M3 Pros Revision 28/4/14 Renal

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1 M3 Pros Revision 28/4/14 Renal Q1. Mr Ravi is a 35- year old construction worker from India with no significant past medical history. He presents with a 3- day history of high fever (Tmax = 39.5), polyarthritis, and a confluent erythematous rash with islands of sparing. State the most likely diagnosis What confirmatory tests would you like to do Four days later, his fever subsides. However he now complains of abdominal pain and his BP is 92/50. He was transferred to ICU and aggressively resusitated. 12h later, the nurse calls you for poor urine output 30ml in 12 hours via catheter. What would you do at the bedside, and what investigations would you order? His vitals are stable. You order some preliminary blood tests and the results are: Hb 13.5 Na 125 WBC 10 K 6.5 Plt 40 HCO3-18 Hct 50 % Cl - 95 Urea 12 Cr 240 (baseline Cr 70) (e) (f) (g) Interpret the blood tests and formulate a problem list. Suggest three possible causes for the rise in creatinine and your approach to differentiate them How would you manage this patient? What are the indications for emergent dialysis in this patient

2 Q2. Mr Bo Chup is a 75- year old retiree with end- stage renal failure on thrice- weekly hemodialysis. He has turned up today for your long case exam. Take a history from Mr Bo Chup Perform a directed physical examination His routine blood results on the last outpatient follow- up read: Hb 11.3 Na 142 LDL 5.2 Ca 1.6 WBC 7 K 5.2 HDL 0.8 PO4 3.2 Plt 280 Cl - 99 TG 2 PTH MCV 75 HCO3-20 HbA1c 8.3 % Vit D low Cr 300 BP 145/90 Urea 8 Urine PCR 150 mg/mmol Interpret the blood tests Suggest how would you manage Mr Bo Chup Q3. Ronald is a 7- year old Chinese boy with no significant past medical history. He presents with a 8- day history of progressively worsening lower limb, abdominal, and scrotal swelling. In the past 24h he has also developed severe abdominal pain. (e) Please take a history and explain his symptoms. What physical examination would you like to perform? What investigations would you like to do? What complications do you anticipate and how would you manage this patient? What is the long- term prognosis and potential complications? Q4. Three patients present to your GP clinic with 1 week of hematuria. Ms Yu Ting Ing, a 23- year old university student Ms Gene Ng, a 40- year old housewife Mr Bob Chan, a 54- year old hawker Please take a history from each of them, do appropriate physical examination, and suggest what work up they might need

3 PARTIAL ANSWERS (edited 28/4/14) Q1. Mr Ravi is a 35- year old construction worker from India with no significant past medical history. He presents with a 3- day history of high fever (Tmax = 39.5), polyarthritis, and a confluent erythematous rash with islands of sparing. State the most likely diagnosis Dengue What confirmatory tests would you like to do Platelets Dengue NS1Ag Dengue IgG/IgM Four days later, his fever subsides. However he now complains of abdominal pain and his BP is 92/50. He was transferred to ICU and aggressively resusitated. 12h later, the nurse calls you for poor urine output 30ml in 12 hours via catheter. What would you do at the bedside, and what investigations would you order? Check catheter, percuss bladder ( is this really NPU or is it blocked cath ) Take vitals Assess fluid status for signs of volume overload or dehydration Investigations: FBC, Renal panel, Calcium panel, ABG, CXR ECG, cardiac enzyme possible cardiac event PT/PTT, GXM coagulopathy, transfusion LFT may have rise Fibrinogen, fibrin degradation products haemorrhagic fever His vitals are stable. You order some preliminary blood tests and the results are: Hb 13.5 Na 125 WBC 10 K 6.5 Plt 40 HCO3-18 Hct 50 % Cl - 95 Urea 12 Cr 240 (baseline Cr 70) Interpret the blood tests and formulate a problem list. Low platelets dengue. Raised hematocrit, urea dehydration Raised creatinine, hyperkalemia AKI (RIFLE classification F) Hyponatremia likely third spacing. Problem list: 1. Hyperkalemia secondary to acute renal failure 2. Acute renal failure secondary to dengue shock syndrome 3. Dengue shock syndrome

4 (e) Suggest three possible causes for the rise in creatinine and your approach to differentiate them Prerenal hypovolemia, hypotension Renal acute tubular necrosis secondary to ischemia Postrenal catheter blockage Approach Postrenal cause can be clinically excluded percuss for bladder, if in doubt do renal ultrasound Fluid challenge urine output should increase UFEME brown granular casts suggest acute tubular necrosis Urea: creatinine ratio much higher in prerenal than in renal causes as urea is reabsorbed Urine electrolytes high urine osmolarity, low urine Na, high urine Cr : plasma Cr suggest prerenal dx (f) How would you manage this patient? Goals of management 1. Emergent management of hyperkalemia 2. Restore circulating volume 3. Supportive management for ATN and dengue. Paras, fluids, activity, monitoring Close clinical monitoring Q1h KIV central line insertion Fluid challenge - 1L IV normal saline stat Normal diet Investigations FBC, Renal panel, UFEME, urine electrolytes Septic workup if febrile or hypothermic. Management Stop nephrotoxic management 10ml 10% calcium gluconate IV 10 units insulin + 50mL IV 50% dextrose Resonium PO 15-30g Send for telemetry, hourly vitals, check K, glucose (g) What are the indications for emergent dialysis in this patient Fluid overload e.g. pulmonary edema Hyperkalemia refractory to medical treatment Severe acidosis Symptomatic uremia e.g. pericarditis This patient so ans e.g. dialysable toxin ingested should not be given

5 Q2. Mr Bo Chup is a 75- year old retiree with end- stage renal failure on hemodialysis. He has turned up today for your long case exam. Take a history from Mr Bo Chup Important to have a systematic approach to history taking: diagnosis & ddx, etiology, complications, management, management of complications, complications of management. Also comorbids History of renal disease When diagnosed Cause of renal disease Course e.g. typically starts with longstanding DM (>20yrs), then proteinuria, then kidney failure with some residual protein output, then zero urine output. Complications of renal disease Anemia BP - Hypertension Calcium, phosphate, bone disease (osteoporosis, fractures) D Vit D Electrolyte Fluid overload Complications of primary disease(s) and comorbidities Main cause of death in such patients is cardiovascular disease. Management Details of dialysis (PD vs HD) Control of renal dx Compliance with dialysis, meds, diet, fluid; cost and social issues Management of primary disease Management of complications Complications of management Issues with dialysis vascular access issues (thrombosis, infection), hypotension during dialysis Management of complications e.g. hypotension, etc. Perform a directed physical examination Signs of etiology Ballot for ADPKD Diabetic dermopathy, other signs e.g. peripheral amputations, diabetic ulcers Nephrectomy scars

6 Signs of management AV fistula check for patency Old AV fistulas/grafts, tenckoff scars Fluid status any signs of overload Signs of complications Fluid overload lungs, limbs, ascites Look for anemia conjunctival pallor, nail bed pallor, koilonychia BP Cardiac exam for signs of cardiac failure Interpret the blood tests How would you manage Mr Bo Chup Again structure your answers and have the goals in mind Management of ESRF: renal damage cannot be reversed unfortunately, so goal is to keep the pt alive by replacing renal function. Needs diet counselling, fluid restriction. Ultimate solution is transplant but that is not without its problems. Management of complications e.g. EPO injections for anemia, hypertensive meds (don t give diuretics they don t work anymore!), calcium carbonate as phosphate binder, vitamin D, bisphosphonates for osteoporosis Management of complications of management e.g. need for access creation, etc Management of comorbids management of DM, cardiovascular risk factors etc.

7 Q3. Diagnosis is nephrotic syndrome with spontaneous bacterial peritonitis. Must anticipate complications in this case electrolyte imbalances, pulmonary edema Immediate management: Problem Investigations Management 1 General Paras Q1h Strict IO charting Daily weight 2 SBP FBC Pleural fluid tap + c/s 3 Fluid overload Renal panel Urine PCR Serial dipstick 4 Nephrotic syndrome KIV Renal biopsy if steroid unresponsive Ampi + genta Analgesia Paracetamol Fluid restrict IV frusemide IV albumin Monitor for pulm edema Steroids KIV second line drugs ACE- I 5 electrolyte imbalances e.g. metabolic acidosis ABG IV bicarbonate Long term complications and management Hypertension Hyperlipidemia Risk of thrombosis Steroids - Cushingoid appearance, complications e.g. cataracts, prox myopathy, DM, osteopenia, AVN hip Immunosuppression infections. Vaccinate

8 Q4. Hematuria Ms Yu Ting Ing, a 23- year old university student à UTI. Presented with 2 days of dysuria and hematuria. No fever, systemically well. Ms Gene Ng, a 40- year old housewife à post- infectious GN. Presents with 1 week of hematuria, associated with hypertension and oliguria. Mr Bob Chan, a 54- year old hawker à Bladder cancer. Presents with 2 weeks of painless hematuria. Smoker.