ESIM 2014 WHEN CHRONIC BECOMES ACUTE

Transcription

1 ESIM 2014 WHEN CHRONIC BECOMES ACUTE Anna Salina, MD Pauls Stradins Clinical University Hospital Riga, Latvia

2 37 years old female, 50 kg, 150 cm Complaints Severe edema +8 kg Tiredness, dry cough Chills and elevated body temperature Abdominal pain, nausea, vomiting

3 Objective Anasarca Body t - 38 C Tachycardia -120 x, BP - 160/100 mmhg Breathing - 22 x, bilaterally in lower lobes diminished breath sounds Abdomen - enlarged, diffusely painful, peritoneal signs negative

4 Strategy:

5 Strategy: Blood tests, Urine test Blood culture, Urine culture RTG thorax USG Abdomen, Gastroscopy

6 Medical history: Nefrotic syndrome from year (Steroid resistant), Repeated infections, CKD II, secundary hipertension Kidney biopsy: Focal segmental glomerulosclerosis (No glomeruli globally sclerosed) Previously prescribed treatment: Tab.Cyclosporin A 50 mg b.d.,tab.prednisone 10 mg q.d., Tab.Torasemidum 50 mg q.d.,tab.atorvastatin 40 mg q.d., Tab.Perindopril 8 mg q.d., Caps.Omeprazol 20 mg q.d., Calcigran 1000 mg q.d.

7 Diagnosis?

8 Diagnosis: Nephrotic syndrome Focal segmental glomerulosclerosis Chronic kidney disease Secondary arterial hypertension Influenza? Pneumonia? Urinary tract infection? Sepsis? Gastrointestinal bleeding? Secondary anemia? Pregnancy?

9 Blood tests: WBC l RBC l Hgb g/l Hct % Plt l Total cholesterol 9.0 <5.0 mmol/l Triglyceride 1.6 <1.7 mmol/l HDL mmol/l LDL 7.65 <3 mmol/l

10 Blood tests: WBC l RBC l Hgb g/l Hct % Plt l Total cholesterol 9.0 <5.0 mmol/l Triglyceride 1.6 <1.7 mmol/l HDL mmol/l LDL 7.65 <3 mmol/l Urea mmol/l Creatinine μmol/l GFR 9.1 >60 ml/min Chloride mmol/l Potassium mmol/l Total Protein g/l Albumin g/l CRP mg/l Cyclosporine in blood 1.3!! ng/ml

11 Urine: Protein ( 0.25 g/l) Total protein g/24h (<0.14 g/24h) Rtg Thorax: Pleural effusion USG Abdomen: Ascites. Bilateral chronic kidney parenhimal damage. Left sided hydrothorax

12 Urine: Protein ( 0.25 g/l) Total protein g/24h (<0.14 g/24h) Rtg Thorax: Pleural effusion USG Abdomen: Ascites. Bilateral chronic kidney parenhimal damage. Left sided hydrothorax Started treatment with: Tab.Torasemidum 200 mg q.d., Sol.Ceftriaxone 2 g q.d., Caps.Omeprazole 20 mg b.d., Sol.Metoclopramidum 10 mg, Sol.Albumin 20% 200 ml, Erythrocyte transfusions

13 Abdominal pain becomes more intense, Peritoneal signs - positive, urine 400 ml/24h.

14 Abdominal pain becomes more intense, Peritoneal signs - positive, urine 400 ml/24h.

15 Abdominal pain becomes more intense, Peritoneal signs - positive, urine 400 ml/24h. Abdomen, thorax CT scan: hydrothorax on left side, smaller hydrothorax on right side. Ascites.

16 Abdominal pain becomes more intense, Peritoneal signs - positive, urine 400 ml/24h. Abdomen, thorax CT scan: hydrothorax on left side, smaller hydrothorax on right side. Ascites. Puncture and drainage of ascites ml (culturenegative) Left side pleura puncture ml (culture-negative)

17 Urine culture - negative Gastroscopy - no signs for bleeding Echocardiography - no pathological structures on valves

18 Urine culture - negative Gastroscopy - no signs for bleeding Echocardiography - no pathological structures on valves Blood culture: Grows A group β-hemolitic streptococcus - Str. Pyogenes

19 Urine culture - negative Gastroscopy - no signs for bleeding Echocardiography - no pathological structures on valves Blood culture: Grows A group β-hemolitic streptococcus - Str. Pyogenes Medical treatment in hospital : Sol.Ceftriaxone 2 g q.d. (11 days) -> Sol.Penicillin G 2 milj. q.i.d. + Sol.Clindamycin 600 mg t.i.d. (7 days) Tab.Torasemid 200 mg -> 100 mg q.d. Sol.Fraxiparine 0.3 ml q.d. Tab.Bisoprolol 2.5 mg q.d., Tab.Lercanidipine10 mg q.d.,tab.moxonidine 0.2 mg q.d. Caps.Omeprazole 20 mg b.d., Sol.Metoclopramidum 10 mg Sol. Albumin 20% 200ml, Erythrocyte transfusions

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21 WBC 10 9 l 14,8 8,8 11,2 10,6 6,5 DAY

22 Creatinine μmol/l DAY WBC 10 9 l 14,8 8,8 11,2 10,6 6,5 DAY

23 Nephrotic syndrome Diagnosis Anasarca, Ascites, Bilateral hydrothorax, Hypoalbuminemia, Hyperlipidemia Focal segmental glomerulosclerosis Acute kidney Injury Chronic kidney disease V Sepsis (A grup β-hemolytic streptococcus Str.Pyogenes) Peritonitis Secondary anemia Secondary arterial hypertension

24 After two weeks GFR (MDRD) 11 ml/min

25 After two weeks GFR (MDRD) 11 ml/min Dynamic kidney scintigraphy: Filtration disorder in both kidneys. Decreased renal function.

26 After two weeks GFR (MDRD) 11 ml/min Dynamic kidney scintigraphy: Filtration disorder in both kidneys. Decreased renal function. Peritoneal dialysis chateter implantation.

27 Take home message Patient education and cooperation is an indispensable foundation for the effective therapy. There can be expressive differences in GFR calculation methods. Loss of kidney function (CKD V) can develop without a severe glomerular sclerosis in a kidney biopsy. There is an important place for Internal medicine in the future of Medicine.

28 Thank you!