CME case

This is a case of 40 year old male with Chronic kidney disease on maintenance hemodialysis since 7 years.

At around 6 years of age , patient father died due to some unknown illness.Patient used to drink alcohol ,when he was in intermediate along with his friends and it went out of control.He used to take more than 180ml of whisky per day and also used to drink toddy.He says as there was no father figure in his life , he continued to drink heavily.He started working as a collection agent in a finance company and used to drink and smoke heavily ( around 15cigarettes perday ) while he was on job.At around 26 years of age, patient got married and there was a marital issues between the patient and the wife due to his chronic alcohol behaviour at around 29 years of age , his daughter was born.and now she was 11 years old.

10 years back , in 2012, he was admitted in Kamineni De addiction Centre for treatment of his chronic alcoholism.He was sober for around 4 months, then after he started drinking heavily again.

At around 33 years of age , patient had fever along with loss of appetite, where he went to RMP and used some medication, but didn't got subsided and visited local doctor , where he found his renal parameters were deranged and reffered to Kamineni for hemodialysis and hemodialysis initiated at around 7 years back ( at age of 33 years ).

Then onwards patient on maintenance hemodialysis with 3 sessions per week.

Even after starting dialysis patient, used to alcohol and smoke 10 cigarettes per day.

In March 2020, Patient had Shortness of breath and on evaluation found to have B/L lower lobe consolidation with B/L pleural effusion and lights criteria showed exudative and ada was 15.. patient was treated with antibiotics and therapeutic pleural tap was done got discharged.

In June 2020, patient developed swelling of the AV fistula where Doppler was done ,which showed subcutaneous edema and treated conservatively

In September 2020, patient developed Low back ache and X ray showed degenerative changes and treated conservatively

In Jan 2021, patient developed flash pulmonary edema and immediately dialysis was done and symptomically improved 

In March 2021, patient developed Ascites , on diagnostic tap showed High saag and therapeutic was also done

After 6 months , patient developed Umbilical hernia with ascitic fluid as the herniating content.

In my thesis study, I found that there were slightly significant increase in the number of deaths , with duration of dialysis less than 1 year.

Out of 12 , who survived more than 1 year , the longest duration of hemodialysis was this patient,which is about 7 years

So the question arose ,what is the different or what are the factors giving him better prognosis.

1) I have come to summarise /analyse that his increased survival may be because ofbhis hemoglobin level ,which was maintained via repeated blood transfusions and regular erythropoietin injection and lesser admission due to heart failure. 

2) Is initiating the dialysis at 33 years of with out conservative management is the reason for better prognosis

Out 

Inspection: 

3*3*2 cm globular swelling arising from umbilicus, 

Expansile cough impulse positive

Skin over the swelling is stretched 

Surface over the swelling is normal 

No scars, sinuses, engorged veins, pulsating vessels 

Palpation :

No local rise of temperature, non tender, all the inspectory findings are confirmed with respect to site site shape 

Surface over the swelling is smooth 

Skin pinchable 

Cough impulse positive 

Reducible 

1*1 cm defect noted in umbilicus 

Doughy consistency 

Percussion

Dull note present 

Auscultation : Bowel sounds absent