charged positive, the effect of anticoagulants. Serum albumin was also charged negative
4.
Fuction or albumin

26.  Albumin as buffer
Albumin acts as a buffer in the presence of residual charge and albumin molecules and a
relatively large amount in plasma. In the state
normal pH albumin is negatively charged and was instrumental in the formation of cluster
anions that can affect acid-base status. Decreased levels albumin will cause metabolic
alkalosis, due to a decrease in albumin 1 g / dl will increase bicarbonate levels 3.4 mmol / L
and production bases > 3.7 mmol / L and a decrease in anion 3 mmol / L
 The antioxidant effect of albumin
Serum albumin in a state acts to block the neurotoxic oxidant stress induced by hydrogen
peroxide or copper, acid Ascorbic which when oxidized will produce free radicals
Addition to those mentioned above also play a role defend
albumin microvascular integrity so as to prevent the entry of
germs into the intestine in the blood vessels, so avoid
spontaneous bacterial peritonitis

27. WHAT ISTHE DEFINITION OF EDEMA?
Edema is the accumulation of interstitial fluid in the tissues.
Extravascular fluid can also be assembled in the cavities of the
body, such as hydropericardium, hydrothorax, or
hidroperitoneum.
5.

28. WHAT ARETHETYPES OF EDEMA ?
 Pitting edema, referring to the movement of interstitial water by finger
pressure on the skin, leaving the basin. Once the pressure is released, take
a few minutes for this basin to return to the original condition. As in the
sacrum when lying, and on the lower leg while standing.
 Non-pitting edema seen in areas such as folds of loose skin on the face
periorbital space. Non-pitting edema can occur after deep-vein
thrombosis, particularly the superficial veins.

29.  Subcutaneous edema, usually often accumulates on the body that is located farthest
from the heart and the bottom. EdemaThis gives a clue to their heart or kidney
disease.
 Pulmonary edema, found on the left ventricle failure, renal failure, respiratory failure
syndrome, infection, and inflammation of the lungs. Edema can interfere with the
function of normal ventilation, diffusion of oxygen that can cause death.
 Edema of the brain, if swelling is severe, the brain can herniate through the foramen
magnum.With increased intracranial pressure, cerebral vascular supply can be
interrupted which can lead to death.
Source :
 Kumar V, Abbas A.K, Aster J.C. Buku Ajar Patologi Robbins. 9th Ed. Elevier Saunders. Pages 72-74.
 Kumar V, Cotran R.S, Robbins S.L. Textbook of Pathology Robbins. 7th Ed. Vol 1. Jakarta: EGC. pages 87-88
 Tambayong, Jan. Pathophysiology for Nursing. Jakarta: EGC. page 22

30. HOW IS THE PATHOMECHANISM
OF EDEMA AND DESEASE RELATED
TO EDEMA ?

31. CAUSES
OF
EDEMA
Decreasing the concentration of
plasma proteins
Decreasing the concentration of
plasma proteins cause a decrease in
plasma osmotic pressure. This leads to a
decrease in filtration fluid out of the
vessel is higher, while the amount of fluid
reabsorbed less than normal; thus there is
additional fluid is left behind interstitial
space.

32. Edema caused by a decrease in plasma protein concentrations
can occur in several ways:
 over-spending plasma protein in the urine due to kidney disease;
 a decrease in plasma protein synthesis due to liver disease (liver
synthesize nearly all plasma proteins);
 Less food containing protein; or expense of protein due to extensive
burns.

33. INCREASED PERMEABILITY OFTHE CAPILLARY
Increased permeability of the capillary walls causing plasma
protein out of the capillaries into surrounding interstitial fluid more. A
decline in plasma colloid osmotic pressure which decreases towards the
temporary increase in interstitial fluid colloid osmotic pressure which
cause by excess protein dicairan interstitial pressure increases towards
the outside. These imbalances have contributed to a localized edema
associated with injury (eg, blisters) and allergic responses (eg, urticaria).

34. INCREASEDVENOUS PRESSURE
Increased venous pressure, for example unstoppable in venous blood,
will be accompanied by increased capillary blood pressure, capillary
because they drain the contents into a vein. Increasing pressure towards
the capillary wall is especially instrumental in the edema that occurs in
congestive heart failure. Regional Edema can also occur because of local
restrictions venous return. One example is is swelling of the legs and feet
are common in pregnancy.

35. BLOCKAGE OFTHE LYMPHVESSELS
Blockage of the lymph vessels causing edema, due to excess fluid
filtered out stuck in interstitial fluid and can not be returned to the
blood via the lymph system. The accumulation of proteins in the
interstitial fluid aggravate the problems through osmotic effects. Local
arms are clogged due to removal of lymph nodes during surgery for
breast cancer.

36. More widespread lymph blockage occurs in filariasis, a parasitic
disease transmitted by mosquitoes which is mainly found in tropical
regions. In this disease, filarial worms infect small thread-like lymph
vessels, causing disruption of lymph flow. Parts of the body are affected,
especially the scrotum and extremities, suffered severe edema. The
disorder is often referred to as elephantiasis, because of swollen
extremities such as elephantiasis.

37. SODIUM AND WATER RETENTION:
Sodium retention occurs when sodium excretion in the urine is
smaller than the (intake), because the concentration of sodium rises will
occur hipertoni. Hipertoni cause water to be detained so that the
amount of extracellular water, both the intravascular and the interstitial
increases become edema

39. HOW ISTHE PATHOMECHANISM OF
ALBUMINURIA?
Two major mechanisms are responsible for the abnormal urinary excretion of proteins
that characterizes all glomerular diseases.
1. An increased charge and size permeability of the glomerular capillary wall, leading to
the transglomerular passage of albumin and of proteins of HMW that usually do not
cross the glomerular barrier
2.The second is the consequent impairment of the mechanism of reabsorption of all
proteins and, in particular, of the LMW proteins by the epithelial cells of the proximal
tubule
8.

40. CAUSED BY
Increased work
Injury
Toxic deriving from the increased load of the
abnormally filtered proteins in the tubular lumen

41. WHAT CAUSE PERIORBITAL AND PITTING
EDEMA?
 Distribution of edema – localized and
generalized
 Nephrotic syndrome has generalized edema
which is especially evident in:
the very soft tissue of the eyelids and face, and
tends to be most pronounced in the morning
because of the recumbent posture assumed
during the night (fluid flow and accumulate
easier into the loose connective tissue of the
periorbital areas due to gravity)

42. Edema on the ankle is usually the result of
venous and/or lymphatic obstruction. It
becomes pitting due to change in pressure.
The normal interstitial volume is 12 L and it
exerts a negative pressure of about 3 mm
Hg. It applies a slight suction effect and
holds the tissues together.
However, in abnormal conditions, where
the interstitial fluid volume increases
enormously, the pressure becomes positive.
This cause the fluid to become free fluid
that are not bounded to proteoglycan
meshwork. Therefore leaving an
indentation when pressed down with a
finger

43. HOW ISTHE PATIENT’S URINE
OUTPUT INCREASE?
When the osmotic pressure decreases, plasma angiotensinogen II
stimulates the adrenal glands to release aldosterone, which increases
retention of sodium in the distal convoluted tubule. Meanwhile, the
hypothalamus will stimulate ADH to retain water in the kidneys. To inhibit
sodium reabsorption, the patient is then prescribed with thiazide diuretics.

44. CONCLUSIONS
 The total water in the body is differentiated into extracellular fluid (1/3)and
intercelular fluid (2/3). The extracellular fluid consists of interstiial fluid, plasme,
and transcelullar fluid. Edema is the accumulation of interstitial fluid in the
tissues. Extravscular fluid can also be assembled n the cavities of the body, such as
hydropericcardium, hydrothorax, or hidroperitoneum. There are any different
types of edema, such as pitting edema, non-pitting edema, subcutaneus edema,
pulmonary edema, and edema on the brain. The total water in the body is
differentiated into extracellular fluid (1/3) and intercellular fluid (2/3). The
extracellular fluid consists of interstiial fluid, plasme, and transcelullar
fluid.Causes of edema are decreasing concentration of plasma protein, increased
permeablit of the capilary, increased venous pressure, blockage of the lymph
vessels, and sodium and water retention.

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