General Medicine July 2021 Bimonthly blended assessment
Question 1
Competency tested for Peer to peer review and assessment :
Question 2:
Question 3:
Question 4:
Chronic kidney disease (CKD)—or chronic renal failure (CRF), as it was historically termed—is a term that encompasses all degrees of decreased kidney function, from damaged–at risk through mild, moderate, and severe chronic kidney failure.
The guidelines define CKD as either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2 for at least 3 months. Whatever the underlying etiology, once the loss of nephrons and reduction of functional renal mass reaches a certain point, the remaining nephrons begin a process of irreversible sclerosis that leads to a progressive decline in the GFR.
Staging:
Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2)
Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m2)
Stage 3a: Moderate reduction in GFR (45-59 mL/min/1.73 m2)
Stage 3b: Moderate reduction in GFR (30-44 mL/min/1.73 m2)
Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m2)
Stage 5: Kidney failure (GFR < 15 mL/min/1.73 m2 or dialysis).
Diagnosis:
By itself, measurement of GFR may not be sufficient for identifying stage 1 and stage 2 CKD, because in those patients the GFR may in fact be normal or borderline normal. In such cases, the presence of one or more of the following markers of kidney damage can establish the diagnosis.
Albuminuria (albumin excretion > 30 mg/24 hr or albumin:creatinine ratio > 30 mg/g [> 3 mg/mmol])
Urine sediment abnormalities
Electrolyte and other abnormalities due to tubular disorders
Histologic abnormalities
Structural abnormalities detected by imaging
History of kidney transplantation in such cases
Signs and symptoms:
Signs of alterations in the way the kidneys are handling salt and water in stage 5 include the following:
Peripheral edema
Pulmonary edema
Hypertension.
Laboratory studies used in the diagnosis of CKD can include the following
Complete blood count (CBC)
Basic metabolic panel
Urinalysis
Serum albumin levels: Patients may have hypoalbuminemia due to malnutrition, urinary protein loss, or chronic inflammation
Lipid profile: Patients with CKD have an increased risk of cardiovascular disease.
Imaging studies also done accordingly.
Mangement:
Delaying or halting the progression of CKD: Treatment of the underlying condition, if possible, is indicated
Diagnosing and treating the pathologic manifestations of CKD
Timely planning for long-term renal replacement therapy
Acute kidney injury (AKI)—or acute renal failure (ARF), This condition is usually marked by a rise in serum creatinine concentration or by azotemia (a rise in blood urea nitrogen [BUN] concentration).[1]However, immediately after a kidney injury, BUN or creatinine levels may be normal, and the only sign of a kidney injury may be decreased urine production.
A rise in the creatinine level can result from medications (eg, cimetidine, trimethoprim) that inhibit the kidney’s tubular secretion, while a rise in the BUN level can also occur without renal injury, resulting instead from such sources as gastrointestinal (GI) or mucosal bleeding, steroid use, or protein loading. Therefore, a careful inventory must be taken before concluding that a kidney injury is present.
AKI may be classified into 3 general categories, as follows:
Prerenal - As an adaptive response to severe volume depletion and hypotension, with structurally intact nephrons
Intrinsic - In response to cytotoxic, ischemic, or inflammatory insults to the kidney, with structural and functional damage
Postrenal - From obstruction to the passage of urine.
Diagnosis:
The following tests can aid in the diagnosis and assessment of AKI:
Kidney function studies: Increased levels of blood urea nitrogen (BUN) and creatinine are the hallmarks of renal failure; the ratio of BUN to creatinine can exceed 20:1 in conditions that favor the enhanced reabsorption of urea, such as volume contraction (this suggests prerenal AKI)
Complete blood count (can indicate infection; acute blood loss or chronic anemia; thrombotic microangiopathy)
Peripheral smear (eg, schistocytes such as hemolytic-uremic syndrome and thrombotic thrombocytopenic purpura)
Serologic tests: These may show evidence of conditions associated with AKI, such as in lupus nephritis, ANCA vasculitis or anti-GBM disease or syndrome
Complement testing: Pattern may indicate AKI related to endocartis or various glomerulonephritidites
Fractional excretion of sodium and urea in the setting of oliguria
Bladder pressure: Patients with a bladder pressure above 25 mm Hg should be suspected of having AKI caused by abdominal compartment syndrome
Ultrasonography: Renal ultrasonography is useful for evaluating existing renal disease and obstruction of the urinary collecting system
Aortorenal angiography : Can be helpful in establishing the diagnosis of renal vascular diseases, such as renal artery stenosis, renal atheroembolic disease, atherosclerosis with aortorenal occlusion, and certain cases of necrotizing vasculitis (eg, polyarteritis nodosa)
Renal biopsy: Can be useful in identifying intrarenal causes of AKI and directing targeted therapy
Treatment:
Maintenance of volume homeostasis and correction of biochemical abnormalities remain the primary goals of treatment and may include the following measures:
Correction of fluid overload with furosemide
Correction of severe acidosis with bicarbonate administration, which can be important as a bridge to dialysis
Correction of hyperkalemia
Correction of hematologic abnormalities (eg, anemia, uremic platelet dysfunction) with measures such as transfusions and administration of desmopressin or estrogens
Question 5:
Testing scholarship competency in logging reflective observations on your concrete experiences of this last month :
Experiencing the assessment in the form of elogs and exposing to clinical aspects and going through the problems of patients and seeing efforts put by doctors present there solving the case,I realized to make more effort in understanding the case.The importance of inculcating the knowledge of books in practice especially the history taking ,general examination and their importance in pointing towards the source of the disease in patient and conserving valuable resources.And I have to say that I had better understanding about the elogs and this online communication and learning process than last month.And the Telemedical learning experience,eventhough it was found helpful in community at present situations of pandemic ,I felt it lack some psychological aspects in doctor patient interaction.The most interesting and enthusiastic aspect brought to me by this elogs is going through different journals where fascinating and unique ideas of individual's I came across and their contributions in bringing a better outcome in various fields of Medicine.
Thank you
Soumya Menda
Roll no. 80.
