40 MALE HYPERTENSIVE CHRONIC KIDNEY DISEASE ON HEMODIALYSIS WITH HFpEF

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DEIDENTIFIED DISCHARGE SUMMARY

Age Gender : 40 Years/Male

Address

Checharge Type: Relieved

Admission Date: 20/03/2024 03:46 PM

Name of Treating Faculty

DR.SRIRAMULU HOD

Diagnosis

CKD ON MHD

K/C/O HYPERTENSION

Case History and Clinical Findings

CHIEF COMPLAINTS-

C/O SWELLING OF B/L LOWER LIMB

C/O FACIAL PUFFINESS

C/O SOB ON EXERTION

HISTORY OF PRESENT ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR AGO, THEN HE DEVELOPED B/L PEDAL

EDEMA FACIAL PUFFINESS, AND SOB ON EXERTION

NO H/O ORTHOPNEA/ PND

NO H/O BURNING MICTURITION

NO H/O HEMAT URIA

NO H/O ABDOMINAL PAIN

PAST HISTORY-

K/C/O HYPERTENSION-1 YEAR AND ON MEDICATION 

N/K/C/O EPILEPSY/CVA/ CAD/THYROID DISORDERS

GENERAL EXAMINATION

PATIENT IS C/C/C

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

TEMP-AFEBRILE

PR-82BPM

RR-16CPM

BP-140/90MMHG

SPO2-98%

CVS-S1,S2 HEARD, NO MURMURS

RS-BAE+

P/A SOFT, NON TENDER, NO ORGANOMEGALY

CNS-NFND

Investigation

CBP HBTCNLEM B PLT SMEAR RFT UR CR UA CA+2 P NA+ K+ CL. H/ HBSAG HCV

24HR URINE/CREATININE RATIO

24 HRS URINE PROTEN 136.2MG/DAY

24 HRS URINE CREATININE 0.7G/DAY

URINE VOLUME 200ML

HEMOGLOBIN-9.7GM/DL

SMEAR

RBC-NORMOCYTIC NORMOCHROMIC

WBC-WITHIN IN NORMAL LIMIT

HEMOPARASITES-NO HEMOPARASITES SEEN

IMPRESSION NORMOCYTIC NORMOCHROMIC ANESMIA

RFT-

UREA75MG/DL

CREATININE 10 MG/DL

URIC ACID-2.7MMOL/L

CALCIUM-9.6MG/DL

PHOSPHORUS-4.1MG/DL

SODIUM-136MMOL/L

POTASSIUM-4.4 MMOL/L

CHLORIDE 103MMO/L

SERUM IROM-44UG/DL

LFT-

TOTAL BILIRUBIN 0.79 MG/DL

DIRECT BILIRUBIN-0.20MG/DL

SGOT(AST-19IU/L

SGPT(ALT-16 IU/L

ALKALINE PHOSPHATE 1031LVL

TOTAL PROTEIN6.5GM/DL

ALBUMIN-3.6GM/DL

A/G RATIO-1.25

BLOOD SUGAR RANDOM-RBS-91MG/DL

COMPLETE URINE EXAMINATION

COLOUR-PALE YELLOW

APPEARANCE CLEAR

REACTION ACIDIC

SP.GRAVITY-1010

ALBUMIN++

SUGAR NIL

BILE SALTS NIL

BILE PIGMENTS NIL

PUS CELLS 3-4

EPITHELIAL CELLS-3-4

RBCS NIL

CRYSTALS NIL.

CASTS NIL

AMORPHOUS DEPOSITS ABSENT

OTHERS NIL

BLOOD GROUPING-

BLOOD GROUP-B

RHTYPING-POSITIVE

ANTI HCV ANTIBODIES RAPID-NON REACTIVE

HBS-AG RAPID-NEGATIVE

HIV12 RAPID TEST-NON REACTIVE

USG REPORT-

RT KIDNEY-7.8X3.5CM

LT KIDNEY-8.7X3.4CM

IMPRESSIONS- BILATERAL PLEURAL EFFUSION

-B/L GRADE III RPD CHANGES

2D ECHO-

MODERATE MR, MODERTAE TR WITH PAH, MODERATE AR

NO RMMA, MILD CONCENTRIC LVH+

ALL CHAMBERS DILATED

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION

NO PE/CLOTS

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION <2GM/DAY

T.NIFEDIPINE XL30 MG PO/QID

T. TELMA80 MG PO/OD

T. DYTOR 100 MG POOD

T. MET XL 25 MG PO/BD

T SHELCAL-CTPO/OD

T.OROFER-XT PO/OD

T. ARKAMINE 0.1 MG PO/TID

INJ. EPO 4000 IU SC/BI WEEKLY

INJ. IRON SUCROSE 100MG M ONCE EEKLY

Advice at Discharge

FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION <2GM/DAY

T.NIFEDIPINE XL 30 MG PO/QID

T. TELMA 80 MG PO/OD

T. DYTOR 100 MG PO/BD

T MET XL 25 MG PO/BD

T SHELCAL-CT PO/OD

T OROFER-XT PO/OD

T ARKAMINE 0.I MG PO/TID

INJ. EPO 4000 IU SC/BI WEEKLY

INJ. IRON SUCROSE 100MG  BI WEEKLY

Follow Up

COME FOR DIALYSIS WEEKLY 3 TIMES

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATT END EMERGENCY DEPARTMENT

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADICE DONOTMISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration: The medicines prescribed and the aduce regarding preventive aspects of care when and how to obtain urgent care have been explained to me in my own language SIGNATURE OF PATIENT/ATTENDER SIGNATURE OF POINTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date

Date: 10/04/2024

CASE REPORT:

40-year Male 

Auto driver by occupation 

Resident of Nalgonda.

Chief complaints

C/o pedal odema since 6 months 

C/ o shortness of breath since 3 months

History of present illness.

Patient was apparently asymptomatic one yr back, later he developed blurring of vision in both eyes, for which he went to the hospital and was diagnosed with Hypertension (hypertensive changes in the retina - papilledema) and Renal injury ( raised creatinine 1.6 mg/dl). Since then he was on conservative managenment. 6 months back, he developed bilateral lower limb swelling, insidious in onset, gradually progressive, pitting type, aggravated on work and prolonged standing, relieved on rest. Lower limb swelling was initially till ankle now progressed till knee.

He also complains of sob since 3 months, initially on ordinary physical activity that has gradually progressed to sob at less than ordinary physical activity, limiting his daily activities. Since jan, he also had complaints of Breathlessness in supine position (orthopnea). No seasonal or diurnal variation in breathlessness. Not associated with cough, cold. In December 2023, he also had complaints of vomiting 4-5 episodes per day, watery content, non projectile nonbilious relived on medication . 

He was only on milk from dec and did not take any food because of the vomitings. He also had complaints of facial puffiness since jan. Complaints of decreased urinary output since January 2024. In jan the severity and frequency of the episodes also increased hence he went to the local nalgonda hospital where they did the investigations and diagnosed as kidney failure and advised to go to NIMS, Hyderabad for further treatment; At NIMS, he underwent 4 cycles of hemodialysis in the month of feb. He came to our hospital in march and is continuing the hemodialysis.

No complaints of chest pain, palpitations. 

No complains of PND.

No complains of fever, Burning micturition.

Past history 

Known case of hypertension since 1 year and on medication TAB. NIFEDIPINE 20 mg OD.  

Personal history 

Appetite lost

Diet mixed

Sleep normal   

Bowel moments Regular

Decreased urinary output

Addictions no

No allergies

General examination

Patient was conscious coherent cooperative well oriented with time and place

Temp afebrile 

BP = 180/110 mmHg

PR = 92 bpm

RR = 18 cpm

Spo2 = 98 % on room air (21% FiO2)

No Pallor, icterus , cyanosis , clubbing , lymphadenopathy 

System examination

Cvs = s1s2 heard, JVP raised

Rs = bae + 

P/A = soft and Non tender

INITIAL ASSESSMENT:

2D ECHO :

Mild concentric LVH

All chambers dilated 

No systolic dysfunction 

No diastolic dysfunction 

No RWMA

No Pericardial effusion

Moderate MR

Moderate AR

Moderate TR with PAH

EF 64%

Ultrasound Report of Renal Parameters:

Right Kidney Size: 7.8 x 3.5 cm, CMD LOST

Left Kidney Size: 8.7 x 3.4 cm, CMD LOST

Impression: B/L GRADE 3 RPD CHANGES

LABORATORY VALUES:

Initial Presentation

Hemoglobin (Hb): 9.7 g/dl

Blood Urea: 75 mg/dl

Serum Creatinine: 10 mg/dl

eGFR: 6 ml/min/1.72m²

Serum Sodium (Na+): 136 mEq/L

Serum Potassium (K+): 4.4 mEq/L

Serum Chloride (Cl-): 103 mEq/L

Serum Calcium (Ca+2): 9.6 mEq/L

Serum Phosphorus: 4.1 mEq/L

Total Bilirubin: 0.79 mg/dl

Direct Bilirubin: 0.20 mg/dl

AST/SGOT: 19 IU/L

ALT/SGPT: 16 IU/L

ALP: 103 IU/L

Total Proteins: 6.5 g/dl

Serum Albumin: 3.6 g/dl

Urine Analysis (CUE): Albumin 2+, Sugar nil

Serum Iron: 44 µg/dl.

MANAGEMENT :

FLUID RESTRICTION < 1.5L/DAY

SALT RESTRICTION  < 2GM/DAY

TAB. NIFEDIPINE XL 30 MG PO/QID

TAB. TELMISARTAN 80 MG PO/OD

TAB. TORSEMIDE 100 MG PO BD

TAB. METAPROLOL 25 MG PO/BD

TAB. SHELCAL-CT PO/OD

TAB. OROFER-XT PO/OD

TAB. ARKAMINE 0.1 MG PO/TID

INJ. EPO 4000 IU SC/BI WEEKLY

INJ. IRON SUCROSE 100MG BI WEEKLY

FOLLOW-UP:

LABORATORY VALUES:

Hemoglobin (Hb): 7.4 g/dl

Blood Urea: 41 mg/dl

Serum Creatinine: 5.2 mg/dl

eGFR: 13 ml/min/1.72m²

Serum Sodium (Na+): 138 mEq/L

Serum Potassium (K+): 4 mEq/L

Serum Chloride (Cl-): 102 mEq/L

Serum Calcium (Ca+2): 10 mEq/L

Serum Phosphorus: 4.1 mEq/L

Total Bilirubin: 1.40 mg/dl

Direct Bilirubin: 0.20 mg/dl

AST/SGOT: 17 IU/L

ALT/SGPT: 14 IU/L

ALP: 104 IU/L

Total Proteins: 5.7 g/dl

Serum Albumin: 3.1 g/dl

Urine Analysis (CUE): Albumin 3+, Sugar nil

Serum Iron: 60 µg/dl

2D Echo:

MILD Concentric LVH(+) (1.48cms)

NO RWMA 

Moderate to severe MR (MP Jet Area 7.32 cm2)

Moderate AR (AP-PHT-840 m/ sec)

Moderate to Severe TR with Moderate PAH

EF =60%. RVSP = 65 mmHg

MAC+ ; sclerotic Av, NO AS/MS

Good LV Systolic function 

No Diastolic dysfunction 

IVC size (2.24 cms) Dilated, Non collapsing

All chambers Dilated

 

IVS 1.48 cms

ESD-3.72cm  

EDD 5.62cms

Major Criteria:

Functional:

TR velocity: Moderate PAH implies a TR velocity likely >2.8 m/s (estimated PASP > 35 mmHg).

Point: 2

Morphological:

Left Ventricular Mass Index (LVMI) and Relative Wall Thickness (RWT):

Concentric LVH is noted with a septal thickness of 1.48 cm. Assuming LVMI > 149 g/m² (for men), and RWT > 0.42.

Point: 2

Minor Criteria:

Morphological:

Left Atrial Volume Index (LAVI):

As all the chambers are dilated, it is likely elevated.

LV Wall Thickness: ≥12 mm (noted as 1.48 cm, which is 14.8 mm).

Point : 1

Biomarker:

NT-proBNP or BNP levels are not done.

Calculation:

Major Criteria: 4 points (2 points for TR velocity >2.8 m/s and 2 points for LVMI and RWT).

Minor Criteria: 1 point (LV wall thickness ≥12 mm).

Total Points = 4 (Major) + 1 (Minor) = 5 points.

Interpretation:

≥ 5 points: HFpEF

Using the HFA-PEFF diagnostic algorithm, his total score of 5 points indicates a diagnosis of HFpEF.

HFA-PEFF ALGORITHM:-

Major criteria:

1. Functional

septal e’<7 cm/s or lateral e' < 10 cm/s or Average E/e'≥ 15 or TR velocity > 2.8 m/s (PASP>35 mmHg)

2. Morphological

  LAVI > 34 ml/m² or LVMI >=149/122 g/m² (m/w) and RWT>0,42 

3. Biomarker (SR)

NT-proBNP > 220 pg/ml or BNP > 80 pg/ml

4. Biomarkers (AF)

NT-proBNP > 660 pg/ml or BNP >240 pg/ml

Minor criteria:

1. Functional

Average E/e' 9-14 or GLS<16%

2. Morphological

LAVI 29-34 ml/m² or LVMI>115/95 g/m² (m/w) or RWT > 0,42 or LV wall thickness≥12 mm

3. Biomarker (SR)

NT-proBNP 125-220 pg/ml or BNP 35-80 pg/ml

4. Biomarkers (AF)

NT-proBNP 365-660 pg/ml or BNP 105-240 pg/ml

Each Major Criteria: 2 points

Each Minor Criteria: 1 point

≥ 5 points: HFpEF

2-4 points: Diastolic Stress Test or Invasive

He doesn't followed fluid intake restriction of <1.5 liters/day

At follow-up:

He had 2 emergency hospitalizations due to acute cardiogenic pulmonary edema.

He also quited clonidine for 2 days and landed up in uncontrolled hypertension which was controlled later on with addition of clonidine back into the treatment regimen. 

DIAGNOSIS:

1. STAGE V CHRONIC KIDNEY DISEASE ON MAINTAINENCE HEMODIALYSIS

2. HFpEF; 

HYPERTENSIVE HEART DISEASE WITH LVH AND DIASTOLIC DYSFUNCTION;

MODERATE TO SEVERE MR, AR, TR WITH PAH

3. ANEMIA OF CHRONIC KIDNEY DISEASE. 

4. HYPERTENSION