The Impaired of Renal, Heart and Liver Functions Due to Complications of

Dengue Infection by Heparinization and Hemodialysis

Abstract
Multiple organ complication because of Dengue infection, sometime is found in some
hyperendemic Dengue such as Indonesia. If it happens the patients death will be difficult to
avoid. Here we inform a report of Dengue infection with complication of acute renal failure
(CCT 7,24), acute lung oedem et causa STEMI anterior septal (CKMB 85,9 U/L) and hepatic
insufficiency (total bilirubin 3,3 mg/dL). Hemodialysis, heparanization and high doses of
corticosteroid (methylprednisolone 2 x 250mg/day) for 5 days. In a result, the patient went home
in good condition.

Keywords : Dengue infection, acute renal failure, creatinine clearance test, acute lung
oedem, STEMI, high doses methylprednisolone injection.

Background of the Study

Dengue infection is a disease happened in tropic countries such as Indonesia. Based on
the Indonesian healthy record of 2016, Dengue fever was the third out of ten highest case using
JKN for hospitalization in 2016, after diarrhea and inersia uterus secondary.(1) WHO reported
that the death rate caused by Dengue infection reached from under 1% to more than 20%, if is
depend on disease level and its treatment.(2) Spreading of complex immune and multiple organ
impairment, including renal reported.(3,4,5) Prathima, et al reported that hemodialysis was given to
the patient of acute renal failure who also liver function impairment caused by Dengue fever.(7)
However, there is no special report about the treatment for more than two organs at the same
time, included renal failure caused by Dengue infection. Hemodialysis should be used to treat
renal failure, but there is no the report do hemodialysis or not.(6)
This article reported there were three organs affected by infection, which were STEMI,
hepatic insufficiency and acute renal failure. Heparanazation is used to treat the hepatic
insufficiency and hemodyalisis used to treat acute renal failure.
Case Report
Women, 59 years old, weight 50 kg, care to emergency room (18-10-16) because of fever
for 3 days before had come to the hospital. The patient had gasping respiration, painful chest
spreading to the left arm and back for one day before had come to the hospital. The patient also
complaint about coughing up white phlegam, nausea (+) but didn’t vomitus, body and joint aches
had been felt for 3 days before had come to the hospital. History for coughing, diabetes mellitus,
hypertension, and the other systemic diseases were denied. History of bleeding was denied.
At the time to came into the emergency room, blood pressure was 90/60, heart rate
133x/minute, respiration rate 26x/minute, temperature 38,8˚C, oxygen saturation 90%. Petechie
was found in arm and leg. Smooth wet rhonchi in basal (+/+). In abdomen, mild hepatomegaly
(+), epigastric pressure pain (+), urination painless, light yellow urine, without leg eodem and
ascites.laboratory test showed : Hb 14,7%, leukocytes 6100/mm3, diff count 0/0/1/93/6/0,
hematocrit 38%, platelet count 48.000/mm3, SGOT 130,7 U/L, SGPT 39,8 U/L, total bilirubin
3,3 mg/dL, ureum 161,1 mg/dL, creatinine 5,87 mg/dL, urinary erithrocytes 250/ul, leukocytes
550/ul, blood glucose 122 mg/dL, albumin 2,86 mg/dL, CKMB 85,9 U/L, total cholesterol 159,5
mg/dL, HDL 7,2 mg/dL, LDL 87 mg/dL, triglyceride 308,5 g/dL, potassium 6,36 mg/dL,
antibody IgG Dengue (+), IgM (-), rontgen thorax slightly enlarged cor and showed pulmonary
congestion. Infiltrates in the lungs (+). EKG showed ST-segment elevation lead V1 – V4 with
heart rate 140x/minute. USG showed no enlargement of the hepar, no ascites, no nodul, fatty
liver (+), slightly enlarged renal dextra and small stone in renal sinitra. Gall bladder and lien
showed normal.
Based on the data, the diagnosis were cardiogenic shock, acute pulmo oedem et causa
STEMI anteroseptal and acute kindey injury, that all caused by severe Dengue infection, also
thought of secondary infection (infection tractus urinary). Patient admitted to Intensive Care
Unit. On progress ureum and creatinine on fourth day treatment increased to 318 mg/dL and 6,6
mg/dL. Lowest platelet count 13.000/mm3.
The treatment had given in the patient were Ringer lactate, hydroxylethyl stracth
(widahess), dobutamin injection, enoxaparine sodium (lovenox) injection, furosemide injection,
fargoxin injection/6 hours, high doses methylprednisolone injection, sleeding scale bood glucose
every 6 hours, aspillet, clopidogrel, nitrat and cito hemodialysis on the fourth day of the
treatment.
The patient was discharged on the 10th day of care in good condition. The patient had
never controlled to Poli Penyakit Dalam and just do controlled on 22 December 2016 with
laboratory results Hb 10,2 gr%, HT 21%, platelet 239.000 /mm3, leucocytes 7800 /mm3,
MCV/MCH/MCH 84/28/33 (normal limit ), Sodium 145 mg/dL, calcium 4.4 mg/dL, chloride
124 mg/dL, ureum 18.3 mg/dL, creatinine 1.32 mg/dL.

Discussion
The incidence of renal failure in terms of CCT <60, in patients infected dengue-based
creatinine value at the time of admission was 4.04% of all patients infected Dengue.(6) And from
4.04%, 28.57% will experience death. If CCT <15 then the death is about 45%. While deaths
from dengue infections in hospitals in children (<15 years) are in the range of 0.5-3.5% (data on
adults not yet agreed).(6) The presence of AKI, in patients infected dengue, based on creatinine
When admitted to hospital is 35.7%. And when using creatinine data at the time of entry and
return, then the impaired renal function in patients infected Dengue virus is 27.1%.(6) The details
based on RIFLE value are Risk 21.6% (CCT 60-89), Injury 2.9% (CCT 15-59) and Failure 2,6%
(CCT <15).
Based on the data above shows that most patients with impaired renal function that
occurs due to Dengue viral infection, will heal itself. This is consistent with what Lizarraga and
Ali Nayer said.(9) While mortality occurs mainly when the kidney function disorder has reached
the value of CCT <15. Where it is approximately 45%. The death will increase if in addition to
suffering from renal failure (CCT <15), the patient also suffers from acute myocard infarct. Data
in the US in 2008 mentioned 1 of 4 deaths in the US caused by heart disease.(10)
Based the basis of this case is an interesting case to report. In this case in addition to renal
failure with CCT <15 also obtained acute myocard infarct and hepatic insufficiency.
It was decided to do hemodialysis in this patient after ureum 318 mg/dL and creatinine
6,6 mg/dL (CCT 7,24), potassium 6,04 mg/dL, sodium 138,8 mg/dL, calcium 8,32 mg/dL, and
platelet count 19,000 /mm3, CKMB 11,83 U/L, while the patient isn’t crowded. Blood pressure
160/90 mmHg. The HD formula given to this patient is a 400cc pull (UFG) within 3 hours and
without heparin. QB 150 and QD 300, and the provision of bicnat raised 1 level. Other settings
are provided by default. Post HD ureum 138.4 mg/dL, creatinine 2.63 mg/dL, potassium 4.56
mg/dL, sodium 136.4 mg/dL, calcium 8.49 mg/dL. But the platelet count felt 13,000 /mm3. The
patient was discharged on the 10th day of care in good condition. Unfortunately the patient just
do controlled on 22 December 2016 with laboratory results Hb 10,2 gr%, HT 21%, platelet
239.000 /mm3, leucocytes 7800 /mm3, MCV/MCH/MCH 84/28/33 (normal limit ), Sodium 145
mg/dL, calcium 4.4 mg/dL, chloride 124 mg/dL, ureum 18.3 mg/dL, creatinine 1.32 mg/dL.
Another important point from this patient is the corticosteroid intravenous injection in
high doses (500mg/day of methylprednisolon which given in twice of 250 mg). Those
corticosteroid was given for 5 days. Meanwhile, to prevent the occurance of tachycardia and
hyperglichemic on the patient as a result of corticosteroid in high dos, the patient was given
fargoxin 1 cc/ 6 hours and a sliding scale of blood sugar in every 6 hours.
Commonly the corticosteroid in high dose , basically planned to prevents severe attack of
Dengeu viral. But, particulary its show probability that hypersensitivity type 3 its basically
pathogenesis and pathophysiology of hemorrhagic dengue fever from T.Mudwal is correct.
Which is effect and reaction of hypersensitivity type 3 on the patient with hypersensitive with
dengue viral its accusating on lupus nephritis incidents. However ANA or DNA its not evaluated
we must considering of lupus nephritis.

Laboratory value development table :

Item Early entry During treatment final
CKMB 85,9 37,75 11,33
Ureum 161 318 19,3
Creatinine 5,8 6,6 1,3
Potassium 6,3 6,04 4,5
Total Bilirubin 3,3 1,4
SGOT 130,7 30,2
SGPT 39,8 41,2
Platelet 48.000 13.000 239.000
Imaging of EKG
When entry

Last imaging

Conclusion
It’s hard to avoid if this case one of the lost case. The patient had a better prognosis the
most possible causes is from uses of corticosteroid in high doses beside another treatment.
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