Renal Case Study

Faith, Nelson, and Helena Physiology 142 Lab Renal Case Study April 4, 2017 Renal Case Study

M.K. 51 year old African American male presents to Emergency Department in the afternoon. Part A: Questions: 1. What are normal vital signs? What are M.K.’s vital signs? What could be some causes of the abnormal vital signs? a. Normal Vital Signs: Blood pressure should be between 90/60 mm/Hg to 120/80 mm/Hg, breathing between 12 to 18 breaths per minute, a pulse between 60 to 100 beats per minute, and a temperature between 97.8°F to 99.1°F (average of 98.6°F). b. M.K. Vital Signs: A high blood pressure at 168/92 mm/Hg, carries a breath rate of 21 per minute, a high pulse of 112 beats per minute, and a relatively high body temperature of 100.2 °F. c. Some systemic inflammation from a possible allergic reaction to the I.V. dye can be the cause for a higher body temperature. The possibility that this patient has kidney failure can also explain the high blood pressure, having an elevated heart- rate, and experiencing shortness of breath. Part B: Questions: 1. What are normal lab values of labs listed? What does M.K.’s lab show? Patients Value Normal Range Na 146 135-145 WBC 14.3 5-10 Cl 104 96-106 BUN 28 8-21 Hgb 14 13.5-17.5 Hct 39 38.8-50 Cr 1.3 0.6-1.2 Plt 312 150-450 K 5.1 3.5-5 Glu 212 65-110 CO2 21 23-29 PH 6.8 7 (Neutral) 2. What would be some causes of his abnormal values? Are the values expected based on his chief complaint? a. A low value of CO2 combined with a low PH can cause metabolic acidosis. This

Questions: 1. What is the difference between subjective and objective data? a. Subjective data refers to information from a patient's point of view, such as pain levels, feelings and perceptions. b. Objective data refers to measurable aspects of a patient's condition found through diagnostics, tests and examination. 2. What do the new lab values show? What could be some reasons why? a. Old Patients Value New Patients Value Na 146 149 WBC 14.3 15.0 Cl 104 108 BUN 28 56 Hgb 14 22 Hct 39 42 Cr 1.3 4.9 Plt 312 86 K 5.1 6.1 Glu 212 336 CO2 21 34 b. For the majority of the patient’s lab values they increased, except for his Plt value, it decreased drastically. He started to double up on his medication of metformin. Went from 500mg to 1000mg. 3. What is GFR? What are the normal values? What is it useful in diagnosing? a. GFR is glomerular filtration rate. It’s a test to check how well the kidneys are working b. Normal values are 90 to 120 mL/min /1.73 m 2 c. Yes, GFR below 15 shows that the patient has kidney failure. 4. What could be causing his skin problems? a. He could potentially be of the end stage of renal failure. Kidney failure may make changes in the sweat glands and oil glands, which causes the skin to dry out. 5. What is kidney failure? What is the difference between acute and chronic? What risk factors does M.K have? Which do you think M.K has and why? a. Kidney failure is a condition where the kidneys lose the ability remove waste and balance fluids. b. Chronic kidney failure is a condition where the kidneys’ ability to filter waste from the bloodstream becomes worse over time, generally over a period of years.

Acute kidney failure is the sudden and dramatic loss of kidney function. c. The risks factors are diabetes, high blood pressure, heart disease, and a family history of kidney failure. d. We think M.K has the diabetes and the high blood pressure, which are both signs of chronic kidney failure, because diabetes will often lead to chronic kidney failure, and high blood pressure is a common symptom of diabetes. 6. What could be going on? What could have caused it? How do you treat it? a. A lot of things could be going on such as doubling his metformin dosage. b. Metformin may not have been efficient or side-effects from the metformin may be a cause. c. Lower metformin intake, find alternative medication( such as insulin), or seek other ways (such as changing diet). Part E There are many reliable websites on the internet for patients to go to research their diagnoses. These include the AHA, or NIH. 1. What websites would you recommend M.K. to go to learn about kidney failure? There are numerous websites available such as mayoclinic.com, webmd.com, and medlineplus.gov which would explain his symptoms. 2. Based on the websites what are some expected symptoms that M.K. could experience in relation to Kidney Failure and A. Sleep - Waste buildup in the body can cause an overall uncomfortable, sick and tired feeling, leaving one unable to sleep. Also, RLS can be a factor as a side effect of his medication. (https://www.davita.com/kidney-disease/overview/living-with-ckd/sleep- issues-and-chronic-kidney-disease/e/4896) B. Appetite - Loss of appetite may be due to feeling overall sick and due to abdominal pain. The metallic taste the patient is experiencing may also contribute to lack of appetite. (https://www.davita.com/kidney-disease/kidney-disease/symptoms-and-diagnosis/stage- 4-of-chronic-kidney-disease-(ckd)/e/686) C. Joints - Protein buildup due to kidney dysfunction can cause deposits to form in the tissues and joints, causing stiffness and joint pain (http://www.medicinenet.com/kidney_failure/page7.htm) D. Mental Health - Patient may feel sick and tired all the time, leading to possible depression. On top of this, the inability of the kidneys to process medications may also lead to insufficient interactions of psychiactric medications the patient may already be on (http://www.psychiatrictimes.com/articles/psychiatric-issues-patients-renal-disease) Part F Physiology Questions a. What is the ECF and the ICF? i. ECF (extracellular fluid) is the fluid outside the cells. ICF (intracellular fluid) is the fluid enclosed in the cells. b. Where does reabsorption occur in the nephron? i. Proximal Convoluted Tubule, Loop of Henle, Distal Convoluted Tubule

M.K. was prescribed 500mg daily, but admitted to doubling on his even dosage since he went to urgent care for his stomach problems. Too much Metformin can cause lactic acidosis, a form of metabolic acidosis caused by the body not being able to adequately get rid of lactic acid from the blood. With a buildup of lactic acid the individual can experience nausea, vomiting, abdominal pain, and mental status changes can occur. M.K. has experienced these symptoms and more recently. Kidney or liver diseases are medical conditions that usually cause lactic acidosis. Glucose From what we know from the case study, the patient takes metformin, and therefore has type-2 diabetes. Type-2 diabetes renders the body’s immune system incapable of properly using insulin that it produces to help control glucose levels in the blood, which would cause the patient’s blood sugar levels to increase too high; a condition known as hyperglycemia. Under this condition, the extra glucose in the blood needs to be filtered out by the kidneys. Additionally, having hyperglycemia may also explain his symptoms of fatigue and shortness of breath. The purpose and function of the kidneys is filtration, to separate the waste products and useful proteins in the blood. But because of the high blood sugar in this patient, his kidneys would have to perform extra work to filter out the glucose, therefore pump extra blood. If this trend continues in the long-term, the kidneys get can be overworked and they start to lose efficiency, which can potentially lead to chronic kidney failure. How the patient has such high blood sugar from diabetes is through his body’s inability to use insulin produced in proper order to control the glucose from forming hyperglycemia. As mentioned earlier, to counter hyperglycemia, this patient takes metformin. The metformin would essentially re-sensitize the muscle cells to insulin and lower the blood glucose. However with the extra intake that was taken without his prescriber’s supervision, the patient would experience

metabolic acidosis, when lactate increase as glucose levels decrease. Ketoacidosis Another form of metabolic acidosis that the patient is experiencing is diabetic ketoacidosis. Ketoacidosis occurs because the body does not have enough glucose to process and cannot produce enough insulin. Instead of glucose, the body starts to process lipids and proteins, creating ketones which build up in the blood stream. Because the kidney is not functioning properly, it cannot purge these ketones from the body and the body starts to poison itself. As we see in the lab results, the BUN (blood urea nitrogen) levels are high, meaning the kidneys are not filtering urea from the blood and the ketone levels are elevated as well. Both of these results show that a kidney dysfunction or failure is occurring. Conclusion As stated in the introduction, the patient is experiencing systemic effects from the misuse of metformin for type II diabetes which lead to metabolic acidosis and diabetic ketoacidosis. The use of metformin on normal levels can lead to lactic acidosis, and because the patient is noncompliant and taking double the dosage, he is essentially poisoning himself. Along with this, the patient is experiencing metabolic and ketoacidosis. Essentially the patient is not producing enough insulin because he is not processing glucose. Because the patient is not processing glucose, the body instead tries to use proteins and lipids as fuel. This would explain the signs of the dry skin, bleeding gums, and stomach pain. The use of these waste products as fuels essentially poisons the kidneys, causing subsequent kidney dysfunction and failure.

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