1 / 102

Case Conference

Case Conference. 報告者: R3 蕭景中 指導老師: 方基存 醫師 報告日期: 2012/03/28. Patient's Profiles. Age: 48 Gender: male Ethnic: Taiwanese Marital status : married Occupation: 房地產 before Travel history: no travel history in recent 3 months. Chief Complaints.

Download Presentation

Case Conference

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Case Conference 報告者: R3 蕭景中 指導老師:方基存醫師 報告日期:2012/03/28

  2. Patient's Profiles • Age: 48 • Gender: male • Ethnic: Taiwanese • Marital status: married • Occupation:房地產 before • Travel history: no travel history in recent 3 months

  3. Chief Complaints • High blood pressure with headache for 2-3days

  4. The 48year-old male sufferred from high blood pressure with SBP about 200mmHg for 2-3 days • Bitemporal headache,decreased appetitie and bilateral lower leg edema was also noted • Drank 味增魚湯 every day during Chineses year for one month Present Illness

  5. No nasuea,vomiting,shortness of breath,blurred vision,decreased urine output • No fever, cough, dysuria,abdominal pain,tarry stool • Admitted 2011/10/14-2011/10/20 due to acute pyelonephritis • Visit ER once 2012/01/14 due to right ankle swelling r/o gout, discharge after symptomatic relief Present Illness

  6. Visit ER 02/02,hypertension (245/114mmHg)and renal function deterioration • (3.34(01/11)11.97(02/02)) noted • Under the impression of acute on chronic renal failure,he was admitted Present Illness

  7. Past history • Hepatocellular carcinoma,T1N0M0,s/p partial hepatectomy and TACE,s/p cadaver liver transplantation 2009/05,under MMF and tacrolimus • Liver cirrhosis,child C,HCV related,s/p interferon-alpha and ribavirin 2009/07-2010/02 • Chronic kidney disease,stage IV

  8. Past history • Moderate aortic stenosis and aortic regurgication,EF:57%,no surgical indication • Diabetic mellitus under OHA • Recurrent urinary tract infection(6-7 times in current two years) • Spleen rupture due to traffic accident s/p splenectomy 26years ago • Gout

  9. Personal history • Allergy: no known allergy to drugs or food • Alcohol :social but quitted now • Smoking:1PPD*21years,quitted now • Betelnut :social but quitted now

  10. 78 78 Family history DM Old CVA,bedridden 48 46 HCC,HCV,DM

  11. Medication history • Immunosupressant: 2009/05:tacrolimus 1-2mg Q12h MMF:1mg Q12h • HCV: 2009/07-2010/02: interferon-alpha and ribavirin

  12. Physical examination (02/02 at Taipei ER) • T:36/℃ P:70/min R:18/min BP:245/114mmHg • 身高:176CM (20120204) 體重:84.3KG (20120204) BMI:27.2 • GENERAL APPEARANCE: Fair looking • CONSCIOUSNESS: Clear, E 4 V 5 M 6 • HEENT: • Sclera: not icteric • Conjunctiva:not pale • NECK: • Supple • No jugular vein engorgement • No lymphadenopathy

  13. CHEST: Smooth breath pattern Bilateral symmetric expansion Breathing sound: bilateral clear • HEART: Regular heart beat without audible murmur No audible S3; No audible S4

  14. ABDOMEN: Soft and distended No tenderness, No rebounding pain Normoactive bowel sound Operation scar 7cm over midline,12cm over RUQ and LUQ • BACK:no bilateral knocking pain • EXTREMITIES: Freely movable grade II leg edema • SKIN: No rash, no petechiae, no purpura uvula swelling, no erythema or tenderness

  15. admission

  16. admission

  17. admission

  18. 1.acute on chronic renal failure, RIFLE:F, Suspected acute urate nephropathy or malignant hypertension related, r/o RPGN 2.Post transplantation diabetic mellitus 3.Hepatocellular carcinoma,T1N0M0,s/p partial hepatectomy and TACE,s/p cadaver liver transplantation 2009/05,under MMF and tacrolimus 4.Moderate aortic stenosis and aortic regurgication,EF:57%,no surgical indication 5.gout Initial impression

  19. Kidney Sonography 2012/02/03 Left Kidney Length: 11.9 cm Right Kidney Length: 11.8 cm There is focal calyceal dilatation in the upper pole of the right kidney. There are two echo-free lesions (1.3 x 1.3 cm in the pelvis and 1.3 x 1.1 cm in the lower pole) with posterior wall enhancement over the left kidney. No renal mass, or stone is noted. IMP:1. Parenchymal renal disease. 2. Left renal cysts.

  20. GS 02/04 02/05 02/06 02/07 02/08 02/09 02/10 02/11 24hour urine TP Cardiac echo HD OPH BUN 125.8 114.3 106.1 12.22 Cr 11.94 12.18 Hydration:IVF 40cc/hr+allopurinol 0.5pc qd

  21. 02/12 02/13 02/14 02/15 02/16 02/17 02/18 02/19 HD HD HD Serum 50.9 60.8 64.1 BUN 8.98 Cr 10.59 8.84

  22. 02/23 02/20 02/21 02/22 02/24 02/25 02/26 02/27 HD HD HD HD 60.8 46.2 41.2 BUN 8.84 7.73 9.49 Cr Kidney biopsy

  23. 03/02 02/28 02/29 03/01 03/03 03/04 03/05 03/06 HD HD HD 33.9 BUN 65.5 7.2 9.52 Cr TCC

  24. 03/14 03/07 03/08 03/09 03/10 03/11 03/12 03/13 HD HD HD BUN 18.7 Cardiac echo 3.78 Cr

  25. 03/15 03/16 03/17 HD HD BUN Cr

  26. Final impression 1.Acute on chronic renal failure reaching End stage renal disease, diabetic nephropathy related Aggravating factor: hypertension, NSAID, Immunosuppressant, heart failure, gout Under maintanence hemodilaysis Q246 2.Post transplantation diabetic mellitus 3.Hepatocellular carcinoma,T1N0M0,s/p partial hepatectomy and TACE,s/p cadaver liver transplantation 2009/05,under MMF and tacrolimus 4.Congestive heart failiure, Fc III,favored valular heart related,EF:46%

  27. Outline • Early and chronic renal dysfunction after liver transplantation • Early renal dysfunction after liver transplantation • Early kidney dysfunction predict chronic kidney disease • Chronic renal failure after liver transplantation • Post transplantation diabetic mellitus • Definition,impact and risk factor • HCV and PTDM • Immunosupressant and PTDM

  28. Methods: 246 LDLT recipients,to review postoperative renal dysfunction • Results: Intraoperative blood loss and preoperative serum creatinine were significant independent risk factors for the development of early renal dysfunction Patients who required RRT had a lower survival rate

  29. Methods:181 liver transplantation in which recipient was alived during followed up(2.7years),Renal dysfunction defined as Cr>2 • Results: PRT-DM and early postoperative acute renal dysfunction predict chronic kidney disease

  30. Methods: 69,321 persons who received nonrenal transplants in the United States between 1990 and 2000.To estimate the cumulative incidence of chronic renal failure and association of death

  31. Results: The five-year risk of chronic renal failure varied according to the type of organ transplanted — from 6.9% among recipients of heart–lung transplants to 21.3% among recipients of intestine transplants.

  32. Results: increased risk of chronic renal failure was associated with age, female sex, pretransplantation GFR and hepatitis C infection, hypertension,diabetes mellitus, postoperative acute renal failure

  33. Results: The occurrence of chronic renal failure significantly increased the risk of death Treatment of ESRD with kidney transplantation was associated with a five year risk of death that was significantly lower than that associated with dialysis (relative risk, 0.56; P=0.02).

  34. Post transplantation DM • Metabolic complication after solid organ transplantation • Increased cardiovascular mortality and morbidity in transplantation recipients • Multiple risk factors related to develop of PTDM

  35. Incidence of PTDM • Often underestimated due to lack of standard definition • Confounded by patient with diabetics before transplantation • Variable incidence due to different steroid regimen and immunosuppressants

  36. Definition

  37. Impact of PTDM(graft) • Diabetes mellitus after renal transplantation. Transplantation 65:380 –384, 1998 • Outcome of patients with new-onset diabetes mellitus after liver transplantation compared with those without diabetes mellitus Liver Transpl 8:708 –713, 2002 • increasing the risk of graft-related complications such as graft rejection, graft loss,and infection

  38. Outcome of Patients With New-Onset Diabetes Mellitus After Liver Transplantation Compared With Those Without Diabetes Mellitus

  39. Cumulative CV events

More Related