Dr Satish,God evening, This is a very clear cut case of Diabetic Kidney Disease leading on to CKD,CRF. The basic pitfall is the pt is on once a day regular insulin which is not the recommended schedule of insulin, may be because of uncontrolled DM & HTN, he developed DKD,CKD,CRF. Order FPG,2hr PG,HbA1c, rpt RFT, USG to r/ o RPD, renal paranchymal disease, ECG,2D Echo to r/ oCCF, Serum Electrolytes. Please avoid Frusemide, as it further leads to electrolyte imbalance.,take the opinion of Cardiologist & Neontologist, Coming to the treatment part meticulously control DM with rapid acting insulin analogues three times a day, try to avoid long acting insulin analogues, unless otherwise the DMis not controlled, Hypertension should be treated with Olmesartan 40 mg once daily,Cilnedipine 10 mg once daily, Tab Torsemide 100 mg once a day, monitor serum Electrolytes, CPG,BP,RFT on regular basis, continue add on therapies like vit D3, Calcitriol,Calcium based on the readings, treat Anaemia by transfusing packed cells, no need to worry as long as there is required urine output, still take a cross consultation od Cardiologist, Neurologist, finally refer the pt to Ophthalmologist to r/o Retinopathy. Keep me posted, stay connected
Disclose the dose & brand of insulin. Though it is a case of Nephropathy landing on CRF but still urine output will say whether acute on chronic. In such case there is recirculation of insulin for which blood sugar remains low even with small dose of insulin. Better to switch to analogue FIAsp for lesser chances of hypoglycemia. Diuretics like Torsemide can be given but monitoring of electrolytes is essential. Also TFT & Sr Calcium, Sr Phosphorus, Sr Magnesium should be done. Funduscopy should be done to assess the level of Retinopathy as it is associated with Nephropathy.
Dr Ravindra tell me one diuretic that does not cause dyselectrolytemia, I said when compared to frusemide the incidence is less with torsemide, that is the reason I repeatedly said monitor Electrolytes. Even 12.5 mg of Hydrochlorothiazide aldo caused hypokalemia in one of my patients.
Most probably patient is landing up in diabetic nephropathy kindly do USG and 24 hour urinary albumin levels and urine R/M
case of diabetic nephropathy - consult a nephrologist
how long diabetic, does pt have diabetic retinopathy
Diabetic Nephropathy. Regular RFTs.Keep watch on the creatinine report. Keep or ready for RRT. Plan for AV fistula. Renal diet. Decrease high potassium and high sodium content diet. Decrease salt and water intake. Daily weight measurement and intake output balance of liquid intake. Start ARB with close watch on serum potassium level.start frusemide high dose as per creatinine level instead of spironolactone.Check for acidosis.
DM NEPHROPATHY CKD HTN RX HTN IF ON ACE / ARB = STOP THOSE RX CILNIDIPINE CTD CLONIDINE BETABLOCKER MAY BE CHOSEN SALT RESTN. 3 g / day FLUID = 1 L / DAY PROTEIN RESTN. 30 g / DAY DIURETICS FRUSEMIDE/TORASEMIDE CALCIUM SUPPLEMENT NODOSIS 500 mg BD GLYCEMIC CONTROL HYPERTENSION CONTROL BLOOD K + Ca ++ PO 3/4 PARATHORMONE eGFR
a case of acute on chronic diabetic kidney failure with fluids over load. give lasix 60 mg tds. monitoring uop and do electrolyte, calcium, lft, cbc, usg abdomen, pelvis and also ecg echo for r/ o cardiac failure. omite the telmikind tab and give plain amlodipine
It is due to Congestive cardiac failure And tablet Lasix once a day for two days wil help but under observation and due to lasix creatine levels might go up a little but will come down after the symptoms subsides
Cases that would interest you
- Login to View the image
37yf VH done 3yr back P3L3 c/o weakness, loss of appetite, hyperacidity vth regurgitation, low backache..BP-140/100.no H/O DM.HTN.thyroid.scd.her hb- 6.6gm, urea-88,creat-3 .plz help further ix n mgtDr. Santosh Sahu2 Likes32 Answers
- Login to View the image
young female with white nails Differential DiagnosisDr. Neki Yadav2 Likes26 Answers
- Login to View the image
a 60 yrs old male patient. brought to the hospital with complaints of SOB since 2 days bp.180/100mmhg bl.urea63mg/DL.sr.creatinine.10.1mg/DL...RBs 180 mg/DL....wbc...17,000...ESR...100..hb%-6.5gmsDr. Upender Singh1 Like21 Answers
- Login to View the image
70 yrs Male...known htn...and dm....on regular rx...on telmikind 40 h....and gemer 2mg.....last....5 days...c.o...mild dysurea..two vomiting episode.......no swelling on lower limb...otherwise no complains......BP.. 110.70...bsl...pp...248 mgdl......so CBC...kft...done...now.....no complains only..mild dysurea....pt economically poor....so....how to manage..this case....which....antihypertensive....is necessary in this...case...pls...suggest managment. pls....pt not able to do...other blood test.@Dr. Shivraj AgarwalDr. Chand Sharwale2 Likes15 Answers
- Login to View the image
*Restless leg syndrome (RLS* ☝ *Today about*☝ Definition Restless leg syndrome (RLS) or Willis-Ekbom disease(WED) is a common cause of painful legs. The leg pain of restless leg syndrome typically eases with motion of the legs and becomes more noticeable at rest. Restless leg syndrome also features worsening of symptoms and leg pain during the early evening or later at night. Restless leg syndrome Restless leg syndrome is often abbreviated RLS; it has also been termed shaking leg syndrome. Night time involuntary jerking of the legs during sleep is also known as periodic leg/limb movement disorder. History The first known medical description of RLS was by Sir Thomas Willis in 1672. Willis emphasized the sleep disruption and limb movements experienced by people with RLS. Initially published in Latin (De Anima Brutorum, 1672) but later translated to English (The London Practice of Physick, 1685), The term “fidgets in the legs” has also been used as early as the early nineteenth century. Subsequently, other descriptions of RLS were published, including those by Francois Boissier de Sauvages (1763), Magnus Huss (1849), Theodur Wittmaack (1861), George Miller Beard (1880), Georges Gilles de la Tourette (1898), Hermann Oppenheim (1923) and Frederick Gerard Allison (1943). However, it was not until almost three centuries after Willis, in 1945, that Karl-Axel Ekbom (1907–1977) provided a detailed and comprehensive report of this condition in his doctoral thesis, Restless legs: clinical study of hitherto overlooked disease. Ekbom coined the term “restless legs” and continued work on this disorder throughout his career. He described the essential diagnostic symptoms, differential diagnosis from other conditions, prevalence, relation to anemia, and common occurrence during pregnancy. Epidemiology Except perhaps in Asian populations, RLS is a common disorder, occurring in about 10% of the population. The age-adjusted prevalence of RLS determined by telephone interviews in a random population of 1803 adults in Kentucky was 10%. A Canadian survey of 2019 adults estimated the prevalence of RLS symptoms at 17% for women and 13% for men. A population-based survey in West Pomerania, Germany, of 4107 subjects found an overall 10.6% prevalence. Using standardized questions in face-to-face interviews, Rothdach et al. reported an overall prevalence of 9.8% in 369 participants ages 65-83 years in Augsburg, Germany. In a study from Japan, 4612 participants living in urban residential areas were assessed for a single symptom of RLS by a self-administered questionnaire of the following two items: (1) Have you ever been told you jerk your legs or kick sometimes and (2) have you ever experienced sleep disturbance due to a creeping sensation or hot feeling in your legs? The prevalence of RLS ranged from 3% in women ages 20-29 years to 7% in women ages 50-59 years and correlated with age. In contrast to the first three studies, RLS had a higher prevalence in men than women, with the difference reaching significance in those 40-49 years old; in men there was no positive correlation with age. Face-to-face interviews of 157 consecutive individuals ages 55 years and older participating in a health screening program and 1000 consecutive individuals ages 21 years and older from a primary health care center in Singapore yielded much lower prevalence data. Using IRLSSG criteria, the prevalence of RLS in this predominantly Asian population was 0.6% in the older (1 male) and 0.1% (1 female) in the younger cohorts. In the Kentucky and Singapore studies, there was no gender difference; however, in the two German studies, the prevalence was higher in women and in the Japanese study it was higher in men. The Canadian study reported a significantly higher occurrence of bedtime leg restlessness in women. Types Restless legs syndrome (RLS) can be either primary or secondary, and the causes vary. Primary RLS is a neurological disorder. Although the majority of people with RLS begin to experience symptoms in their middle years, some may have signs of the problem in childhood. Their symptoms may slowly progress for years before becoming a regular occurrence. Secondary RLS tends to be more severe than the primary type and stems from another underlying condition, including the following: Anemia or low blood-iron levels Folate deficiency Nerve damage due to diabetes or other conditions Kidney disease or dialysis Attention deficit disorder (ADD) Attention deficit/hyperactivity disorder (ADHD) Pregnancy Rheumatoid arthritis Parkinson’s disease Risk factors RLS/WED can develop at any age, even during childhood. The disorder is more common with increasing age and more common in women than in men. Restless legs syndrome usually isn’t related to a serious underlying medical problem. However, RLS/WED sometimes accompanies other conditions, such as: Peripheral neuropathy: This damage to the nerves in your hands and feet is sometimes due to chronic diseases such as diabetes and alcoholism. Iron deficiency: Even without anemia, iron deficiency can cause or worsen RLS/WED. If you have a history of bleeding from your stomach or bowels, experience heavy menstrual periods or repeatedly donate blood, you may have iron deficiency. Kidney failure: If you have kidney failure, you may also have iron deficiency, often with anemia. When kidneys don’t function properly, iron stores in your blood can decrease. This, with other changes in body chemistry, may cause or worsen RLS/WED. Causes The cause of restless leg syndrome is unknown in most people. However, restless leg syndrome has been associated with Pregnancy, Obesity, Smoking, Iron deficiency and anemia, Nerve disease, Polyneuropathy (which can be associated with hypothyroidism, heavy metal toxicity, toxins, and many other conditions), Other hormone diseases such as diabetes, and Kidney failure (which can be associated with vitamin and mineral deficiency). Some drugs and medications have been associated with restless leg syndrome including: Caffeine, Alcohol, H2-histamine blockers (such as ranitidine [Zantac] and cimetidine [Tagamet]), and certain antidepressants (such as amitriptyline [Elavil, Endep]). Occasionally, restless leg syndrome run in families. Recent studies have shown that restless leg syndrome appears to become more common as a person ages. Also, poor venous circulation of the legs (such as with varicose veins) can cause restless leg syndrome. Symptoms The International Restless Legs Syndrome Study Group described the following symptoms of restless legs syndrome (RLS): Strange itching, tingling, or “crawling” sensations occurring deep within the legs; these sensations may also occur in the arms. A compelling urge to move the limbs to relieve these sensations Restlessness — floor pacing, tossing and turning in bed, rubbing the legs Symptoms may occur only with lying down or sitting. Sometimes, persistent symptoms worsen while lying down or sitting and improve with activity. In very severe cases, the symptoms may not improve with activity. Other symptoms of RLS include the following: Sleep disturbances and daytime sleepiness Involuntary, repetitive, periodic, jerking limb movements that occur either in sleep or while awake and at rest; these movements are called periodic leg movements of sleep or periodic limb movement disorder. Up to 90% of people with RLS also have this condition. In some people with RLS, the symptoms do not occur every night but come and go. These people may go weeks or months without symptoms (remission) before the symptoms return again. Complications Restless legs syndrome rarely results in any serious consequences. However, in some cases severe and persistent symptoms can cause considerable mental distress, chronic insomnia, and daytime sleepiness. In addition, since restless legs syndrome (RLS) is worse when resting, people with severe RLS may avoid daily activities that involve long periods of sitting, such as going to movies or traveling long distances. Diagnosis and test There’s no single test for diagnosing restless legs syndrome. A diagnosis will be based on your symptoms, your medical and family history, a physical examination, and your test results. Your GP should be able to diagnose restless legs syndrome, but they may refer you to a neurologist if there’s any uncertainty. There are four main criteria your GP or specialist will look for to confirm a diagnosis. These are: an overwhelming urge to move your legs, usually with an uncomfortable sensation such as itching or tingling your symptoms occur or get worse when you’re resting or inactive your symptoms are relieved by moving your legs or rubbing them your symptoms are worse during the evening or at night Blood tests Your GP may refer you for blood tests to confirm or rule out possible underlying causes of restless legs syndrome. For example, you may have blood tests to rule out conditions such as anaemia, diabetes and kidney function problems. It’s particularly important to find out the levels of iron in your blood because low iron levels can sometimes cause secondary restless legs syndrome. Low iron levels can be treated with iron tablets. Sleep tests If you have restless legs syndrome and your sleep is being severely disrupted, sleep tests such as a suggested immobilisation test may be recommended. The test involves lying on a bed for a set period of time without moving your legs while any involuntary leg movements are monitored. Occasionally, polysomnography may be recommended. This is a test that measures your breathing rate, brain waves and heartbeat throughout the course of a night. The results will confirm whether you have periodic limb movements in sleep (PLMS). Treatment and medications Treatment for RLS is targeted at easing symptoms. In people with mild to moderate restless legs syndrome, lifestyle changes, such as beginning a regular exercise program, establishing regular sleep patterns, and eliminating or decreasing the use of caffeine, alcohol, and tobacco, may be helpful. Treatment of an RLS-associated condition also may provide relief of symptoms. Other non-drug RLS treatments may include: Leg massages Hot baths or heating pads or ice packs applied to the legs Good sleep habits A vibrating pad called Relaxis Medications may be helpful as RLS treatments, but the same drugs are not helpful for everyone. In fact, a drug that relieves symptoms in one person may worsen them in another. In other cases, a drug that works for a while may lose its effectiveness over time. Drugs used to treat RLS include: Dopaminergic drugs, which act on the neurotransmitter dopamine in the brain. Mirapex, Neupro, and Requip are FDA-approved for treatment of moderate to severe RLS. Others, such as levodopa, may also be prescribed. Benzodiazepines, a class of sedative medications, may be used to help with sleep, but they can cause daytime drowsiness. Narcotic pain relievers may be used for severe pain. Anticonvulsants, or antiseizure drugs, such as Tegretol, Lyrica, Neurontin, and Horizant. Although there is no cure for restless legs syndrome, current treatments can help control the condition, decrease symptoms, and improve sleep. Lifestyle and home remedies Making simple lifestyle changes can help alleviate symptoms of RLS/WED. Try baths and massages: Soaking in a warm bath and massaging your legs can relax your muscles. Apply warm or cool packs: Use of heat or cold, or alternating use of the two, may lessen your limb sensations. Try relaxation techniques: such as meditation or yoga. Stress can aggravate RLS/WED. Learn to relax, especially before bedtime. Establish good sleep hygiene: Fatigue tends to worsen symptoms of RLS/WED, so it’s important that you practice good sleep hygiene. Ideally, have a cool, quiet, comfortable sleeping environment; go to bed and rise at the same time daily; and get adequate sleep. Some people with RLS/WED find that going to bed later and rising later in the day helps in getting enough sleep. Exercise: Getting moderate, regular exercise may relieve symptoms of RLS/WED, but overdoing it or working out too late in the day may intensify symptoms. Avoid caffeine: Sometimes cutting back on caffeine may help restless legs. Try to avoid caffeine-containing products, including chocolate and caffeinated beverages, such as coffee, tea and soft drinks, for a few weeks to see if this helps.Dr. Shailendra Kawtikwar9 Likes15 Answers