Biweekly internal assessment

 

1) Anatomical diagnosis -? Kidney( nodular Glomerulosclerosis)   secondary to diabetic insipidus                            Etiological diagnosis -  ?? Nephrotic syndrome secondary to the diabetic nephropathy or CKD.

     2)Reasons for I) Azotemia : impaired renal excretion of urea and creatinine secondary to CKD. II) Anemia : decreased erythropoietin. III) Hypoalbunemia: capillary basement membrane and podocytes damage. IV)  acidosis: acidification of urine is lost.                                      3) Rationale : syp potchlor was given because of the hypokalemia.. Inj. NaHCO3 was given because of metabolic acidosis ..Insulin and antihypertensives are given because known case of DM and HTN. Orofer XT was given because of anemia.. Inj. Lasix was given to decrease her volume overload. Spironolactone was given it was a potassium sparing diuretic.Calcium was given to the patient  because of hypocalcemia secondary to CKD. Indications of NaHCO3:metabolic acidosis in cardiac arrest, Tricyclic antidepressants, aspirin and phenobarbitone overdoses, Hyperkalemia, Crush injuries, C/I  in certain conditions because of adverse reactions like Hypernatremia, metabolic alkalosis, cellulitis, seizures, Tetany, sodium retention, peripheral edema.                       4) indication of dialysis in this pt: worsening of SOB secondary to metabolic acidosis with Anuria not resolved with high ceiling diuretics...Crucial factor: pt became symptomatic on 3rd day....                                      5) Causes of same condition : primary : Minimal change disease, Focal segmental glomerulosclerosis, Membranous nephropathy.    Secondary : DM, SLE, HIV , Viral hepatitis, malaria, amyloidosis,  Sarcoidosis, Drugs : Nsaids, gold, pencillamine Cancer: Hodgkin's and non Hodgkin's, solid tumours of GIT, RCC and lung.                                                                        6) The expected outcomes Are mainly:  High mortality is seen in CKD with hypoalbuminemia   http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5752034.                                                              7) Macrovascular changes accompanying CKD, such as Hypertension and arterial stiffening, have been described to contribute to HFpEF development. Furthermore, several renal factors have a direct impact on the heart and coronary microvasculature and may underlie the association between CKD and HFpEF.                     http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC6737277.....                                                                              8)efficacies of drugs over placebo in anaemia : 117 patients received oral ferric citrate and 115 patients received placebo for a 16 week randomized period... 52.1% patients receiving ferric citrate achieved primary endpoint of increased HB levels ..comparing to 19.1% patients receiving placebo.. Overall in pts with CKD.. Found Oral ferric citrate found to be safe and efficacious treatment for IDA..            Another trial : between Ferumoxytol and placebo for anemia in IDA and GI disorders... A trail was performed in 231 pts with IDA and GI disorders vs placebo in pts who had failed or were intolerant to oral iron therapy.... Results : pts with IDA receiving Ferumoxytol achieved a levels of >_ 20g/dl in HB vs placebo pts. https://www.dovepress.com/ferumoxytol-versus-placebo-in-iron-deficiency-anemia-efficacy-safety-a-peer-reviewed-fulltext-article-CEG 

https://www.uspharmacist.com/article/oral-iron-supplements-found-safe-effective-in-users-with-ckd

9) Anemia contributes to the impairment of health related quality of life (HRQoL)  in patients with CKD.. It's impact on patients HRQoL burden is exacerbated by reduced physical capacity and energy Levels among these patients.. 

10) S. Albumin is believed to be the principle nutritional marker used to identify malnutrition in patients with CKD.... But according to MDRD study.. Restricted dietary protein intake to as little as 0.56g/kg/day..there S. Albumin remained > 4mg/dl....Even more severe restriction of dietary up to 0.3-0.4g/kg/day did not cause reduction in Serum albumin... In no of observational studies including the enrolling dialysis pts, the Low S. Albumin levels in dialysis pts are associated with Systemic inflammation with little evidence implicating inadequate nutrition as causative factor. In Summary a plethora of corroborative clinical in General population and in pts with CKD showed S. Albumin is an insensitive indicator of malnutrition. 

SGA tools : Based on 7 point likert scale.. It includes history taking and physical examination.. Under medical history : weight loss during 6 months, dietary intake change, GI symptoms, Functional capacity and Co morbidities that affect nutritional requirement 

Physical examination : Subcutaneous fat, muscle wasting, ankle edema and or Ascites..  

11) 58M had history of fever with cough and elevated TLC which indicates acute renal injury.. And also there is no albuminuria and Edema. Where as in 45F had a pedal edema, Facial puffiness, abdominal distension, anuria which clearly indicates nephrotic nephritic syndrome.. And investigations showed that there is microalbuminuria, micro haematuria.. In this patient.