Sugar ‘N Spice, Aint Everything Nice

1. Sugar ‘N Spice, Aint Everything Nice SGD Case 4

2. History, PE, Laboratory and Ancillary Tests Sanez, John Ericson T.

3. 60 y/o, male, CC: persistent nausea and vomiting Sanez, John Ericson T

4. 60 y/o, male, CC: persistent nausea and vomiting Sanez, John Ericson T

5. 60 y/o, male, CC: persistent nausea and vomiting Sanez, John Ericson T

6. 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

7. 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

8. Sanez, John Ericson T

9. Sanez, John Ericson T

10. Sanez, John Ericson T

11. Sanez, John Ericson T

12. Ultrasound of the Kidney • Right kidney • 9.7 x 3.9 cm • Cortical thickness 1.1 cm • Increased parenchymalechogenicity • Left kidney • 9.9 x 3.8 cm • Cortical thickness 1.2 cm • Increased parenchymalechogenicity • No stones, mass, nor structural deformity noted bilaterally Sanez, John Ericson T

13. 2. Compute for the estimated renal function using the present serum creatinine of 9.3 mg/dL. SALES, Maria Stephanie

14. 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 spaces U = urine concentration of the solute V = urine flow P = concentration of the solute in plasma SALES, Maria Stephanie

15. 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

16. Creatinine Clearance SALES, Maria Stephanie

17. Cockcroft-Gault Method * 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

18. MDRD (modification of diet in renal disease) Source: http://www.nkdep.nih.gov/professionals/gfr_calculators/orig_con.htm SALES, Maria Stephanie

19. 3. What is the gold standard in estimating renal function? SALES, Maria Stephanie

20. Inulin • Exogenous starch-like fructose polymer • Fulfills all the criteria for use of a substance to measure GFR SALES, Maria Stephanie

21. SALES, Maria Stephanie SALES, Maria Stephanie

22. 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

23. 6. Tabulate the differences/similarities between acute and chronic renal failure. SALES, Maria Stephanie

24. SALES, Maria Stephanie

25. SALES, Maria Stephanie

26. DIABETIC NEPHROPATHY Diabetic nephropathy is kidney disease that develops as a result of diabetes mellitus (DM). Presenter: Regina Ma. N. San Pedro

27. PATIENT • 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. DIABETIC NEPHROPATHY 5 years PTA: 2+ proteinuria 5 months PTA: bubbly urine Admission: albumin +++ 5 years PTA: 51mL/min 4 months PTA: 30.7mL/min Admission: 9.9mL/min Admission: 160/90mmHg Presenter: Regina Ma. N. San Pedro

28. STAGES OF DIABETIC NEPHROPATHY Presenter: Regina Ma. N. San Pedro Source: www.emedicine.medscape.com

29. 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 STAGES OF CKD (KDOQI) With demonstrated kidney damage (persistent proteinuria, abnormal urine sediment, abnormal blood and urine chemistry, abnormal imaging studies) Presenter: Regina Ma. N. San Pedro

30. End stage renal disease Accumulation of toxins, fluid and electrolytes UREMIC SYNDROME Presenter: Regina Ma. N. San Pedro

31. Anemia Malnutrition Abnormal metabolism of CHO, fats and CHON U R E M I C S Y N D R O M E Impaired host of metabolic and endocrine functions Altered plasma levels of hormones (PTH, insulin, glucagon, sex hormones, prolactin) Worsening systemic inflammation Elevated CRP MALNUTRITION-INFLAMMATION-ATHEROSCLEROSIS/CALCIFICATION SYNDROME Presenter: Regina Ma. N. San Pedro

32. 9. Therapeutic Plans SANTOS, Mary Elaine S.

33. Therapeutic Goals • To slow the progression of the disease • Treatment of comorbid conditions • Managing complications • Preparation for kidney replacement therapy • Patient education

34. 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

35. Slowing the progression of CKD • 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.

36. 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.

37. Slowing progression of Diabetic Renal Disease • 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.

38. 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

39. Managing other complications of CKD • 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

40. Preparation for Renal Replacement Therapy

41. 10. What are the most common causes of chronic renal failure in the USA? Philippines? SANTOS, Mary Elaine S.

42. National Kidney Foundation (www.kidney.org)Philippine Renal Disease Registry Annual Report in 2008