Joshua Erin Babaran

Reagan Tyler Go
Tactto Kobayashi
Blessing San Pedro
Thea Ferina Vital
4CPH

RENAL FAILURE

CHRONIC KIDNEY DISEASE is defined by the reduction in the glomerular filtration rate and/or urinary abnormalities
or structural abnormalities of the renal tract. It is also defined as the loss of kidney function over time. It includes
conditions that damage the kidneys and decrease its ability to function normally.
Possible complications of CKD include:
1. High Blood Pressure
2. Low blood count
3. Weak bones
4. Poor nutritional health
5. Nerve damage
CKD can be caused by:
1. Diabetes
2. High blood pressure
3. Glomerulonephritis
4. Interstitial nephritis
5. Polucystic kidney disease
6. Prolonged obstruction of the urinary tract
7. Vesicourethral reflux
8. Recurrent kidney infection

There are different stages of Chronic Kidney disease. The National Kidney Foundation divided kidney disease into 5 stages.
STAGE 1
- Normal or high GFR (GFR > 90mL/min)
STAGE 2
- Mild CKD (GFR = 60-89mL/min)
STAGE 3A
- Moderate CKD (GFR = 45-59 mL/min)
STAGE 3B
- MODERATE CKD (GFR = 30-44 mL/min)
STAGE 4
- Severe CKD (GFR = 15-29 mL/min)
STAGE 5
- End stage CKD (GFR <15 mL/min)

Risk Factors of having renal failure include:

1. Diabetes
2. High blood pressure
3. Heart and blood vessel disease
4. Smoking
5. Obesity
6. Being African-American, Native American or Asian-American
7. Family History of kidney disease
8. Older age
Signs and Symptoms of CKD include:
1. Nausea
2. Vomiting
3. Loss of apetite
4. Fatigue and weakness
5. Changes in how much the patient urinate
6. Decreased mental sharpness
7. Muscle twitches and cramps
8. Swelling of feet and ankles
9. Persistent itching
10. Chest pain, if fluid builds up around the lining of the heart
11. SOB
12. High blood pressure that is difficult to control

CKD can be diagnosed through routine blood test or urine tests. Blood tests is used to measure the estimated glomerular
filtration rate while urine tests is carried out to check the levels of substances called albumin and creatinine in the
urine and to check blood or protein present.

PATIENT DETAILS
Patient’s Name: D.A.V. Age: 53 y/o Gender: Male
Chief Complaint:
Bilateral knee joint pain
HPI:
One week PTA, patient complained of persistence of generalized body weakness, anorexia, fever of about 37.5oC,
bipedal edema, extortional dyspnea with noted decrease in urine output. No dysuria, no hematuria, no hesitancy,
no orthopnea, no PND. Patient consulted at Amang Rodrigues wherein he was noted to have high bacteria in
urine, with this, he was diagnosed to have UTI, given Ciprofloxacin for 7 days. 3 days PTC, patient still has persistent
bilateral severe knee joint pain causing difficulty in ambulation accompanied by dizziness characterized as feeling
of rotational movement, loss of apetite, generalized weakness, cough. There was also noted further decrease in
urine output at this time. Patient has bipedial edema. Few hours PTC, persistence of bilateral severe knee joint
pain, difficulty in ambulation, and bipedal edema prompted consult at UST ERCD, and subsequent admission.
PMH:
 Recurent urolithiasis since 2001
 Polycythemia Vera (2007)
 Therapeutic phlebotomy 10 sessions (2007)
 Gouty arthritis (2010)
 Nephrolithomy R; DJ stent, L; RDG, L (2012)
Family History:
 (+) gout – father
 (+) anemia – Mother
 (+) lung cancer – brother
 (+) cervical cancer – sister
Social History
 None alcoholic beverage drinker
 Non-smoker
 No illicit drug use
Review of Systems:
General Survey: (+) body weakness, (+) fever, (+) weight loss
Skin: dry skin, (-) rashes, (-) palor, (-) easy bruisability
HEENT: (-) eye discharge, (-) pruritus, (-) pain; (-) ear discharge, (-) tinnitus, (-) tragal tenderness; (-) colds, (-)
epistaxis, (-) nasoaural discharge; (-) voice hoarseness, (-) dysphagia, (-) sore throat, (-) oral ulcers
Lungs: (+) exertional dyspnea, (+) cough
Heart: (-) chest pain, (-) nocturnal dyspnea, (-) orthopnea, (-) palpitations, (-) syncope
 Extremities: (+) bipedal edema, (+) severe knee inflammation, (+) joint knee pain
Abdomen: (-) vomiting, (+) melena
Neurologic: (-) headache, (-) seizures, (-) mental changes
Physical Exam:
Temp: 36.9oC
BP: 130/80 mmHg
Respiratory Rate: 20 cpm
Pulse Rate: 87 bpm

Gen: conscious, coherent, not in distress

Skin: warm dry skin
HEENT: no deformities, pale palpebral conjunctiva, anicteric sclera, pupils 2-3mm ERTL, (+) ROR, no nasal
tenderness, no skin tags, no aural discharge, non-hypereremic EAC, nasal septum midline, dry lips, pink
buccal mucosa, midline uvula, thyroid moves upon deglutition, no palpable cervical lymph nodes
Lungs: no deformities, no retractions, symmetrical chest expansion
Heart: adynamic precordium, apex beat at the 5th LICS AAL, no heaves, lifts & thrills, no murmurs, S1>S2 at apex,
S2> S1 at the base
Abdomen: flat, normoactive bowel sound dull, no direct or rebound tenderness, tympanitic on all quadrants
Extermities: (+) tophi on elbow, (+) swelling on both ankles

Laboratory Tests:
Urine Chemistry
- Sodium: 45 mmol/L
- Potassium: 14.85 mmol/L (LOW)
- Uwine Osmolality: 325mOsm/kg (LOW)
Radiologic Report
- Chest (PAL/APICO – Lodortic views)
- Faint reticular nodular densities are seen in both lung bases
- The heart is not enlarged. Diaphragm and sinuses are intact
CBC
- HGB: 133 g/L
- HCT: 0.42
- PLT: 151x109/L
- WBC: 8.50x109/L
Blood chemistry
- Sodium: 125 mmol/L (LOW)
- Potassium: 5.5 mmol/L (High)
- Inorganic Phosphate: 4.18 mg/dL
- Ionized Ca: 0.9 mmol/L (LOW)
- Creatinine: 2.03 mg/dL
INPUT OUTPUT
3/9/15 Venoclysis Blood Oral Others TOTAL Urine Secretion Vomitus Others TOTAL
6-2 500mL - 200 - 700mL 600mL - - - 600mL
2-10 240mL 0 300 0 740mL 500mL - - - 500mL
10-6 480mL - 200 - 680mL 400mL - - - 400mL
TOTAL 1420mL 0 700mL 0 2120mL 1500mL 0 0 0 1500mL

Physician’s Orders:
Date Time Notes
5:15PM  Heplock IVF 1L PNSS to run at 70mL/hr
 Request for 12L ECG, CXR, CBC with plt, creatinine
 Na, K, iCa, iPO4, U/A, Urine Na, Sputum AFB
 8PM  Dolcet tab, 1 tab, q4PRN
 Suggest urine analysis, CBC, ultrasound, KUBP
 Accurate input and output monitoring
March 5  Ice compress on both knees for 15 minutes Q4
11:55 PM  Shift IVF to D5NSS 1L at 70 mL/hr
 Round the clock Dolcet tab q8
 Facilitate repeat Na at 5AM
10:15 AM  Hold IVF
 Start colchicine 0.5mg/tab, 1 tab OD
 Start allopurinol 100mg/tab, 1tab OD
 Sputum AFB
March 6  May have soft diet
 Continue Ice compress on both knees
 Deep breathing exercise
12:10 PM Hold Allopurinol for now
Hold d5nss 0.3%
Decrease IVF D5NSS at 60mL/hr
For repeat Na after 6 hours post hooking to IVF
Apply cold compress on all affected areas Q4
Add to diet: Low purine diet
Accurate input and output reading
5PM Maintain amount and rate of IVF for now
Repeat serum Na after 4 hours
7 March Start NaCl tab 1g TID
2 AM Repeat serum Na after 4 hours
11:10AM Deep breathing exercises
March 7 Awaiting Day 2 of smear AFB
3:20 PM Continue NaCl tab, 1 tab TID
Give Paracetamol 500mg tab, 1tab OD or 1 tab Q4 PRN if T is greater than
or equal to 38.3oC
Continue colchicine 0.5mg/tab, 1 tab OD
3:30 PM For repeat serum Na tomorrow at 6AM instead of 8PM tonight
March 8 8:50 AM Awaiting Day 2 of sputum AFB
Retrieve official CXR results
Keep to moderate to high back rest
Encourage deep breathing exercises
Refer for sudden dyspnea

Medications
Name of Medication Dose Route Frequency Remarks

Dolcet tab N/A Oral Q8H RTC Completed

Colchicine 0.5mg/tab Oral 1 tab OD Completed
Allopurinol 100mg/tab Oral 1 tab OD Not given
NaCl tab 500mg/tab Oral 1g tab TID completed
Paracetamol tab 500mg/tab Oral 1 tab OD or 1 tab q4 Not given
PRN

IV Fluids/ IV Infusions
Name Of Dose Route Frequency Remarks
Medication
 Heplock IVF 1L IV 70mL/hr Shifted to D5NSS
D5NSS 1L IV 70mL/hr Decreased rate to 60mL/hr
D5NSS 0.3% IV 60mL/hr consumed

Pharmacotherapeutic Goals

Medication Therapeutic Goals

Dolcet (Tramadol + Paracetamol) Relief of Pain
Colchicine Treatment of gout
Allopurinol Treatment of gout
NaCl tab Prevention of hyponatremia and muscle cramps
Paracetamol Lower the temperature/ Reduce fever

GUIDELINES VS ACTUAL MANAGEMENT

Guidelines (NKF)
Patients with chronic kidney disease should be evaluated to determine the following: specific diagnosis
(type of kidney disease), comorbid conditions, disease severity (assessed by the level of kidney function),
complications (related to the level of kidney function), risk for loss of kidney function, and risk for development
of cardiovascular disease.
Treatment of patients with chronic kidney disease includes the following: therapy based on the specific
diagnosis, evaluation, and management of comorbid conditions; measures to slow loss of kidney function;
measures to prevent and treat cardiovascular disease; measures to prevent and treat complications of
decreased kidney function; preparation for kidney failure and kidney replacement therapy; and replacement of
kidney function by dialysis or transplantation if signs and symptoms of uremia are present.

Actual Management
1. The attending physician closely monitored the fluid input and output of the patient.
2. The physician based his orders from the laboratory test values.
3. The attending physician treated the conditions such as hyponatremia and muscle cramps
4. The physician also treated the patient’s gouty arthritis

RECOMMENDATIONS AND INTERVENTIONS

Chief Complaint: Bilateral Knee joint pain

Generalized body weakness, anorexia, exertional dyspnea, bipedal edema, decreased urine output

Past Medical History:

S • Recurrent urolithiasis since 2001
• Polycythemia Vera (2007)
• Therapeutic phlebotomy 10 sessions (2007)
• Gouty Arthritis (2010)
• Nephrolithotomy R; DJ stent, L; RDG, L (2012)
Medication History:
• Ciprofloxacin 500 mg po BID (UTI)
• Naproxen Na 220 mg po q8hrs (Joint pain)
O Physical Examination:
Temp: 36.90C
BP: 130/80 mmHg
 Respiratory Rate: 20cpm
Pulse Rate: 87 bpm
General Appearance : conscious, coherent, not in distress
Skin: warm, dry skin
HEENT: no deformities, pale palpebral conjunctiva, anicteric sclera, pupils 2-3mm ERTL, (+) ROR, no
nasal tenderness, no skin tags, no aural discharge, non- hyperemic EAC, nasal septum midline, dry
lips, pink buccal mucosa, midline uvula, thyroid moves upon deglutition, no palpable cervical lymph
nodes
Lungs: no deformities, no retractions, symmetrical chest expansion
Heart: adynamic precordium, apex beat at the 5th LICS AAL, no heaves, lifts & thrills, no murmurs,
S1>S2 at apex, S2>S1 at the base
Abdomen: flat, normoactive bowel sound dull, no direct or rebound tenderness, tympanitic on all
quadrants
Extremities:(+) tophi on elbow, (+) swelling on both ankles

Laboratory Test Results:

• Urine Chemistry
 Sodium-Urine: 45 mmol/L
 Potassium-Urine: 14.85 mmol/L
 Urine Osmolality: 325mOsm/kg
• Radiological Report
 Chest (PAL/ APICO- Lordotic views)
 Faint reticular nodular densities are seen in both lung bases.
 The heart is not enlarged. Diaphragm and sinuses are intact.
• CBC
 HGB: 133 g/L
 HCT: 0.42
 PLT: 151 x 10^9/L
 WBC: 8.50 x10ˆ9/L
• Blood Chemistry
 Sodium: 125 mmol/L
 Potassium: 5.5 mmol/L
 Inorganic Phosphate: 4.18 mg/dL
 Ionized Ca: 0.9 mmol/L
 Creatinine: 2.03 mg/dL

Untreated indication: Chronic tubulointerstitial injury, obstructive uropathy (both diseases increase
uric acid levels and may cause the development of a gouty arthritis)
Improper drug selection:
 Naproxen Na (May address the pain that comes with gouty arthritis but cannot treat the
A gout itself)
 Ciprofloxacin (Addresses the urinary tract infection but does not address the treatment for
chronic tubulointerstitial injury and obstructive uropathy)
Contraindication:
 Colchicine is contraindicated in patients with renal injury
 Address the treatment for chronic tubulointerstitial injury by giving glucocorticoids
(preferably prednisone). Consider dose tapering for glucocorticoid treatment.
 Include alpha-receptor antagonist (e.g. prazosin, tamsulosin) to treat obstructive uropathy.
P If the symptoms of obstructive uropathy persists, immediate drainage through stents,
nephrostomy tubes or a Foley catheter may be considered.
 Continue Dolcet for pain
 Continue PNSS to treat low sodium levels
  Start Allopurinol to treat the chronic progression of gout but the tapering or reduction of
dose is needed to inhibit the progress of renal injury caused by allopurinol.
 Colchicine may only be taken with allopurinol for acute gouty flares. It should never be taken
along with allopurinol to treat chronic gout. Dose of colchicine must also be tapered.
 Check creatinine clearance and kidney function regularly with the use of alpha-receptor
antagonist, allopurinol and colchicine.

Patient Counselling

 For potassium regulation, regulate alcohol intake and drug use such as NSAIDS, antibiotics, ARBS, ACE, blood
thinners. Regulation of food intake that are rich in potassium content is also recommended.
 For calcium regulation, take calcium supplements and dairy products that are rich high calcium.
 For creatinine regulation:
⁃ increasing water intake of at least 8 glasses of water a day is recommended
⁃ regulate salt intake such as salty foods and foods that are rich in sodium content
⁃ avoid strenuous exercise (as this encourages the breakdown of creatinine)
⁃ reduce minerals such as sodium and potassium in your diet and avoid foods such as soybean, peanuts,
pumpkin seeds, nuts and seafood (as they tend to increase the livers production of creatinine)
⁃ avoid sodas, tea and coffee with herbal teas and water

References:

http://www.mims.com/philippines/drug/info/colchicine/?type=brief&mtype=generic
http://www.mims.com/philippines/drug/info/tamsulosin/?type=brief&mtype=generic
http://www.mims.com/philippines/drug/info/ciprofloxacin/?type=brief&mtype=generic
http://www.mims.com/philippines/drug/info/tramadol%20%2b%20paracetamol/
http://www.mims.com/philippines/drug/info/allopurinol/?type=brief&mtype=generic
http://www.msdmanuals.com/professional/genitourinary-disorders/obstructive-uropathy/obstructive-
uropathy#v1052523
https://medlineplus.gov/ency/article/000507.htm
http://emedicine.medscape.com/article/778456-medication#2