30 yr male with anasarca

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Case presentation:

30 year old male patient- who is a wood cutter . 3rd in birth order .who was married 10 years back and having 2 daughters . 

His wife expired 3 months back due to some cardiac issue .He is worried about his daughters future as his health is detiorating  .He 

 gives  history of jaundice 5years back . He noticed yellowish discoloration of urine and eyes 5 years  back . Later he got tested and was said to have jaundice ,for which patient used herbal medication for 3 days .later it subsided .

One month back patient noticed bilateral pedal edema  along with decreased urine output .Patient went for usual work and while he was washing his feet ,he noticed pedal edema .over a period of 2 days pedal edema progressed till knee .

It was not associated with shortness of breath ,No PND,no palpitations 

No facial puffiness ,no hematuria ,no burning micturition ,no fever episodes ,no vomiting ,no nausea .no frothing of urine .

Patient used to smoke -1 pack of beedi for every 3 days  for 20 years and stopped since he developed pedal edema .

Patient was  an occasional alcoholic but consumed toddy daily almost 2 litres/day  during lock down.

Denovo HTN ,on Nicardia 10 mg twice daily since 1 month ,but patient took antihypertensives for 10 days and stopped 

Non Diabetic ,no history of tuberculosis ,no asthma ,CVA,CAD 

He went to local RMP initially ,then went to nephrologist in Hyd .As patient couldn't afford treatment over there .He came to our hospital .

He was started on Hemodialysis last month . Underwent 5 dailysis .

He was admitted last month

Investigations during that period-

Anemia-due to low erythropoietin

Dilutional Hyponatremia-due to fluid excess as kidneys fail to excrete extra fluid

Hyperkalemia-as potassium excretion is impaired

Hypocalcemia-dimnished vit d formation

Hyperphosphatemia-due to phosphate retention

Low Ca,high PO4 stimulate PTH-Hyperparathyroidism develops with increased bone turnover and osteitis fibrosa cystica

phosphate is a calcium chelator and inhibits formation of calcium hydroxyapatite in bones (which gives strength to bones).

DAY 1

Patient had sudden onset of shortness of breath today morning with streaky hemoptysis and epixstasis .Profuse sweating + 

Patient was conscious 

His spo2 was 35 at room air , immediately CPAP was connected and later SPo2 improved to 95 % with FIo2 -100% 

His BP-150/100 mmHg 

Due to 

1. volume expansion

2. Nephron loss- low gfr-raas(+)-renin-angiotensin

Vasoconstriction-raised bp

PR-100/min 

RR-40 /min 

As there is metabolic acidosis lungs try to compensate to remove excess acid (CO2) by increasing resp rate

RS- left infraxillary coarse crepetations + 

CVS- S1 ,S2 heard no murmurs 

He was given lasix 80 mg .

Underwent DIALYSIS

On general examination : 

Pallor + 

Bilateral grade 2 pitting edema + 

No raised JVP 

Patient initially had 15.2 Hb ,later dropped to 12 after 4 HD 

Serum creat -10 ,urea- 159 

 investigations on day 1

cbp-

RFT-

LFT-

Abg-

Xray 

Input and output 

I-650ml,O-500ml

DAY 2-

On examination -

Temp-100.2F

RR : 35 cpm

Bp : 160/90 mm hg

Pr : 107 bpm regular

Cvs : s1 s2 heard no murmurs

Rs : bae + fine crepts present in rt and left isa iaa ima and wheeze present in rt ima

P/a :soft non tender

Assesment : ?COVID

Investigations on day2-

abg-

CUE-

CXR-

Day 3 CXR-

Day4-

C/o sob 

Bp-160/100mmhg

Pr-90bpm

CVS-S1S2 heard

Rs-BAE present,coarse crepts present in rt ISA,IAA,left ISA,IAA

P/A-soft, non tender

Grbs-120mg/dl

DIAGNOSIS:

?ARDS with community acquired pneumonia (?viral)

 CKD on MHD with

Anemia - secondary to Blood loss /Chronic kidney Disease ? 

? glomerulonephritis

? PULMONARY-RENAL SYNDROME

HTN + ,chronic smoker +

TREATMENT-

1.fluid restriction <1.5 L/day and salt intake <2 gm/day(as there will be dilutional hyponatremia which responds well to water restriction)

2.T.LASIX 40 MG BD

3.T.NICARDIA 10 mg BD

4.inj.Fe 10 in 100 ml NS slowly over 1/2 hr after test dose

5.T.NODOSIS 550 mg BD

6.T. alpha D3 0.25 MCG/OD

7.T.SHELCAL 500 mg OD

To increase calcium and decrease PTH-which reduces bone turnover and increase strength of bones.

#Tab.sevelamer is preferred over ca and vitd3 which is a po4 binder

#k bind sachet-ca+sodium polystyrine sulphonate

8.T.OROFER XT OD

9.inj.PIPTAZ 4.5 gm iv stat followed by 2.25 gm qid

10.inj.PANTOP 40 mg iv bd

11.inj.TRENEXA 500 mg iv bd

intermittent Bipap if spo2 <80%