Factors influencing the decision of initiation of dialysis
Case 1:
https://tejasree25.blogspot.com/2022/04/nephrotic-syndrome-with-type-i-dm.html
This is a case of 22 year young married female with DM 1 since 11 years and Hypertension since 6 months
1st presentation : April 2022
Presenting complaints of
B/L pedal edema since 1 months
•Shortness of breath (grade 2-3 ) since 1 months,which is insidious on onset gradually progressive not associated with orthopnea /PND
•Decreased urine output since 10 days
•Swelling of lips since 3 days
On examination
Anasarca +, Pallor +
Her baseline creatinine at time of admission was 4.7 , urea 82, serum albumin :2.8 , hb:7.8,
Chest xray showing b/L moderate pleural effusion
2D echo : EF :60, good LV systolic function
With severe metabolic acidosis ( anion gap :21 at admission , 8.2 at time of discharge )
Microvascular complications of diabeties + in this patient such as albuminuria, diabetic retinopathy changes
24 hours urinary protein 2.1 grams
Fundoscopy : Diabetic retinopathy changes +
We managed her conservatively with glycemic control, antihypertensives and diuretics and discharged her after 10 days of admission with creatinine of 3.2
2nd admission :
With similar complaints admitted in month of May
She has been initiated on dialysis as she has above indications since may 2022
Placed right IJV and she underwent 4 dialysis and discharged on 4th June 2022 ( cr:3.1 , urea : 48)
10th June 2022 : She came for follow up
Continued on dialysis as her sypmtoms are persist and not getting relieved on medical management
Planned for AV fistula - was done
24 hrs urinary protein increased from 2.1 gm to 4.2 gms
Below are the trends during her hospital stay ( 3rd admission)
4th admission : July : on maintenance haemodialysis
We placed her on femoral line as IJV placed for longterm and it was removed to prevent the infections
Av was done , but the flow is not adequate , as it takes minimum of 30-45 days for fistula maturation
5th admission : September : patient came for regular haemodialysis on day care basis
On examination there was discharge from the fistula site and limb swelling .. urology opinion was taken and advise followed .on examination there was no thrill on ascultation ( fistula failure ) : Though the patient has been explained about the care of the fistula she has not followed
Patient was not compliance to dialysis not to other medications
Multiple times she has been admitted to icu i/v/of uncontrolled sugars and fluid over load symptoms
In month of Nov 2022 , she came with breathlessness ( grade 4 ) ? Acute Pulmonary odema treated with inj NTG and immediately taken for dialysis and put her on CPAP
Post dialysis also patient has not improved
Around 3:45pm BP suddenly was 240/130mmhg and diffuse crepts were present
There was sudden fall in saturation and heart rate and pink frothy sputum was present
CPR was initiated according to ACLS guidelines
Patient was intubated and inspite of all resuscitative efforts and 30 minutes of CPR but patient couldn’t be revived and was declared dead at 4:34pm on 04/11/2022 with no electrical activity and ECG showing flat line
IMMEDIATE CAUSE: ACUTE CARDIOGENIC PULMONARY ODEMA SECONDARY TO HFrEF
ANTECEDENT CAUSE: CKD ON MHD SECONDARY TO NEPHROTIC SYNDROME
K/C/O HTN (1 year)& Type 1 DM(12years)
Conservative ------> Dialysis (1.5 months )
Comments
Post a Comment