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    Clinicopathological Conference 2

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    Rem Alfelor
    This patient is a 75-year-old female admitted with confusion and laboratory abnormalities. Over 4 days in the hospital, her condition deteriorated with worsening vital signs, crackles in the lungs, edema, and jaundice. Based on her history of hypertension, decreased kidney function with elevated BUN and creatinine, and estimated GFR of 17.6 mL/min/1.73m2, she was diagnosed with chronic kidney disease stage 4 or 5. Key factors in her condition were age, gender, hypertension, and decreased renal function.

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    Clinicopathological Conference 2

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    Rem Alfelor
    128 views23 pages
    This patient is a 75-year-old female admitted with confusion and laboratory abnormalities. Over 4 days in the hospital, her condition deteriorated with worsening vital signs, crackles in the lungs, edema, and jaundice. Based on her history of hypertension, decreased kidney function with elevated BUN and creatinine, and estimated GFR of 17.6 mL/min/1.73m2, she was diagnosed with chronic kidney disease stage 4 or 5. Key factors in her condition were age, gender, hypertension, and decreased renal function.

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    Chronic Kidney Disease

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    This patient is a 75-year-old female admitted with confusion and laboratory abnormalities. Over 4 days in the hospital, her condition deteriorated with worsening vital signs, crackles in the lungs, edema, and jaundice. Based on her history of hypertension, decreased kidney function with elevated BUN and creatinine, and estimated GFR of 17.6 mL/min/1.73m2, she was diagnosed with chronic kidney disease stage 4 or 5. Key factors in her condition were age, gender, hypertension, and decreased renal function.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    128 views23 pages

    Clinicopathological Conference 2

    Uploaded by

    Rem Alfelor
    This patient is a 75-year-old female admitted with confusion and laboratory abnormalities. Over 4 days in the hospital, her condition deteriorated with worsening vital signs, crackles in the lungs, edema, and jaundice. Based on her history of hypertension, decreased kidney function with elevated BUN and creatinine, and estimated GFR of 17.6 mL/min/1.73m2, she was diagnosed with chronic kidney disease stage 4 or 5. Key factors in her condition were age, gender, hypertension, and decreased renal function.

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    CLINICOPATHOLOGICAL

    CONFERENCE
    UPON ADMISSION
    Physical Examination
    Awake and disoriented
    BP 120/80mmHg
    HR 79bpm
    RR 20 cpm Laboratory
    Temp 36.70C CBC
    High PMN, LYM, MONO, RDW
    Low RBC MCHC
    Blood chemistry
    High BUN, creatinine
    Low Na
    Day 2
    Physical Examination
    BP 110/90mmHg
    HR 88bpm
    RR 26 cpm
    Temp 370C
    Laboratory
    CBC
    Prothrombin time: Prolonged (21.0 sec)
    % Activity: 0.35
    INR: 1.88
    Activated Partial Thromboplastin time: Prolonged
    (53.9 sec)
    Blood chemistry
    Low: albumin, pCO2, pO2, HCO3, BE
    High AST
    Normal ALT
    O2 sat:95.3%
    TCO2: 22.3 mmol/L
    SBs 254.1 mmol/L
    Glycosylated hemoglobin: increased (6.4)
    Day 3
    Physical Examination
    Drowsy
    Occasional crackles on both lung
    field
    BP 130/80mmHg
    HR 63 bpm
    RR 25 cpm
    Temp 37.1 0C Laboratory
    CBC
    High MONO, RDW
    Low RBC, MCHC, PC
    Day 4
    Physical Examination
    GCS score 3
    BP 110/90mmHg
    HR 88bpm
    RR 26 cpm
    Temp 370C Laboratory
    Icteric sclera CBC
    Tacchycardia Low PMN, RBC, HG, RDW,PC
    Occasional crackles in High LYM, MCV, MCHC
    both lung fields Blood chemistry
    Supraclavicular retraction Glucose: increase
    Grade 2 bipedal edema High BUN, Creatinine, Na, Cl(111;
    O2 saturation 70% =106)
    LowTC
    Liver Ab titer
    HBsAg: 0.49 non-reactive
    Anti-HCV: non-reactive
    Differential Diagnosis:
    CHRONIC KIDNEY DISEASE
    RULE IN RULE OUT
    Duration 4 months On presentation
    GFR 17.6 mL/min per 1.73 m2 No dilated neck veins
    Polypharmacy No peripheral edema
    Hypertension and DM No murmur
    Abnormal urinalysis: Sediments, Adynamic precordium
    +2 protienuria PMI in normal anatomic location
    Metabolic acidosis
    Tachypnea
    Anemia
    Changes in sensorium
    Multiorgan involvment
    Inc BUN (25.5mmol/L)
    Inc serum creatinine (2.8 mg/dL,
    321.0 mmol/L) on 9/3, 9/6
    Hyponatriemia (132.7 mmol/L) on
    9/3
    Differential Diagnosis:
    CONGESTIVE HEART FAILURE
    RULE IN RULE OUT
    Hypertension On presentation
    Left atrial dilation No dilated neck veins
    Left atrial hemiblock No peripheral edema
    Left ventricular remodeling No murmur
    Mitral and aortic stenosis Adynamic precordium
    Inc serum creatinine (2.8 mg/dL, PMI in normal anatomic location
    321.0umol/L) 9/3, 9/6
    Slight tachycardia with normal
    rhythm on presentation
    Crackles on both lung fields on day 4
    Hepatomegaly
    Differential Diagnosis:
    LIVER CIRRHOSIS
    RULE IN RULE OUT
    Female No dilated neck vein on presentation
    Alcoholism Hypernatremia (147mmol/L) on 9/6
    RUQ Pain Anicteric sclerae on presentation
    Hepatomegaly
    Anemia
    Thrombocytopenia (101, 109 x 10 3/l)
    on 9/6, 9/7
    Prolonged prothrombin time (21.0sec)
    on 9/4
    High AST (171 U/l) on 9/4
    High ALT (53 U/l) on 9/4
    Edema on lower extremities on day 4
    Jaundice on day 4
    RISK
    HYPERTENSI
    FACTORS:
    ON
    75 y/o
    Ventricular
    FEMALE
    remodelling
    ALCOHOL

    Pulmonary Pooling of Decrease


    hypertension blood cardiac output

    Chronic
    Pulmonary passive Decrease
    RAAS
    edema congestion renal
    perfusion
    LIVER FAILURE HEART
    RENAL
    FAILURE
    FAILURE

    DEATH
    DIAGNOSIS:
    CHRONIC KIDNEY DISEASE
    defined as abnormalities of kidney structure or function,
    present for > 3 months, with implications for health
    classified based on cause, GFR category, and albuminuria
    category (CGA)

    Source: KDIGO 2012 Chronic Kidney Disease Guidelines


    CKD: DEFINITION
    Multiple etiologies
    Diminished number and function of nephrons
    Leads to End Stage Renal Dse (ESRD)
    Irreversible
    CKD: RISK FACTORS

    Non-modifiable Risk Factor


    Age >60 y/o due to faster rate of GFR decline
    Gender Males are associated with more rapid GFR
    decline
    Race African-Americans and Hispanic-Americans have
    faster GFR decline
    Genetics Diabetic and non-diabetic nephropathies and
    PKD patients with genotype PKD1
    Loss of Renal mass (NOT SURE ABOUT THIS??)
    CKD: RISK FACTORS

    Modifiable Risk Factor


    Hypertension
    Proteinuria associated with faster rate of progression
    Metabolic Markers
    1) Hyperglycemia
    2) Dyslipidemia
    3) Obesity
    4) Hyperuricemia
    D. Others smoking, alcohol, lead exposure, analgesics,
    NSAIDS and recreational drugs,
    PATHOPHYSIOLOGY
    CELLULAR CHANGES
    CELLULAR CHANGES
    EPIDEMIOLOGY OF CKD
    ESRD is the 7th leading cause of death among
    Filipinos
    1 develops CRF every hour
    More the 5,000 are undergoing dialysis
    Cost of medical treatment is beyond the reach
    of ordinary patients
    Shortage of organ donors is a major problem
    Source: nkti.gov.ph
    EPIDEMIOLOGY OF CKD
    9th leading cause of mortality in the Philippines
    Ranks 1st on most number of claims for
    insurance
    Chronic Glomerulonephritis, Hypertensive
    Nephrosclerosis and Diabetic Nephropathy are
    the 3 most common cause of ESRD
    Highly preventable
    Source: chd.12.doh.gov.ph/index.php/162-kidney-month
    Recommended Equations for Estimation
    of GFR
    Equation from the modification of diet in
    Renal disease study
    Estimated GFR (mL/min per 1.73 m2)
    = 1.86 x (PCr)-1.154 x (age)-0.203
    Multiply by 0.742 for women

    =[1.86 x (247) -1.154 x (75) -0.203 ] x 0.742


    = 17.6 mL/min per 1.73 m2
    Recommended Equations for Estimation
    of GFR
    Cockcroft Gault equation
    Estimated creatinine clearance (mL/min)

    (140 age) x body weight (kg)


    72 x PCr (mg/dL)
    Classification of Chronic Kidney Disease
    Source: Harrisons Principle of Internal Medicine 18th ed
    Table 280-1

    Stage Description GFR, mL/min per 1.73m2


    0 With CKD risk factors >90
    1 Kidney damage with normal or 90
    increased GFR

    2 Kidney damage with mildly 60-89


    decreased GFR

    3 Moderately decreased GFR 30-59

    4 Severely decreased GFR 15-29


    5 Renal Failure <15 (or dialysis)

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