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  1. khaled
  2. General Nephrology Questions
  3. Sunday, 08 April 2012
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Dear experts , I 'm asking about a patient , 57 years old . She is diagnosed as ESRD , CKD stage 5 , GFR = 13 ML/M , after long standing diabetes 40 years ago , hypertension 2 years ago. now her last serum creatinine = 3.4 mg/dl , blood urea = 205 mg/dl , k = 4.4 meq/l the patient is hypotensive ( on antihypertensives) , with no lower limb edema or lung crackles. The patient has urinary catheter giving 3000 liters/day while her input is the same ( as mentioned by her family ) her weight is 57 kg . the question is should we start dialysis on these parameters or should we treat her dehydration first as a cause of her hyperuremia? thank you .  
Responses (11)
Accepted Answer Pending Moderation
Hi Kaled,

It is always the correct answer to correct volume contraction if present. And indeed, it may improve renal function, sufficient to delay dialysis further. Missing from your post would be her symptoms of uremia and level of plasma bicarbonate as both would contribute to indications to begin dialysis.

Jordan

Dr. Jordan Weinstein, MD
Division of Nephrology, St. Michael's Hospital
Assistant Professor of Medicine
University of Toronto
  1. more than a month ago
  2. General Nephrology Questions
  3. # 1
Accepted Answer Pending Moderation
Dear Dr.jordan
Thank you Sir for your reply
actually the patient has no symptoms of uremia
her bicarbonate is 20
So when should we start dialysis for this patient?
  1. more than a month ago
  2. General Nephrology Questions
  3. # 2
Accepted Answer Pending Moderation
my question is : we can start dialysis for her after volume correction for her low GFR ? or should we wait for her serum creatinine to elevate more?
  1. more than a month ago
  2. General Nephrology Questions
  3. # 3
Accepted Answer Pending Moderation
Hello,

GFR was estimated at 15 cc/min (http://ukidney.com/egfr-calculator - assuming patient is caucasian). So, at this GFR, one would certainly consider renal replacement therapy. In the absence of an absolute indication, some might wait. If however the patient develops symptoms of uremia, or if at any point an absolute indication develops, then one would start renal replacement. Currently, it is a judgement call. I would see if there is any recovery of renal function with volume expansion and if nothing reversible exists, it is certainly time to at least consider starting.
  1. more than a month ago
  2. General Nephrology Questions
  3. # 4
Accepted Answer Pending Moderation
Yes, I should emphasize that as well. Her amtihypertensives including ACE or ARB should be reconsidered or stopped. The role of these drugs at this point is questionable unless (and perhaps even if) the patient is highly proteinuric.

Jordan
  1. more than a month ago
  2. General Nephrology Questions
  3. # 5
Accepted Answer Pending Moderation
Dear Dr.Jordan
Dear alsayed

Actually the patient is referred from another nephrologist taking ACEI in the form of zestril 20 mg once daily . She was referred with a creatinine 4.4 mg/dl , which declined after a week to 3.4 mg/dl while taking her ACEI for blood pressure control . but with a rise in urea as I mentioned before up to 205 mg/dl .
so should we stop her ACEI despite no rise in creatinine level ?
  1. more than a month ago
  2. General Nephrology Questions
  3. # 6
Accepted Answer Pending Moderation
the patient is on beta blocker , frusomide , and dihydropyridine CCB , and ACEI . I suggest to stop her frusomide as she was clinically dehydrated and for the increased urea creatinine ratio . i advised to increase her fluid intake while monitoring her urine out put .
  1. more than a month ago
  2. General Nephrology Questions
  3. # 7
Accepted Answer Pending Moderation
I agree for your action at this step,but Did you prepared your patient for renal replacement therapy?
  1. more than a month ago
  2. General Nephrology Questions
  3. # 8
Accepted Answer Pending Moderation
also if proteinuria is not significant ,you cant try holding ACE as said by Dr.Jordan
  1. more than a month ago
  2. General Nephrology Questions
  3. # 9
Accepted Answer Pending Moderation
[b]Dear Dr.Jordan
Dear alsayed
for this patient i tried to correct her volume depletion as i mentioned . now the patient appears well , her BP 150 / 90 . her creatinie declined to 2.8 mg% . and her urea to 150 mg%.
there is mild edema in lower limbs now . but no signs of volume overload . i asked the patient to have regular visits for the clinic with regular labs . what do you think ?
  1. more than a month ago
  2. General Nephrology Questions
  3. # 10
Accepted Answer Pending Moderation
regarding renal replacement therapy , the patient has left brachiocephalic fistula ready for use
  1. more than a month ago
  2. General Nephrology Questions
  3. # 11
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