ANALYSIS OF ANASARCA
I am sameera roll no 50 and have been given this case in an attempt to solve in attempt to understand the patient's clinical data analysis to develop my competency in reading and comprehending including history, clinical findings, examination, investigations, and plan of treatment
The complete details of patient's history https://alekyatummala.blogspot.com/2020/09/45-yr-female-with-anasarca.html?m=1 is given in this link
chief complaints:
1. Pedal edema pitting type
2. Generalised edema
3. Shortness of breath at rest (NYHA grade 4)
4. Chest pain on right side
5. Oliguria
FIRST LET US KNOW THE CAUSES OF GENERALIZED EDEMA:
ref;https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.grepmed.com%2Fimages%2F8533%2Fdifferential-generalized-algorithm-diagnosis-anasarca-causes-edema&psig=AOvVaw1lCUsMNY4ytLeR8A-rhmc6&ust=1599660415704000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCOCq7K_d2esCFQAAAAAdAAAAABAD
a. Heart failure
b. Hepatic cirrhosis
c. Edema of renal disease
d. Nephrotic syndrome and other hypoalbumenic states
e. Drug induced edema
f. Nutritional origin
QUESTION CORNER:
1.1) What is your complete anatomic and etiologic diagnosis from the data available in the patient's online record linked above? (ignore the provisional diagnosis on admission mentioned in the case report)
ANATOMICALLY THERE IS RENAL INVOLVEMENT AND APPEARS TO BE RENAL FAILURE
ETIOLOGICALLY THERE IS CHRONIC HISTORYOF DIABETES MELLITUS (5YRS) AND HYPERTENSION (1YR)
SO APPEARS TO BE DIABETIC NEPHROPATHY.
2) What are the reasons for her:
A)Azotemia: Azotemia (azot, "nitrogen" + -emia, "blood condition") is a medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood. It is largely related to insufficient or dysfunctional filtering of blood by the kidneys.[1] It can lead to uremia and acute kidney injury (kidney failure) if not controlled.
Renal azotemia (acute kidney failure) typically leads to uremia. It is an intrinsic disease of the kidney, generally the result of kidney parenchymal damage. Causes include kidney failure, glomerulonephritis, acute tubular necrosis, or other kidney disease.
B)Anemia :
ANEMIA - the kidney's function is to produce adequate amount of erythropoietin , when there is kidney damage these levels are reduced thereby causing anemia ( relative deficiency of erythropoeitin )
other causes include :
- diminished red blood cell survival
- iron deficiency due to loss of appetite and malnutrition
- folate or vitamin b12 deficiency
D) ACIDOSIS - normally kidneys maintains acid-base regulation , which when dsturbed due to any kidney disorder causes metabolic acidosis . in this patient ph = 7.19 and reduced bicarbonate levels of 6.7 mmol/l which indicates metabolic acidosis .it occurs because of :
- increase in endogenous production of acid (such as lactate or ketoacidosis )
- loss of bicarbonate levels
- accumulation of endogenous acids because of inappropriately low excretion of net acid by the kidney ( as in CKD )
3) What was the rationale for her treatment plan detailed day wise in the record?
On day 1 :
1.Inj . NaHCO3 is given inorder to neutralize the acidosis
EFFICACY -
treat acidosis with ventilation and perfusion by increasing plasma bicarbonate , buffers excess hydrogen ions and raises blood ph and reverses clinical manifestations caused by acidosis
also thought to worsen heart conditions and liver functions
USES OF ORAL SODIUM BICARBONATE ARE :
- as an antacid to treat heartburns , indigestion , upset stomach
INDICATIONS OF IV SODIUM BICARBONATE :
- TO treat metabolic acidosis when the underlying disease is diarrhea , vomiting , or kidney related diseases
- high blood potassium
- tricyclic anti-depressant overdose
- cocaine toxicity
CONTRAINDICATIONS :
- contraindicated in patients who are losing chloride
- it should be used with great care in patients of CCF , severe CKD due to its sodium content because in these coditions sodium retention is a problem
- it should be given in patients using corticosteroids with caution
WHY CONTRAINDICATED :
- Hypersensitivity
- metabolic/respiratory alkalosis and hypocalcemia - because alkalosis produces tetany
2. POTCHLOR syrup is given to correct hypokalemia
3. ORAL HYPOGLYCEMIC AGENTS - used as diabetic agent to lower glucose levels in the blood
4. ANTI HYPERTENSIVES - to treat hypertension (to lower blood pressure value)
On day 2 :
1. Inj .HAI - used in type2 diabetes patients when their meat plan , weight loss , exercise and antidiabetic drugs do not achieve targeted blood sugar levels
2. tOROFER - for treatment of iron and folic acid deficiency i.e anemia
3.PAN -Treatment of conditions due to excess acid secretion in the digestive system
4. LASIX - a diuretic which is used to reduce risk of strokes , heart attacks and kidney problems
contraindications are :
- kidney disease
- hypokalemia
- diabetes - when taken furosemide it is hard to control blood sugar levels
- liver disease
On day 3
1.tab Dytor - given to control fluid overload and blood pressure since the patient had higher blood pressure on day 3
2.telma - Telmisartan is given to treat hypertension, heart failure and diabetic kidney disease .may be because of its limitation that it reduces the amount of urine and increases kidney damage it could be stopped
3. Nicardia is given to lower blood pressure
4.Orofer and erythropoietin inj- in order to correct anemia and increase levels of erythropoietin which further corrects anemia
5. Shelcal - it is given to treat hypocalcemia
6. Potchlor syrup - to correct hypokalemia
7.nodosis - it is an antacid, to neutralize the excess acid present in stomach
On day 4:
1.Lactulose - since the patient complained she had constipation she was given lactulose after which she passed the stools
2.inj.monocef- it is an antibiotic. Used to treat UTI, or any other infections
3. Protein x powder - given since the patient is malnourished
but excess use can cause coma, hepatic damage, metabolic disturbances, unpleasant taste in mouth
On day 5
The patient was further evaluated to improve her condition
4) What was the indication for dialysing her and what was the crucial factor that led to the decision to dialyze her on the third day of admission?
- severe breathlessness due to pulmonary edema
- acid-base problems ( METABOLIC ACIDOSIS )
- pericarditis
- electrolyte imbalance
5) What are the other factors other than diabetes and hypertension that led to her current condition?
ANEMIA ;RENAL PARENCHYMAL DISEASE ; VASCULAR DISEASE ; CONSTIPATION
6) What are the expected outcomes in this patient? Compare the outcomes of similar patients globally and share your summary with reference links.
https://www.google.co.in/url?sa=t&source=web&rct=j&url=https://kdigo.org/wp-content/uploads/2017/02/KDIGO-HF-conf-report-FINAL.pdf&ved=2ahUKEwjVuo656dTrAhX763MBHUDcAFwQFjANegQIBBAB&usg=AOvVaw1TOWvXYvbE5qd9WdsVwUVl&cshid=1599405416331
chronic pressure overload , progressive volume overload , cardiomyopathy with the additional risk factor of Diabetes , Anemia could lead to preserved LVEF / reduced LVEF which further lead to the outcome of :
- Progression of CKD
- HF hospitalization
- Sudden arrhythmic death
- Pump failure death
7) How and when would you evaluate her further for cardio renal HFpEF and what are the mechanisms of HFpEF in diabetic renal failure patients?
Evaluation for HFpEF must be done on the day of admission itself if there is suspicion of heart related disorder such as heart failure as per the patient's symptoms ,clinical examination and laboratory diagnosis
Evaluation for cardio-renal HEpEF :
- Echocardiography - provides information on chamber volumes , ventricular systolic and diastolic dysfunction , wall thickness , valve function and filling pressures
- Chest radiography - to screen for other sources of dyspnea
- Electrocardiography - to detect rhythm disturbances or evidence of prior myocardial damage or pericardial disease
- MRI
- global longitudinal strain analysis
- whole -body bioimpedance technique
- extended cardiac rhythm monitoring
- Pulmonary artery ambulatory monitoring
- thoracic impedance monitoring
decreased renal blood flow leads to the stimulation of RAAS mechanism resulting in :
- sodium ,water retention leading to volume overload thereby increasing blood pressure and cardiac work , myocrdial fibrosis finally causing heart failure
8) What are the efficacies over placebo for the available therapeutic options being provided to her for her anemia?
Efficacies suggested in below links
https://pubmed.ncbi.nlm.nih.gov/19245362/
https://www.sciencedirect.com/science/article/pii/S0272638614013572
https://academic.oup.com/ajcn/article/90/1/124/4596794
9.What is the utility of tools like the CKD-AQ that assess the frequency, severity, and impact on daily activities of symptoms of anemia of CKD? Is Telegu among the 68 languages in which it is translated?
reference cited below
https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfz091/5543482
https://www.smartpatients.com/trials/NCT03409107
10) What is the contribution of protein energy malnutrition to her severe hypoalbuminemia? What is the utility of tools such as SGA subjective global assessment in the evaluation of malnutrition in CRF patients?
what is the contribution of PEM to her severe hypoalbuminemia ? what is the utility of tools such as SGA( subjective global assessment ) in the evaluation of malnutrition in CRF patients
Nutritional deficiencies particularly that of iron and zinc and decreased supply of amino acids to liver causes reduced production of albumin levels thus leading to hypoalbuminemia https://www.ncbi.nlm.nih.gov/books/NBK526080/
Nutritional status as determined by Subjective Global Assessment -Dialysis Malnutrition Score is a useful and reliable index for identifying patients at risk for malnutrition and it correlates well with anthropometric and biochemical assessment .May be integrated in regular assessment of malnutrition in patients on maintenance hemodialysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3224408/
Differences in diagnosis of 45 year old female and 58 year old man
As per the clinical findings of the patient of 45 year old
- Albuminuria
- decreased urine output
- Abnormal renal biopsy
- on USG - loss of CMD and increased echogenicity
- Hence could be diagnosed as Ckd due to diabetic nephropathy
- Increased bun/serum creatinine >20:1 which may indicate aki
- Low urinary output
- Flank pain
- On USG - there's no increase in echogenicity and other abnormality is not detected and left kidney size reduced
- Hence could be diagnosed as AKI
Differences in management:
45 year old patient :
- Potchlor was given to correct hypokalemia
- shelcal for hypocalcemia
- Lasix to correct fluid overload
- anti diabetic and anti hypertensive agents are given
- further investigations are done to improve the patient condition
- Piptaz - an antibiotic
- Amlong tablet - for treatment of hypertension
- Lasix to combat fluid overload
- Pantop - an antacid
- HAI - to reduce blood sugar levels
Differences in outcomes
in AKI :
- Mortality (26%)
- Renal recovery (68%)
- https://jasn.asnjournals.org/content/18/4/1292
In CKD :
- Progression of ckd
- mortality risks vary among various individuals
- https://www.karger.com/Article/FullText/254381
Would you agree with provisional diagnosis of 58 year male patient as per the online case report?
Yes I would agree with the provisional diagnosis that is AKI since the patient has bun / cretainine ratios increased >20:1 and he complained of burning micturition, hyponatremia (mild)
References :
1.Dr.Alekya Reddy mam's blog
2. Dr.Bhavya mam's blog
3.Harrison's book of medicine
4.all the links shared at their respective texts
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