My father....

My father, 66 year old male, chronic hypertensive , diabetic, has started having severe pedal pitting edema, arm edema, no other complaints. His Bp remains high despite best management around 180-190 systolic and 100-110 diastoloc, He has been on basal plus bolus regimen,insulin glargine 8 IU at night and aspart TDS 10 IU before lunch For hypertension he takes: Clindipine 20 mg BD, telmisartan 40 mg OD metoprolol 50 mg BD, tosemide 20 mg OD Prazosin 5mg HS nodosis forte TDS aspirin 75 mg OD I have got his basic workup done and am attaching here. I have no clue how to proceed further. Please help me streamline his management for this. Please Investigations HB 11 g/dl HBA1C 7 Albumin creat ratio 3428.09 mg/g creat CREAT 4.11 mg/dl UREA 74.83 Calcium 6.8, potassium 2.8 Vit d 52.66, PTH 365 Total protein 6.26 ALP 213, AST 78, ALT 44

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Thanks for tagging me Dr Majaj Ahmad. This is a clear cut case of Type2DM, Uncontrolled hypertension with ESRD(End stage renal disease) , Renal hyperparathyroidism secondary to renal failure, hypocalcemia, anemia,microalbuminuria, hypoproteinemia, dyselecrolytemia, with pitting edema of feet and arms. Rule out Hypothyroidism by ordering TFT and Antitpo antibodies. Order for USG abdomen and pelvis to rule out tumors, Renal parenchyma disease, Nash etc Coming to the treatment, He requires dialysis followed by renal transplantation which is the final treatment at this stage. Hyperparathyroidism is secondary to chronic renal failure which explains hypocalcemia, hyperphosphatemia and elevation of serum alkaline phosphatase. Mild elevation of serum uric acid is not significant. Coming to the blood sugars, his fasting plasma glucose is low, he is getting into unexplained hypoglycemia due to ESRD and hypoglycemia unawareness. So reduce the night dose of insulin by 2 units to prevent this. You didn't give his PPG. Add centrally acting drug like clonidine and add spironolactone 50mg to control his hypertension. Maintain serum electrolytes. If dialysis is done, his blood pressure will automatically comes down. Advice low phosphorous diet. Continue calcium supplements and vitamin D3. Add erythropoietin injection if erythropoietin is low. Add oral iron tablets, vitamin C, and vitamin B12. Avoid animal protein that is mutton, chicken, beef, fish etc. You can give two egg whites daily. Advice plant protein in limited quantities. Restrict salt intake to 1000 to 1200 mg per day to reduce his blood pressure in DKD. Only two fruits can be given apple and papaya. Restrict fluid intake to1 litre per day plus tea, coffee, buttermilk put together half litre per day. As long as his urine output is good, we can wait, if there is oliguria or anuria, then it becomes emergency to undergo dialysis and followed by kidney transplantation. Only leftover final option is hemo or peritoneal dialysis followed by the renal transplantation apart from above said symptomatic treatment.

? CKD .. RENAL FAILURE.. WITH.. DM..& HT.. NEED'S.. STRICT GLYCEMIC CONTROL WITH ANTIDIABETIC MANAGEMENT WITH EXPERTS OPINION.. CVD .. STUDY..WITH..EXPERTS OPINION.. CONTROL OF HT..WITH.. ARBs.. AND.. DIURETICS.. LOW SALT..LOW FAT DIET.. REGULAR EXERCISE..

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