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CLINICOPATHOLOGICAL

CONFERENCE
UPON ADMISSION
Physical Examination
Awake and disoriented
BP 120/80mmHg
HR 79bpm
RR 20 cpm Laboratory
Temp 36.70C CBC
High PMN, LYM, MONO, RDW
Low RBC MCHC
Blood chemistry
High BUN, creatinine
Low Na
Day 2
Physical Examination
BP 110/90mmHg
HR 88bpm
RR 26 cpm
Temp 370C
Laboratory
CBC
Prothrombin time: Prolonged (21.0 sec)
% Activity: 0.35
INR: 1.88
Activated Partial Thromboplastin time: Prolonged
(53.9 sec)
Blood chemistry
Low: albumin, pCO2, pO2, HCO3, BE
High AST
Normal ALT
O2 sat:95.3%
TCO2: 22.3 mmol/L
SBs 254.1 mmol/L
Glycosylated hemoglobin: increased (6.4)
Day 3
Physical Examination
Drowsy
Occasional crackles on both lung
field
BP 130/80mmHg
HR 63 bpm
RR 25 cpm
Temp 37.1 0C Laboratory
CBC
High MONO, RDW
Low RBC, MCHC, PC
Day 4
Physical Examination
GCS score 3
BP 110/90mmHg
HR 88bpm
RR 26 cpm
Temp 370C Laboratory
Icteric sclera CBC
Tacchycardia Low PMN, RBC, HG, RDW,PC
Occasional crackles in High LYM, MCV, MCHC
both lung fields Blood chemistry
Supraclavicular retraction Glucose: increase
Grade 2 bipedal edema High BUN, Creatinine, Na, Cl(111;
O2 saturation 70% =106)
LowTC
Liver Ab titer
HBsAg: 0.49 non-reactive
Anti-HCV: non-reactive
Differential Diagnosis:
CHRONIC KIDNEY DISEASE
RULE IN RULE OUT
Duration 4 months On presentation
GFR 17.6 mL/min per 1.73 m2 No dilated neck veins
Polypharmacy No peripheral edema
Hypertension and DM No murmur
Abnormal urinalysis: Sediments, Adynamic precordium
+2 protienuria PMI in normal anatomic location
Metabolic acidosis
Tachypnea
Anemia
Changes in sensorium
Multiorgan involvment
Inc BUN (25.5mmol/L)
Inc serum creatinine (2.8 mg/dL,
321.0 mmol/L) on 9/3, 9/6
Hyponatriemia (132.7 mmol/L) on
9/3
Differential Diagnosis:
CONGESTIVE HEART FAILURE
RULE IN RULE OUT
Hypertension On presentation
Left atrial dilation No dilated neck veins
Left atrial hemiblock No peripheral edema
Left ventricular remodeling No murmur
Mitral and aortic stenosis Adynamic precordium
Inc serum creatinine (2.8 mg/dL, PMI in normal anatomic location
321.0umol/L) 9/3, 9/6
Slight tachycardia with normal
rhythm on presentation
Crackles on both lung fields on day 4
Hepatomegaly
Differential Diagnosis:
LIVER CIRRHOSIS
RULE IN RULE OUT
Female No dilated neck vein on presentation
Alcoholism Hypernatremia (147mmol/L) on 9/6
RUQ Pain Anicteric sclerae on presentation
Hepatomegaly
Anemia
Thrombocytopenia (101, 109 x 10 3/l)
on 9/6, 9/7
Prolonged prothrombin time (21.0sec)
on 9/4
High AST (171 U/l) on 9/4
High ALT (53 U/l) on 9/4
Edema on lower extremities on day 4
Jaundice on day 4
RISK
HYPERTENSI
FACTORS:
ON
75 y/o
Ventricular
FEMALE
remodelling
ALCOHOL

Pulmonary Pooling of Decrease


hypertension blood cardiac output

Chronic
Pulmonary passive Decrease
RAAS
edema congestion renal
perfusion
LIVER FAILURE HEART
RENAL
FAILURE
FAILURE

DEATH
DIAGNOSIS:
CHRONIC KIDNEY DISEASE
defined as abnormalities of kidney structure or function,
present for > 3 months, with implications for health
classified based on cause, GFR category, and albuminuria
category (CGA)

Source: KDIGO 2012 Chronic Kidney Disease Guidelines


CKD: DEFINITION
Multiple etiologies
Diminished number and function of nephrons
Leads to End Stage Renal Dse (ESRD)
Irreversible
CKD: RISK FACTORS

Non-modifiable Risk Factor


Age >60 y/o due to faster rate of GFR decline
Gender Males are associated with more rapid GFR
decline
Race African-Americans and Hispanic-Americans have
faster GFR decline
Genetics Diabetic and non-diabetic nephropathies and
PKD patients with genotype PKD1
Loss of Renal mass (NOT SURE ABOUT THIS??)
CKD: RISK FACTORS

Modifiable Risk Factor


Hypertension
Proteinuria associated with faster rate of progression
Metabolic Markers
1) Hyperglycemia
2) Dyslipidemia
3) Obesity
4) Hyperuricemia
D. Others smoking, alcohol, lead exposure, analgesics,
NSAIDS and recreational drugs,
PATHOPHYSIOLOGY
CELLULAR CHANGES
CELLULAR CHANGES
EPIDEMIOLOGY OF CKD
ESRD is the 7th leading cause of death among
Filipinos
1 develops CRF every hour
More the 5,000 are undergoing dialysis
Cost of medical treatment is beyond the reach
of ordinary patients
Shortage of organ donors is a major problem
Source: nkti.gov.ph
EPIDEMIOLOGY OF CKD
9th leading cause of mortality in the Philippines
Ranks 1st on most number of claims for
insurance
Chronic Glomerulonephritis, Hypertensive
Nephrosclerosis and Diabetic Nephropathy are
the 3 most common cause of ESRD
Highly preventable
Source: chd.12.doh.gov.ph/index.php/162-kidney-month
Recommended Equations for Estimation
of GFR
Equation from the modification of diet in
Renal disease study
Estimated GFR (mL/min per 1.73 m2)
= 1.86 x (PCr)-1.154 x (age)-0.203
Multiply by 0.742 for women

=[1.86 x (247) -1.154 x (75) -0.203 ] x 0.742


= 17.6 mL/min per 1.73 m2
Recommended Equations for Estimation
of GFR
Cockcroft Gault equation
Estimated creatinine clearance (mL/min)

(140 age) x body weight (kg)


72 x PCr (mg/dL)
Classification of Chronic Kidney Disease
Source: Harrisons Principle of Internal Medicine 18th ed
Table 280-1

Stage Description GFR, mL/min per 1.73m2


0 With CKD risk factors >90
1 Kidney damage with normal or 90
increased GFR

2 Kidney damage with mildly 60-89


decreased GFR

3 Moderately decreased GFR 30-59

4 Severely decreased GFR 15-29


5 Renal Failure <15 (or dialysis)