sugar ‘n spice, aint everything nice
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Sugar ‘N Spice, Aint Everything Nice. SGD Case 4. History, PE, Laboratory and Ancillary Tests. Sanez , John Ericson T. 60 y/o, male, CC: persistent nausea and vomiting. 60 y/o, male, CC: persistent nausea and vomiting. 60 y/o, male, CC: persistent nausea and vomiting. Physical Exam. - PowerPoint PPT PresentationTRANSCRIPT
Sugar ‘N Spice, Aint Everything Nice
SGD Case 4
History, PE, Laboratory and Ancillary Tests
Sanez, John Ericson T.
60 y/o, male, CC: persistent nausea and vomiting
Sanez, John Ericson T
60 y/o, male, CC: persistent nausea and vomiting
Sanez, John Ericson T
60 y/o, male, CC: persistent nausea and vomiting
Sanez, John Ericson T
Physical Exam
• 160/90 mmHg, 81 bpm, 19/min, 39 C• Wt: 83 kg, Ht: 165, BMI 30• Sallow skin, periorbital and facial swelling• Pale palpebral conjuctivae, (+) retinal
hemorrhage and cotton wool spots• Distended neck veins, JVP 5 cm at 30o• Symmetrical chest expansion, (+) intercostal
and subcostal retractions, (+) bibasilar crackles
Sanez, John Ericson T
Physical Exam
• AB at 6th ICS AAL, no heaves, no lifts, no murmurs
• (+) bulging flanks, (+) fluid wave, (+) grade 2 bipedal edema
Sanez, John Ericson T
Complete Blood CountHemoglobin 83 mg/dLHematocrit 0.26WBC 17.5 x 10/L Segmenters 0.79 Lymphocytes 0.19 Monocytes 0.01 Eosinophils 0.01Platelets adequate
Sanez, John Ericson T
UrinalysisColor YellowTransparency Slightly TurbidpH 6.0Specific gravity 1.020Albumin +++Sugar ++Hyaline casts 0-8/csBroad casts 2-6/hpfRBC 0-1/hpfPus cells 1-3/hpfSquamous cells fewAmorphous urates few
Sanez, John Ericson T
Blood ChemistriesUric acid 8.3 mg/dL
BUN 136.1 mg/dL
Serum creatinine 9.3 mg/dL
FBS 109.1 mg/dL
Albumin 2.6 mg/dL
Serum Na+ 130 mEq/L
Serum k+ 5.9 mEq/L
Ionized calcium 1.10 mEq/L
Inorganic phosphorus 7.9 mg/dLSanez, John Ericson T
Urine ChemistriesUrine submitted 24 hrs
Total volume 800 mL
Creatinine clearance 10 cc/min
Serum creatinine 9.3 mg/dL
Urine creatinine 1.6 g/24 hr (20mg/kg/day)
Urine protein 3.5 g/24 hr (<0.15 g/day)
Sanez, John Ericson T
Ultrasound of the Kidney
• Right kidney– 9.7 x 3.9 cm– Cortical thickness 1.1 cm– Increased parenchymal echogenicity
• Left kidney– 9.9 x 3.8 cm– Cortical thickness 1.2 cm– Increased parenchymal echogenicity• No stones, mass, nor structural deformity noted
bilaterally
Sanez, John Ericson T
2. Compute for the estimated renal function using the present serum
creatinine of 9.3 mg/dL.
SALES, Maria Stephanie
Glomerular Filtration Rate• Generally considered the best overall
indicator of the level of kidney function • Any substance X that has the same
concentration in the glomerular filtrate as in plasma, and is neither reabsorbed nor secreted along the nephron, could serve as a glomerular marker for measuring GFR
GFR = sum of volume flow from the plasma into all Bowman's spacesU = urine concentration of the soluteV = urine flowP = concentration of the solute in plasmaP
V x U GFR
SALES, Maria Stephanie
Creatinine Clearance
• Clinically used to measure GFR• Creatinine is useful for estimating GFR
because it is a small, freely filtered solute that is endogenously produced
• Serum creatinine levels can increase acutely from dietary ingestion of cooked meat
• Creatinine can be secreted into the proximal tubule, leading to overestimation of the GFR
SALES, Maria Stephanie
Creatinine Clearance
(mg/mL)
(mL/min)(mg/mL)(mL/min)
Cr
CrCr
P V x U
C
mg/mL
mL/minmg/mL
093.0 0.56 x 2
mL/min 12
SALES, Maria Stephanie
Cockcroft-Gault Method
72 x (mg/dL) P
(kg) weight body x age)-(140 (mL/min)C
Cr Cr
72 x 3.9
83 x )60140(
mL/min 9.9* this value should be multiplied by 0.85 for women, since a lower fraction of the body weight is composed of muscle
SALES, Maria Stephanie
MDRD (modification of diet in renal disease)
)( agex )(P x 1.86 GFR -0.203154.1Cr
21.73mper ml/min ee
black)if (1.21 x female)if (0.742 x
Source: http://www.nkdep.nih.gov/professionals/gfr_calculators/orig_con.htm
SALES, Maria Stephanie
3. What is the gold standard in estimating renal function?
SALES, Maria Stephanie
Inulin
• Exogenous starch-like fructose polymer• Fulfills all the criteria for use of a substance to
measure GFR
Criteria for Use of a Substance to Measure GFR
1. Substance must be freely filterable in the glomeruli.
2. Substance must be neither reabsorbed nor secreted by the renal tubules.
3. Substance must be neither metabolized nor produced by the kidney.
4. Substance must be physiologically inert (not toxic and without effect on renal function).
SALES, Maria Stephanie
SALES, Maria StephanieSALES, Maria Stephanie
Inulin
• Not a convenient marker for routine clinical testing needs to be injected intravenously
• Problems of intravenous infusion of a GFR marker can be completely avoided by using an endogenous substance with inulin-like properties Creatinine
• In clinical practice, determining the creatinine clearance is an easy and reliable means of assessing the GFR, and such determination avoids the need to inject anything into the patient
SALES, Maria Stephanie
6. Tabulate the differences/similarities between acute and chronic renal failure.
SALES, Maria Stephanie
Acute Renal Failure Chronic Renal Failure
Etiology • Renal hypoperfusion (prerenal)• Diseases that directly involve the
renal parenchyma (intrinsic)• Urinary tract obstruction
(postrenal)
•Diabetic nephropathy•Hypertensive nephropathy
Important Characteristics
•Anuria, Oliguria•Documented recent decline in GFR
• Azotemia for > 3 months• Prolonged uremic signs and
symptoms• Signs and symptoms of renal
osteodystrophy
History of kidney disease,
hypertension, abnormal urinalysis
Absent Present
Reversibility Usually complete Continuing significant irreversible reduction in nephron number
SALES, Maria Stephanie
Acute Renal Failure Chronic Renal Failure
Kidney size Normal Small
Broad casts on urinalysis
Absent Present
Anemia, Metabolic Acidosis,
Hyperkalemia, Hyperphosphatemia
Often present Usually present
SALES, Maria Stephanie
DIABETIC NEPHROPATHY
Presenter: Regina Ma. N. San Pedro
Diabetic nephropathy is kidney disease that develops as a result of diabetes mellitus
(DM).
DIABETIC NEPHROPATHYDIABETIC NEPHROPATHY
Presenter: Regina Ma. N. San Pedro
A clinical syndrome characterized by:
• Persistent albuminuria (>300 mg/d or >200 mcg/min) that is confirmed on at least 2 occasions 3-6 months apart
• A relentless decline in the glomerular filtration rate (GFR)
• Elevated arterial blood pressure.
5 years PTA: 2+ proteinuria5 months PTA: bubbly urineAdmission: albumin +++
5 years PTA: 51mL/min4 months PTA: 30.7mL/minAdmission: 9.9mL/min
Admission: 160/90mmHg
PATIENTPATIENT
Presenter: Regina Ma. N. San Pedro
STAGES OF DIABETIC NEPHROPATHYSTAGES OF DIABETIC NEPHROPATHY
Source: www.emedicine.medscape.com
STAGES OF CKD (KDOQI)STAGES OF CKD (KDOQI)
Presenter: Regina Ma. N. San Pedro
STAGE GFR, mL/min per 1.73m2
0 >902 >/= 903 60-894 15-295 <15
Risk factors: HPN, DM, autoimmune disease, older age,
African ancestry, FH of renal disease, previous episode of ARF, presence of proteinuria, abnormal
urinary sediment, or structural abnormalities of the urinary tract
With demonstrated kidney damage (persistent proteinuria, abnormal urine sediment, abnormal blood and urine chemistry, abnormal
imaging studies)
Presenter: Regina Ma. N. San Pedro
End stage renal disease
Accumulation of toxins, fluid and electrolytes
UREMIC SYNDROME
Presenter: Regina Ma. N. San Pedro
Impaired host of metabolic and endocrine
functions
AnemiaMalnutrition
Abnormal metabolism of CHO, fats and CHON
Altered plasma levels of hormones
(PTH, insulin, glucagon, sex hormones, prolactin)
UREMIC
SYNDROME
UREMIC
SYNDROME
Worsening systemic inflammation
Elevated CRP
MALNUTRITION-INFLAMMATION-ATHEROSCLEROSIS/CALCIFICATION SYNDROME
9. Therapeutic Plans
SANTOS, Mary Elaine S.
Therapeutic Goals
• To slow the progression of the disease• Treatment of comorbid conditions• Managing complications• Preparation for kidney replacement therapy• Patient education
Slowing the progression of CKD
• Protein Restriction– While protein restriction has been advocated to
reduce symptoms associated with uremia, it may also slow the rate of renal decline at earlier stages of renal disease
– daily protein intake of between 0.60 and 0.75 g/kg per day
• Reducing Intraglomerular Hypertension and Proteinuria
– 125/75 mmHg– ACE inhibitors and ARBs
• inhibit the angiotensin-induced vasoconstriction of the efferent arterioles of the glomerular microcirculation.
Slowing the progression of CKD
Slowing progression of Diabetic Renal Disease
• Control of Blood Glucose– Preprandial glucose = 5.0–7.2 mmol/L (90–130
mg/dL)– Hgb A1C = < 7%– As the GFR decreases with progressive
nephropathy, the use and dose of oral hypoglycemics needs to be reevaluated.
– As renal function declines, renal degradation of administered insulin will also decline, so that less insulin may be required for glycemic control.
• Control of Blood Pressure and Proteinuria
– Antihypertensive treatment reduces albuminuria and diminishes its progression.
– In addition to treatment of hypertension in general, the use of ACE inhibitors and ARBs in particular is associated with additional renoprotection.
Slowing progression of Diabetic Renal Disease
Managing other complications of CKD
• Hyperphosphatemia– low-phosphate diet – use of phosphate-binding agents
• taken with meals and complex the dietary phosphate to limit its GI absorption
• E.g. calcium acetate, calcium carbonate
• Hypertension– blood pressure should be reduced to 125/75– Salt restriction and diuretics are first line therapy– ACE inhibitors and ARBs
• slow the rate of decline of kidney function
• Anemia– target a hemoglobin concentration of 110 to 120
g/L– recombinant human EPO and modified EPO
products– oral iron supplementation– vitamin B12 and folate
Managing other complications of CKD
Preparation for Renal Replacement Therapy
10. What are the most common causes of chronic renal failure in the
USA? Philippines? SANTOS, Mary Elaine S.
National Kidney Foundation (www.kidney.org) Philippine Renal Disease Registry Annual Report in 2008