Pginternalassessment/chandanavishwanatham

1..Anatomical diagnosis - pedal edema causes

 1) increased hydrostatic pressure

 2) decreased oncotic pressure 

 3) lymphatic obstruction 

?kidney

 ?cardiac

 ?liver.

 Etiological diagnosis - ?long standing CKD ( 6months history of pedal edema) sr creatine and blood urea levels are high ?diabetic nephropathy ? nephrotic pattern hypoalbuminemia ? abdomen distension ? right heart failure

2..reason of 

Azotemia:decreased excretion of nitrogenous waste by kidney causing increased BUN

Anemia:iron deficiency, erythropoietin deficiency 

Hypoalbuminemia:albumin in urine is ++++, as there is proteinuria,there is hypoalbuminemia, nutritional cause may also contribute

Acidosis:decreased resorption of bicarbonate, increased H+ ion secretion

3.. syp potclor was given to correct hypokalemia 

IV bicarbonate was given to correct metabolic acidosis and prevent adverse effects of acidemia(esp cardiovascular) 

IV bicarbonate should not be used in patients with high and low anion gap because it worsens lactic acidosis and has shown no benefit in diabetic ketoacidosis. The rate of decline of blood glucose, the mean time to achieve an arterial pH>7.3 and the recovery rates of plasma bicarbonate level and pH are similar among DKA patients with or without sodium bicarbonate infusion. 

Inj erythropoietin and tab orofer given for anemia

Telma 40mg for hypertension

Human actrapid for sugar control

Inj lasix to maintain urine output and decrease fluid overload

4..indication of dialysis:metabolic acidosis associated with shortness of breath

5..immune complex deposition and release of inflammatory cytokines causing glomerular basement membrane damage.(glomerulonephritis, Iga nephropathy) 

7.2d echo is used to evaluate HFpef.Diabetic macrovacular changes, Hypertension and cardiorenal syndrome caused diastolic dysfunction leading to HFpef. 

8.oral iron is of not much use because in inflammatory state there will be increased hepcidin and decreased oral Iron absorption. And erythropoietin is beneficial for CKD rather than AKI as anemia is occurring due to EPO deficiency. 

mean Hemoglobin levels,before and after study,in rhuepo group we’re 8.85+ or - 1.01g/do and 9.90+ or - 0.29 g/dl,respectively(p less than 0.001) and in control group were,9.00+ or -g/dl and 7.81 + or - g/dl,respectively

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293514/

CKD-AQ is a effective tool to measure anemia in subjective way, in terms of symptomatic problems and to assess any decrease in quality of life due to anemia. Yes, telugu is one among the 68 languages.

Anaemia contributes to the impairment of health-related quality of life (HRQoL) in patients with CKD [7]. Its impact on patients’ HRQoL burden is exacerbated by reduced physical capacity and energy levels among these patients.

10.protein energy malnutrition can be a major cause of her hypoalbuminemia.As she also has iron deficiency, she is not well nourished. It can detect changing trend in nutritional status which can be missed in one time anthropometry. Subjective global assessment:

7 point SGA using a 7-point Likert scale for the subjective ratings to assess nutritional status based on the medical history and physical examination. The medical history consisted of five criteria that focused on weight loss during 6 months, dietary intake change, gastrointestinal symptoms, functional capacity and co-morbidities that affect nutritional requirements based on the statement from patients. The physical examination evaluated subcutaneous fat, muscle wasting, ankle edema and/or ascites. Finally, the patients were classified into three SGA categories according to the score of each part and the general condition: A = well nourished (score 6 or 7), B = moderately malnourished (score 3, 4, or 5), C = severely malnourished (score 1 or 2)."This is an important measure to treat hypoalbuminemia.

Q2 a. Diagnosis: I agree with the diagnosis. it can be prerenal AKI because of sepsis there can be third space loss and decreased Renal blood flow

Platelets, fibrin, stiff red blood cells and leukocytes together with endothelial cell swelling are responsible for capillary occlusion [21]. Increased vascular permeability is a common feature in sepsis and leads to interstitial edema and fluid retention (Figure 1) [22, 23]. In addition to its association with the severity of sepsis, fluid overload and interstitial edema increase the diffusion distance for oxygen to target cells [24]. Similar findings can be observed in the renal microcirculation [25]. Furthermore, as the kidney is an encapsulated organ, fluid accumulation and tissue edema contribute to the observed deterioration of renal microcirculatory perfusion by altering transmural pressures and by aggravating venous congestion

Referance:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495653/

B. Differences in terms of

Diagnosis:in the previous case there is a background of CKD (pedal edema since 6months)but in this case only AKI

Therapy:Both the patients have metabolic acidosis but in the first case the patient had shortness of breath and 2nd patient is symptomatically better. So hemodialysis was not done for this patient. 

 C.size of the kidney is increased to more than 3cms in ultrasound abdomen 

 it might be because of 

 1.increase in size 

 2 stenosis with over compensation of the normal kidney