Analysis on 45year old female patient with anasarca.
D. Arun Kumar
Roll no: 46
I have been given this case in an attempt to solve in attempt to understand the patient's clinical data analysis to develop my competency in reading and comprehending including history, clinical findings, examination, investigations, and plan of treatment
The complete details of the patient's history https://alekyatummala.blogspot.com/2020/09/45-yr-female-with-anasarca.html?m=1 are given this case
The main complaints of the patient are -
1. Pedal edema pitting type
2. Generalized edema
3. Shortness of breath at rest (NYHA grade 4)
4. Chest pain on the right side
5. Anuria
Causes of generalized edema :
1.Heart failure
2.cirrhosis of liver
3.kidney disease
4.hypoalbuminemia
5. Drug-induced edema
6. nutritional origin
what is the anatomical and etiological diagnosis of the patient :
anatomical diagnosis- kidney injury
etiological diagnosis-nephropathy due to diabetes, hypertension
what are the reasons for :
azotemia is a medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood. It is largely related to insufficient or dysfunctional filtering of blood by the kidneys.
ANEMIA - the kidney's function is to produce adequate amount of erythropoietin , when there is kidney damage these levels are reduced thereby causing anemia ( relative deficiency of erythropoeitin )
other causes include :
- diminished red blood cell survival
- iron deficiency due to loss of appetite and malnutrition
- folate or vitamin b12 deficiency
4 ACIDOSIS - normally kidneys maintain acid-base regulation, which when disturbed due to any kidney disorder causes metabolic acidosis . in this patient ph = 7.19 and reduced bicarbonate levels of 6.7 mmol/l which indicates metabolic acidosis .it occurs because of :
- increase in endogenous production of acid (such as lactate or ketoacidosis )
- loss of bicarbonate levels
- accumulation of endogenous acids because of inappropriately low excretion of net acid by the kidney ( as in CKD )
what is the rationale of her treatment plan detailed day-wise in the record ?
On day 1 :
1.Inj. NaHCO3 is given in order to neutralize the acidosis
EFFICACY -
treat acidosis with ventilation and perfusion by increasing plasma bicarbonate, buffers excess hydrogen ions and raises blood ph, and reverses clinical manifestations caused by acidosis
also thought to worsen heart conditions and liver functions
INDICATIONS OF IV SODIUM BICARBONATE :
- TO treat metabolic acidosis when the underlying disease is diarrhea, vomiting, or kidney-related diseases
- high blood potassium
- tricyclic anti-depressant overdose
- cocaine toxicity
- contraindicated in patients who are losing chloride
- it should be used with great care in patients of CCF, severe CKD due to its sodium content because in these conditions sodium retention is a problem
- it should be given in patients using corticosteroids with caution
- as an antacid to treat heartburns, indigestion, upset stomach
- Hypersensitivity
- metabolic/respiratory alkalosis and hypocalcemia - because alkalosis produces tetany
3. ORAL HYPOGLYCEMIC AGENTS - used as a diabetic agent to lower glucose levels in the blood
4. ANTI HYPERTENSIVES - to treat hypertension (to lower blood pressure value)
On day 2 :
1. Inj.HAI - used in type2 diabetes patients when their meat plan, weight loss, exercise, and antidiabetic drugs do not achieve targeted blood sugar levels
2. orofer - for treatment of iron and folic acid deficiency i.e anemia
3.PAN -Treatment of conditions due to excess acid secretion in the digestive system
4. LASIX - a diuretic which is used to reduce the risk of strokes, heart attacks, and kidney problems
contraindications are :
- kidney disease
- hypokalemia
- diabetes - when taken furosemide it is hard to control blood sugar levels
- liver disease
On day 3
1.tab Dytor - given to control fluid overload and blood pressure since the patient had higher blood pressure on day 3
2.telma - Telmisartan is given to treat hypertension, heart failure and diabetic kidney disease .may be because of its limitation that it reduces the amount of urine and increases kidney damage it could be stopped
3. Nicardia is given to lower blood pressure
4.Orofer and erythropoietin inj- in order to correct anemia and increase levels of erythropoietin which further corrects anemia
5. Shelcal - it is given to treat hypocalcemia
6. Potchlor syrup - to correct hypokalemia
7.nodosis - it is an antacid, to neutralize the excess acid present in the stomach
On day 4:
1. Lactulose - since the patient complained she had constipation she was given lactulose after which she passed the stools
2.inj.monocef- it is an antibiotic. Used to treat UTI or any other infections
3. Protein x powder - given since the patient is malnourished
but excess use can cause coma, hepatic damage, metabolic disturbances, unpleasant taste in the mouth
On day 5
The patient was further evaluated to improve her condition
what was the indication for dialyzing her and what was the crucial factor that led to the decision to dialyze her on the 3rd day of admission?
- severe breathlessness due to pulmonary edema
- acid-base problems ( METABOLIC ACIDOSIS )
- pericarditis
- electrolyte imbalance
On 3rd day of her admission, the crucial factor that led to the decision to dialyze her was due to - FLUID OVERLOAD / PULMONARY EDEMA REFRACTORY TO DIURETICS and Refractory anuria
what are the other factors other than diabetes and hypertension that led to her current condition?
it may be due to anemia, vascular disease, and constipation
what are the expected outcomes in this patient? Compare the outcomes of similar patients globally and share your summary with reference links?
as mentioned in the above link :
chronic pressure overload, progressive volume overload, cardiomyopathy with the additional risk factor of Diabetes, Anemia could lead to preserved LVEF / reduced LVEF which further lead to the outcome of :
- Progression of CKD
- HF hospitalization
- Sudden arrhythmic death
- Pump failure of death
How and when would you evaluate her further for cardio-renal HFpEF and what are the mechanisms of HFpEF in diabetic renal failure patients?
Evaluation for HFpEF must be done on the day of admission itself if there is suspicion of heart-related disorder such as heart failure as per the patient's symptoms, clinical examination, and laboratory diagnosis
Evaluation for cardio-renal HEpEF :
- Echocardiography - provides information on chamber volumes, ventricular systolic and diastolic dysfunction, wall thickness, valve function, and filling pressures
- Chest radiography - to screen for other sources of dyspnea
- Electrocardiography - to detect rhythm disturbances or evidence of prior myocardial damage or pericardial disease
- MRI
- global longitudinal strain analysis
- whole -body bioimpedance technique
- extended cardiac rhythm monitoring
- Pulmonary artery ambulatory monitoring
- thoracic impedance monitoring
decreased renal blood flow leads to the stimulation of the RAAS mechanism resulting in :
- sodium, water retention leading to volume overload thereby increasing blood pressure and cardiac work, myocardial fibrosis finally causing heart failure
- leads to vasoconstriction leading to increased afterload, increased blood pressure, leading to heart failure
What are the efficacies over placebo for the available therapeutic options being provided to her for her anemia?
referred link as follows
https://pubmed.ncbi.nlm.nih.gov/19245362/
https://clinicaltrials.gov/ct2/show/NCT01114139
What is the utility of tools like the CKD-AQ that assess the frequency, severity, and impact on daily activities of symptoms of anemia of CKD? Is Telegu among the 68 languages in which it is translated?
CKD-AQ - about frequency, severity of symptoms, signs associated with anemia.
https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfz091/554348
https://www.smartpatients.com/trials/NCT034091072
what is the contribution of PEM to her severe hypoalbuminemia? what is the utility of tools such as SGA( subjective global assessment ) in the evaluation of malnutrition in CRF patients
Nutritional deficiencies particularly that of iron and zinc and decreased supply of amino acids to the liver causes reduced production of albumin levels thus leading to hypoalbuminemia
Nutritional status as determined by Subjective Global Assessment -Dialysis Malnutrition Score is a useful and reliable index for identifying patients at risk for malnutrition and it correlates well with the anthropometric and biochemical assessment. May be integrated into the regular assessment of malnutrition in patients on maintenance hemodialysis
Differences in the diagnosis of a 45-year-old female and a 58-year-old man ;
