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Week 2: PBL 2

Week 2: PBL 2. Manuel van Deventer. Week 2: PBL 2.

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Week 2: PBL 2

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  1. Week 2: PBL 2 Manuel van Deventer

  2. Week 2: PBL 2 Sosobala Mkhize, a forty year old widower who works as a herbalist, is brought into casualty by his daughter. She says that he had been suffering from a white painful plaque in his mouth for three weeks and that he had just returned from a one week visit to his homeland in search for medicinal herbs. Over the past three days he had not eaten anything and drank only a small amount of fluid, this morning, when she went to take him to his shop, she found him weak and unable to coherently explain what was happening. On admission he was intermittently confused. His blood pressure was found to be low and an IV saline was commenced. On catheterisation of his bladder, very little urine was drained.

  3. Personal Details • Name: Sosobala Mkhize • Age: 40 • Marital Status: Widower • Resident: Umzinto, Kwazulu Natal

  4. Social History • Mr Mkhize is herbalist. • Since his wife died he has lived with his daughter in a small town in the KwaZulu Natal • He is independent in all activities. • Smoked up until the age of 30. • Drinks 3 or 4 beers per week.

  5. Past Medical History • No prior history of renal disease • No previous history of confusion or memory loss Current Rx • Possibly self-medicates with herbal remedies

  6. General Examination • White Plaque • Confused, disoriented • Dry mouth, flaccid skin

  7. CVS • Blood Pressure: 90/50 lying; • Pulse rate: 115/minute • Jugular venous pressure was not raised with the patient lying flat • CVS examination otherwise normal

  8. Abdomen/UroGenital • Bowel sounds present. • No organomegaly or masses • No bladder palpable • Urinalysis: Oliguric • Catheterisation produced a small amount of urine

  9. Investigations

  10. Investigations

  11. Investigations

  12. Is this Acute / Chronic

  13. Pre-Renal / Intrinsic Prerenal Urea/Creat > 75 U-Na < 10mmol/l FeNa < 1 % Urine:plasma Osmol > 1.3 ATN Urea/Creat < 75 U-Na > 20 mmol/l FeNa > 1 % Urine:plasma Osmo < 1.3

  14. Urea / Creatinine • Urea: 21.6 mmol/l • Creatinine: 770 μmol/l Urea 21.6 mmol/l Creatinine 0.770 mmol/l = = 28 ATN

  15. Protein Distal Tubule Amino acids Glomerulus Proximal Tubule NH3 Urea Cambamoyl phosphatase Ornithine Arginine Urea cycle 40-60 % Citruline Arginosuccinate Collecting duct Aspartate Urea

  16. Creatinine Creatine Kinase Creatine Phosphocreatine ATP ADP Creatinine

  17. U-Na • 60 mmol/l ATN

  18. Fe-Na Urine [Na] Plasma [Cr] FeNa= -------------- X --------------- X 100 Plasma [Na] Urine [Cr] 60 0.770 FeNa= -------------- X --------------- X 100 135 20 FeNa= 1.7 ATN

  19. Osmolality • Measured Osmolality • Freezing point depression • Calculated Osmolality • 2 Na + Urea + Glucose = 2(135) + 22 + 3 = 295

  20. Osmolality • U-Osmolality = 260 • = 260/295 = 0.88 • Also U Osmo < 350 ATN

  21. U-Microscopy • Increased renal tubular cells and granular casts ATN

  22. Etiology of ATN in this patient

  23. Electrolyte abnormalities

  24. www.aafp.org/afp/20060115/283.html

  25. Anion Gap Cations = Anions Cations - Anions • Na+ + K+ – Cl- – HCO3- ↑ Unmeasured Anions (Proteins, PO43-, SO42-) ↑ Anion Gap

  26. Anion Gap 135 + 6.6 – 101 – 13 = 27.6 ↑

  27. Anion Gap • M = Methanol toxicity • U = Ureamia of renal failure • D = Diabetes Mellitus • P = Paraldehyde toxicity • I = Isoniazid / Iron toxicity / Ischemia • L = Lactic acidosis • E = Ethylene glycol toxicity • S = Salicylate toxicity

  28. http://upload.wikimedia.org/wikipedia/commons/a/a2/Renin-angiotensin-aldosterone_system.pnghttp://upload.wikimedia.org/wikipedia/commons/a/a2/Renin-angiotensin-aldosterone_system.png

  29. ↑ Aldosterone Distal Renal Tubule Na+ K+ H+

  30. ↓ Aldosterone Distal Renal Tubule Na+ K+ H+

  31. SIADH H20

  32. SIADH • Clinically Euvolemia • Plasma Osmolality < 270 mosmol/kg • Hyponatraemie Na < 130 mmol/l • Exclude • Cardiac • Renal • Thyroid • Adrenal • Exclude • Pituitary surgery • Medication known to stimulate ADH • Urine Osmolality inappropriately high • U-Na > 20 mmol/l

  33. TCO2 • Bicarbonate (HCO3) ↓ pH α ↓ HCO3 ↓PCO2

  34. Total Protein

  35. Rx

  36. Prevention • Fluid management • Avoid nephrotoxic drugs

  37. Drug Dosaging • Creatinine Clearance • = U*V P = 20 * 300/24/60 0.77 = 5.4 ml/min

  38. Rx of Complications

  39. Hyperkalaemia • Exchange resins – Kayexalate 30-60g po or pr 6hrly • Insulin and dextrose • Dialysis

  40. Acidosis Treated when: • CO2 <15 and pH <7.2 • Bicarbonate • Dialysis

  41. Uremia • Complications of uremia • What in the history and investigations of this patient suggestive of uremia • Possible indications for dialysis

  42. Fluid Overload • Aggressive diuresis if still passing urine • Dialysis if oligoanuric • Fluid restriction

  43. Indications for dialysis • Acidosis (severe acidosis resistant to conservative measures) • Electrolytes (Hyperkalemia resistant to conservative measures) • Intoxication (alcohols and dialyzable drugs) • Overload (of fluid) • Uraemia

  44. Conclusion

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