Topic: Complications of diabetes mellitus, coagulation disorders, leukemia
Question: 70 year old patient with uncontrolled type 2 diabetes mellitus of 20 yrs duration presents with tingling and pain in the legs,blurring of the vision, weakness, easy fatigability and bony pains. Investigations revealed blood urea 130 mg/dL and serum creatinine 45mg/dL.
① what is the likely diagnosis?
② How will you classify the chronic kidney disease?
③ Discuss the management of advanced renal failure?
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The likely diagnosis in this case is diabetic nephropathy. Diabetic nephropathy is a common long-term complication of diabetes mellitus, particularly type 2 diabetes. It is characterized by progressive damage to the kidneys due to long-standing high blood sugar levels.
The chronic kidney disease (CKD) in this case can be classified based on the estimated glomerular filtration rate (eGFR) and the presence of kidney damage. The eGFR is calculated using the patient’s serum creatinine level, age, gender, and other factors. Based on the eGFR, CKD is classified into five stages:
- Stage 1: eGFR ≥90 mL/min/1.73 m², with evidence of kidney damage.
- Stage 2: eGFR between 60-89 mL/min/1.73 m², with evidence of kidney damage.
- Stage 3: eGFR between 30-59 mL/min/1.73 m² (Stage 3a: eGFR 45-59 mL/min/1.73 m², Stage 3b: eGFR 30-44 mL/min/1.73 m²).
- Stage 4: eGFR between 15-29 mL/min/1.73 m².
- Stage 5: eGFR <15 mL/min/1.73 m² or on dialysis (end-stage renal disease).
In this case, the patient’s serum creatinine level of 45 mg/dL indicates advanced renal failure, likely corresponding to CKD Stage 5 or end-stage renal disease.
The management of advanced renal failure involves a combination of medical interventions and renal replacement therapy, such as dialysis or kidney transplantation.
The management of advanced renal failure involves a multidisciplinary approach and includes:
- Medications:
- Antihypertensives to control blood pressure
- Diuretics to manage fluid overload and edema
- Erythropoiesis-stimulating agents (ESAs) to treat anemia
- Calcium and vitamin D supplements to prevent bone disease
- Phosphate binders to control phosphorus levels
- Sodium polystyrene sulfonate (Kionex) to manage hyperkalemia
- Diet:
- Low-protein diet to reduce the production of urea and other nitrogenous waste products
- Low-sodium diet to prevent fluid overload and hypertension
- Low-potassium diet to prevent hyperkalemia
- Adequate fluid intake to maintain hydration
- Lifestyle modifications:
- Smoking cessation
- Regular physical activity
- Weight management
- Avoidance of nephrotoxic medications
- Renal replacement therapy:
- Hemodialysis
- Peritoneal dialysis
- Kidney transplantation
Here are medication details commonly used in the management of advanced renal failure:
- Erythropoiesis-Stimulating Agents (ESAs): ESAs, such as epoetin alfa or darbepoetin alfa, are used to treat anemia associated with advanced renal failure. They stimulate the production of red blood cells and can help alleviate symptoms of fatigue and weakness.
- Phosphate Binders: Phosphate binders, such as calcium-based binders (calcium carbonate, calcium acetate) or non-calcium-based binders (sevelamer, lanthanum carbonate), are prescribed to control high levels of phosphate in the blood. They help prevent the complications of excess phosphate, such as bone disorders and calcification of blood vessels.
- Vitamin D Supplements: Vitamin D supplements, such as calcitriol or paricalcitol, may be prescribed to manage mineral bone disorders associated with advanced renal failure. They help regulate calcium and phosphorus metabolism and promote bone health.
- Sodium Bicarbonate: Sodium bicarbonate may be used to correct metabolic acidosis, a common complication of advanced renal failure. It helps maintain the acid-base balance and can alleviate symptoms, such as fatigue and muscle weakness.
- Diuretics: Diuretics, such as furosemide or metolazone, may be prescribed to manage fluid overload and edema in patients with advanced renal failure. They help increase urine output and reduce fluid retention.
- Statins: Statin medications, such as atorvastatin or simvastatin, may be prescribed to manage high cholesterol levels, which are common in patients with advanced renal failure. Statins help lower cholesterol and reduce the risk of cardiovascular complications.
- Antihypertensive Medications: Controlling hypertension is crucial in the management of advanced renal failure. Medications, such as ACE inhibitors (e.g., lisinopril, enalapril) or ARBs (e.g., losartan, valsartan), are commonly used to lower blood pressure and protect kidney function.
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