Case Discussion

30 year male admited through emergency in a severe metabolic acidosis state and drowsy.

He had outside s.creatine of 15mg/dl, and xray showing homogenous opacity involving right

Apex of lung. There was recent history of taking ATT, which he soon gave up after using few

Days as he became more nauseated and had vomiting too. There was an aditional history of

Difficulty in passing urine since many years, and also required once catheterization suprapubically.

We got him inserted Double lumen cather and dialysed , later on Ultrasound kidneys and bladder

Showed markly dillated PC system leaving no cortex bilatteraly and thick wall , mild trabeculated

Bladder.

We concluded that he would be having stricture urethra by his tory which was substaciated with

The fact  when he was tried to pass cather but failed to proceed and subsequently suprabubic cathe

Erization done as he was in retention of urine.

Regarding his homogenous opacity in lung we would work him up for tuberculosis by Blood CP, ESR

Mauntox test, Sputum AFB or moring gastric lavage for AFB or BAL. Urine Dr and C/s. 

Case Disscussion

A 65 year male known  Hypertension ,diabetic, controlled on diet was found collapsed in bath room. On exa: Drowsy, heart rate 50 bpm with BP 140/90 and Tem 36.8 C. Jvp not raised. Heart sound normal and chest clear. Abdomen normal. Left lower limb was externally rottated and painful to move and brusing to thigh.
Lab:     Hb 9.8, tlc 14000, plat 350000,
Na 135, K 6.8, urea 16, creatinine 6.7 mg/dl. Hco3 15.
t bili 1.4, AST 26,  Alp 109 , Alb 4.0,
Urine : blood 2 plus, prot 1 plus,
chest xray normal , xray hip show fracture and dislocation of neck of femure.
ECg : minor t wave abnormalties in lateral leads.


Question: What is diagnosis?
What is the cause of metabolic abnormality and how will u manage the patient?



Answere:  Diagnosis is Rhabdomyolysis. There are two important clues. One is that patient had a fall. Second there is renal failure with disproportionally raised creatine. There is muscle injury ( myositis). Myoglobin is released which is toxic to renal tubules and precipitate renal failure. calcium is found decrease and it binds with myoglobin and potassium and phosphate are high and there are liberated heavilly from damaged muscles.
The management involves adequate hydaration and alkalinization of the urine to reduce precipitation of myoglobin in the renal tubules. Avoid loop diuretic as they cause acidic urine.

Spina Bifida(Neurogenic bladder.)

 Neurogenic bladder , which is usually treated by ileal conduit. It is urinary diversion procedure in which terminal part of intestine , Ileum is dissected and anastomosed with ureters with one end and second end with skin (Stoma formation). we often come across cases in nephrology practice where patients with history of Spina bifida come as renal failure which is complication of this neurogenic bladder.
Now these patients usually need renal replacement therapy. Whenever we consider Peritoneal dialysis in these patients, we must consider patients ventriculo-peritoneal shunt which is often placed in these pateint because of Hydrocephalous. Therefor these children would be prone to meningitis if PD is initiated.

Interstitial nephritis

How interstitial nephritis is presented and what are the some of the drugs which cause?

It is usually presented with fever. maculopapular rash, eosinophilia, eosinophilurea.

Penicillin analogue, cephalosporin, sulphonamide, NSAIDs, cimitidine, allopurinol etc.

Question solution

1. A 30 year female of Chronic nephritis/CRF had a live related renal transplant 1 year back. She seeks your advice regarding future pregnancy. She is receiving Prednisolone, Cellcept and cyclosporine as maintenance immunosuppression . Her BP is well controlled with Enalpril 5mg once daily.

a)      How would u assess her suitability of successful outline of pregnancy what advice would you give?

b)      What if any modification in her current medication is required should she become pregnant?

c)       What complications are expected?

Answere:   Assessment of suitability regarding pregnancy and advice entails:

Assessment of her current renal function, her urine detail report and her course post transplant sofar.

At least 1 year post‐transplantation

 Stable renal function with creatinine <2 mg/dl

No recent episodes of acute rejection

 BP ≤140/90 mmHg on medications

 Proteinuria <500 mg/day

Prednisone ≤15 mg/day Azathioprine ≤2 mg/kg/day

Cyclosporin ≤4 mg/kg/day

 Normal allograft ultrasound

b) Replace cellcept with azathioprin and enalpril with methyldopa. Atenolol and metoprolol can also be given. In severe hypertension nefidipine and hydralazine can be given.

d)     Gestational diabetes, preeclamsia, preterm labour .

 Rate of uti more especially whose primarily renal disease is secondary to Pyelonephritis.