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Foreign let’s quickly discuss about eki type 2 diabetes and hypertension so you see diabetic patients are at a greater risk of regarding hospitalization and they have risk of experiencing api because most of the time they even have a background ckd and that just gets worsened because of any insult which could be sepsis which could be a drug that that could just
That trigger it type 2 diabetes also increases the long term mortality and morbidity of api and among type 2 diabetes patient api increases the risk of advanced ckd by over three-fold independent of the other risk factors and this is one thing that you know that keeps worsening in in the patients so it’s very important that over the period of follow-ups you keep
On checking their pretty nine clearance you keep on checking their egfr and you keep documenting that in your prescription because it always may not be may not hit with the uh you know creatinine level because sometimes you if you don’t calculate the egfr you would not know which stage of secreting the patient is on because sometimes these patients with a high
Normal retinaing around 1.4 1.5 the moment you can put it in the calculator you see that the egfr comes to around 35 40. where all your calculation of the drug dosings will have to be changed i think this is a fine line that we often miss as clinicians that’s one of the reasons for keeping this particular content in the case is that we must be aware of checking
The gfr and documenting it that’s very important so based on their gfr values uh you know their medications should be titrated and also then insulin doses should also be adjusted if the patient is an insulin then you must make sure that your patient is not given extra amount of insulin so that the patient will will not have that risk of hypoglycemia so whenever
Your egfr values are going down in subsequent follow-ups that’s where you raise a red flag and you try to readjust the dose of the medications you know in your prescription so that your patient do not end up uh with a progression of ckd because of an acute itself that’s very very important in the ico setting blood glucose levels should be maintained at a at a
Normal level and when we talk about the blood glucose level in the icu it would mean try to keep it within 180. you don’t want too tight control of blood glucose level at the same time you don’t want hypoglycemia so try to keep the blood sugar around 180 that minimizing the aki risk without elevating mortality rings now as i said drug induced aki is a very very
Important component and nsaids are the most commonly associated drug remember when you are using fluoroquine alone this is very commonly used by general practitioners in their daily practices uh ciprofloxacin levofloxacins are dependent on the renal function that’s very important moxifloxacin is not dependent on renal function that’s a very important take on point
About alone one of the catholic sporting cephy prime is contra indicated in patients with eg for less than 30 due to risk of cns toxicity that’s also an important take on point amino glycosides vancomycin cafezadine kefazodine fluconazole pipeline carb penins uh sulfamethoxazole require dose adjustments in renal impairment careful aspirins and penicillins have
A wider therapeutic indices and vary in the need for those adjustments once again a quick highlight to all of you that whenever you’re prescribing take any medication it’s quickly easy to check on their egfr and see if the drug needs any dose adjustment as per their renal function this is even applicable to the use of you know oral anti-diabetic drugs and the
The various molecules which we use in the treatment of diabetes so a textbook picture this is how to approach a case with oliveira you try to categorize it whether it’s readingal whether it’s intranal whether it’s post renal if it’s a preninal then obviously you’re born to creatinine ratio will be more than 20s to one pena will be less than one percent during
Specific gravity more than 1.02 there’ll be more presence of high lean costs in the urine sediment and there would not would not be any evidence of obstruction or intranal causes what do you do you just hydrate eliminate the toxins and you treat the causes if you’re looking at an intranal cause you know the bun to creatinine ratio would be between 10 to 20 fina
Will be more than one urine specific gravity will be between 1.01 to 1.02 and there’ll be tubular or granular casts in the urine ultrasound may show medical kidney disease or normal no obstruction would be there and the other cause is of course the posterior cause which would definitely show up some kind of a pressure effect that is hydronephrosis serum and urine
Tests have similar results to the intranal causes so if it’s an intranal causes you definitely try to rule out the particular cause you treat the cause you eliminate the toxins some and very important is that whenever you are suspecting an intranal cause you must refer to a nephrologist that’s very very important pre-renal you can correct it and perineal azotemia
Will be corrected and that gets completely reversed but if you’re suspecting an intrudinal cause it’s very important you bring the nephrologist into the picture and again when you look at the post renal cause you’re looking at an obstruction you need to bring in a urology you need to order a ct and see if that obstruction is evident or not and treat the patient
Accordingly so renal components does exist in patients with metabolic problems and this is something that as physicians as clinician we must look at so how do you manage this space and iv fluid resuscitation to maintain adequate renal perfusion so it’s again that fluid balance very important you correct planar provide imbalance you use diuretics to correct the
Volume of a load at the same time you don’t make the patient get dehydrated so that is very very important that balance is important discontinuing all the nephrotoxic drugs keep a steady glycemic control target cbg less than 180 if the patient needs other supportive measures like ventilation and india management etc you give them and of course renal replacement
Therapy will be required in such cases if there is a refractory hyperkalemia that’s very important unresponsive dollar mobile load if there is a uromic pericardite is pluritis or encephalopathy happening or if there is an intractable acidosis or in cases of acute poisoning those would be the indications of putting a patient on renal replacement therapy in the
Setting of aki let’s go back to the case and try to understand how the patient was about a few months ago so let’s look at the past vision this patient had an outpatient clinic visit six months ago with complaints of lethargy pain swelling tingling and numbness in the feet nausea and vomiting going on for a month and at that point of time the patient was still
Overweight dp was on the high side 170 by 90. the respiratory rate was 18 saturation was normal temperature was normal it was not in any acute distress but the patient was definitely having elevated blood pressure weak palpable peripheral pulses and had diminished pen sensation along with tingling and numbness in the both lower lips so definitely you can see
The patient was going into a state where the patient was definitely having uh you know neuropathy with probable evidence of peripheral artery disease and the patient was also having erratic differences in his blood pressure and you remember from the history your patient is a smoker that is also very important in the past visit the patient had absolutely normal
Uh you know cardiovascular examination normal breath sounds nothing called abdomen cns examination was normal and in the fundoscopy the patient was having evidences of diabetic retinopathy remember this again a very take home point is in a patient who would have some category of nephropathy they would definitely have a coexisting retinopathy so that’s also
Very important so if you have a patient with microalbuminumia worsening kidney function rising creatinine trend do not forget to check the patient for retinopathy because the patient would definitely have a coexisting retinopathy which would also be past progressing so that’s that’s a very important take home from this case how was the blood parameters in the
Past visit remember i kept referring to the fact that you need to see the the previous creatinine what was the previous creatine level so this is how your patient was six months back passing 186 pp 249 a1c 8.8 so sugar was not under control despite of being on insulin and his baseline creatine six months back was 1.5 so yes your patient does have a degree of
Renal parenthymal disease maybe an early stage this would be a stage one or a stage two ckd if you calculate the jfr uh so the egfr sorry had been calculated to be around uh 24 so that that that’s quite actually bad and also the patient had a proteinuria of one plus so that was six months back and at that point of time the patient had some degree of cpd but what
Caused this aki was not the ckd but the acute insult of some inadverant use of drugs especially in this case in seed which actually aggravated the ckd into a stage of incline what was the other findings you see the doppler of the lower limbs had mild stenosis of bilateral femoral artery so definite evidence of peripheral artery disease and 10 gram monofilament
Testing of was done of both the feet there was loss of protective sensation and increased risk of ulceration so that is very very important so you definitely have signs of neuropathy as well as peripheral artery disease going on for the last six months in this patient so this is your diagnosis you have a patient with hypertension diabetes kidney disease as well
As diabetic neuropathy which was which is now presented with aki and heart failure with preserved ejection fraction with a bad focus now uh this patient was as i said earlier was being managed with atenolol and anadopril for the management of hypertension he was a metformin thousand milligram twice a day and human insulin now this is again why we keep pushing
On this point is would you really be comfortable going ahead with this thousand milligram twice daily metformin with this eeg fr no you needed to adjust that which was not done so that is the titration that needs to be done so see there are a lot of triggers you know if you don’t adjust the drugs on the right time your patient will present with a acute kidney
Injury or repression patient will present with a complication because of the drugs so these are the pitfalls of clinical medicine that that needs to be picked up patient was on pregabaline patients was educated on proper foot care to be followed to avoid foot ulcers and the patient was advised to follow up with the gp uh with three to six months as a follow-up
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Type 2 – Diabetes & HTN | Medvarsity By Medvarsity Online Limited
