BIWEEKLY ASSESSMENT
5 SEPT EXAM
Good morning .This is an online assessment exam of our inpatients.
1st patient
1) ANATOMICAL diagnosis :
Glomerular damage (NEPHRITIC - NEPHROTIC SYNDROME).
It's acute kidney injury superimposed on a chronic diabetic nephropathy
Etiologies - RPGN /DPGN
? Post infectious Immune mediated destruction
?SLE
?IGA NEPHROPATHY
? MICROSCOPIC POLYANGITIS ( VASCULITIS)
Pt is also chronic diabetic and hypertension
2) AZOTEMIA :
- Inflammatory response within glomeruli→ GBM disruption → loss of renally excreted RBC (acanthocytes) and ↓ GFR → hematuria, oliguria, azotemia, and ↑ renin→ edema and hypertension
- ANEMIA : bcoz of
? decreased erythropoesis
hemodilution
reduced red blood cell survival time
Hemolysis if suspecting vasculitis.
Or Secondary to iron deficiency.( Nutritional anemia )
- Hypoalbuminemia is due to protein loss in urine which is NEPHROTIC range proteinuira .
- Pt is having METABOLIC ACIDOSIS With Uncompensated respiratory alkalosis .
Metabolic acidosis is due to impaired excretion of daily load of acid .
Although initially a hyperchloremic metabolic acidosis develops, widening of the anion gap is often seen as the result of accumulation of phosphate, sulfate and small organic anions .
Severe metabolic acidosis, often with marked elevation in the anion-gap may develop, as a result of underlying systemic disease, such as lactic acidosis due to tissue hypoperfusion, sepsis.
3) Pt was intially started on fluid and diuretic challenge to see for response .
Inj NaHCO3 doesn't cause any added benefit ,as bicarb repletion is often indicated only in conditions where there is loss of bicarbonate like in diarrhea and RTA. Replacement of NAHCO3 as symptomatic regimen is not recommend.
Metabolic acidosis is usually associated with a reduction in plasma pH, although serum concentration of hydrogen ions may be near normal when a mixed acid-base disorder is present. For instance, the coexistence of vomiting-induced metabolic alkalosis may contribute to the rise in plasma pH in patients with metabolic acidosis. Common causes of metabolic acidosis include diabetic ketoacidosis (DKA), lactic acidosis, and hyperchloremic acidosis due to diarrhea or renal tubular acidosis. Excess net dietary acid load in the presence of chronic kidney dysfunction induces metabolic acidosis with elevation of chloride and unmeasured anions. In acute conditions, such as DKA, lactic acidosis, and septic shock, the magnitude of the fall in plasma pH usually reflects the severity of the causative illness.
4) On third day dialysis was intiated as she wasn't responding to fluids and diuretics in view of refractory anuria and also in view of ? acute pulmonary edema as she had sob .
Even refractory metabolic acidosis can be an indication for dialysis.
5) Apart from diabetes and hypertension
Acute glomerulonephritis is probably secondary to immune complex deposition..?post infectious
Or secondary to ? SLE
? Vasculitis (Microscopic polyangitis)
6) Expected outcomes depends on underlying etiologies for which biopsy would be recommend.
If it's RPGN pt can land up in CKD with permanent renal damage .
Various histopathologic lesions are indicative of the prognosis. The extent of crescentic involvement on microscopic findings is indicative of the prognosis. Usually, a focal lesion with more than 50% normal glomeruli has a more favorable prognosis, almost 90% or more renal survival after 5 years follow up after treatment. Whereas more than 50% of glomeruli with cellular crescent has a less favorable prognosis of around 75% renal recovery at 5 years follow up. When more than 50% of glomeruli are globally sclerosed, the renal recovery is less than 25% up to 5 years follow up period. Variants include cellular, fibrocellular, and fibrous crescent. The extent of chronic tubule-interstitial fibrosis lesions can also impact the prognosis inversely. The disruption of Bowmen’s capsule is associated with poor outcome
7) mechanisms of hfpef in renal failure.
- Activation of renin angiotensin aldosterone system.
-Hypercalcemia
Hyperphostameia
- Uremic toxins
- Anemia
-Increased levels of fgf -23.
9 ) Subjective Global Assessment (SGA) is a tool that uses 5 components of a medical history (weight change, dietary intake, gastrointestinal symptoms, functional capacity, disease and its relation to nutritional requirements) and 3 components of a brief physical examination (signs of fat and muscle wasting, nutrition-associated alternations in fluid balance) to assess nutritional status.
Second patient :
This patient differs from first pt in ,,
No albuminuria or hematuria i.e no glomerular pathology
No generalized anasarca
No anuria ( his urine output is always maintaining although it was less intially )
Pt responded to fluid challenge and diuretics.
This patient might be having an Renal AKI ( post infectious , inflammatory) with underlying CKD ( kidney size normal as in diabetic nephropathy )
And also anemia and Hypoalbuminemia would point out for a chronic kidney disease.
But as pt was having adequate urine output and was responding to diuretics and fluid challenge,hence dialysis wasn't intiated in him.
USG KIDNEY :
In first pt although kidney size was normal there was increase echogenicity
But normal size of kidneys can be due to diabetic nephropathy in both patients.
Second pt dint have any raised echogenicity picture .
Thank you ! :)
Wow so much of pink
ReplyDelete