Cases in Kidney and liver disease
1)A 45 year old man presents with jaundice feeling unwell. He is tender in his
abdomen and has a temperature of 39 oC
You check his LFTs and find
Bil 9
Ast 200
Alk P 2000
Alb 3.3
What are you suspecting?
How will you confirm, how will you manage?
2)You are asked to review some U+E’s for a 50 year old lady with known
diabetes.
Na 136
K 5.0
BUN 70
Creat 8.0
This lady takes the following medication…
Metformin 500mg bd
Gliclazide 10mg od
Captopril 25mg bd
Frusemide 40 mg bd
Aspirin 75 mg od
She also takes the following for recent knee pain…
Ibuprofen 400mg tid
Panadol 1 g tid
What is going wrong?
How will you decide what to do?
3)A 18 year old man is admitted with fever and unwell, he is complaining of dark
coloured urine.
Temp 39 oC, BP 100/60, HR 100, Resp 30, sats 95%
You notice his urine is very black
Na 136
K 5.0
BUN 70
Creat 8.0
What is the likely diagnosis?
Provided by T. Whitfield, 2012
How will you manage the patient?
4)You are asked to review the bloods of a 60 year old diabetic in clinic
Na 140
K 4.6
BUN 60
Creat 3.0
Calcium 2.0
Albumin 2.9
Hb 8.9
WCC 5.0
Plt 200
MCV 90
What is the above picture and what is the best management?
5)A 39 year old male presents with abdominal swelling.
LFTs
BIl 10
Ast 2000
Alk P 1000
Alb 1.2
Na 129
K 3.9
BUN 10
Creat 1.1
What is the diagnosis?
What test will you order? What result do you expect?
6) A 20 year old male presents with jaundice and feeling unwell for the past
week.
BIl 7.0
Ast 2000
Alk P 1000
Alb 3.2
He has been well previously
What do the LFTs show?
What is your management plan and differential diagnosis?
Provided by T. Whitfield, 2012
7) a 23 year old lady presents with general body swelling shortness of breath for
the past three months.
She has no major past medical history.
Na 125
K 3.8
BUN 30
Creat 0.9
Bil 2.3
Ast 20
Alk P 100
Alb 2.9
What do the bloods suggest/ what is confusing?
What test will you do to confirm the diagnosis?
8) A 29 year old female post pregnancy presents unwell with generalized
oedema.
Na 130
K 6.0
BUN 100
Provided by T. Whitfield, 2012
Creat 11.0
HCO 15.0
Ca 2.8
Alb 3.0
CO 2 (low)
Hb 11.0
WCC 10.0
Plt 300
What is going on?
What is your management plan?
Provided by T. Whitfield, 2012
Answers
1)
the LFTs have raised alk P +++, combined with raised bil suggests obstructive
jaundice.
Causes of obstructive jaundice…
Gall stones
Pancreatic/ cholangio- carcinoma
Billary stricture
In view of the pain it is likely gall stones
The temperature suggests cholangitis, an ultrasound to confirm diagnosis and
antibiotics to treat the infection are advised.
In acute settings you would wish to check amylase to r/o pancreatitis
After confirmation to refer to surgeon
2) this lady has a degree of renal failure we are unsure if it is acute or chronic
renal failure in diabetes is common, it is common also in hypertension.
She is however on a number of reno toxic drugs, especially ibuprofen.
Captopril is toxic to the kidneys in renal artery stenosis and should be stopped in
cases of renal failure and gradually reintroduced at low levels whilst monitoring
the U+Es.
Metformin is excreted by the kidneys and should be stopped in renal failure.
Frusemide causes some renotoxicity but is still widely used in Malawi.
To assess kidney function we must first know fluid balance.
Fluid balance is judged by hard signs (good signs)…
Oedema (look at the sacrum and ankles)
Blood pressure (if low can be fluid deplete or could be heart failure)
JVP
Soft signs are dry skin, mucus membranes and skin turgor.
Monitor renal function with a catheter and look at fluid in and out.
3) this man has black water fever,
this is acute kidney injury due to massive haemolysis in severe falciparum
infection.
He needs IV quinine, catheter an lots of fluids to rehydrate, his HB should be
checked, he may necessitate dialysis
4) likely chronic renal failure in diabetes,
this has caused decrease EPO and a normocytic anaemia
Provided by T. Whitfield, 2012
the low calcium is also indicative of chroic renal failure, he has no acute need of
dialysis, can be monitored controlling his blood sugar and BP as best possible.
5) the increased ALT above alk phos indicates intrinsic liver damage, he also has
low albumin and high billirubin indicating poor synthetic function.
Low sodium is expected due to the fluid shifts in hypoalbuminanaemia, the
patient is not fluid deplete.
He has liver failure and is likely to have ascites, he will ned a tap of his abdomentherapeutc and diagnostic. Followed by diuretics to keep the fluid off, (start with
spironolactone)
Investigation into possible causes of liver failure.. ? meds (TB meds commonly,
some HIV meds), hep B, alcohol
6) this is more likely acute hepatitis such as hep A and EBV, it could also be acute
Hep B.
he needs AUSS, hep B serology and observation
7) the cxr suggests heart failure examination will confirm this, Crepitations on
the chest are to be expected. There is definite failure to get fluid through the left
side of the heart
if it is CCF we look for
JVP raise
Oedema in the feet, ankles, ascites
Hepatomegaly
Murmurs may be heard as valvular heart lesion following rheumatic heart
disease is the most common cause of heart failure in young people in Malawi
Order an echo and ECG, control the BP and need to give diuretics titrated against
the BP.
8) she has post partum renal failure, possible causes include hypoperfusion,
aswell as preeclampsia.
She will need urgent dialysis as she is…
Acidotic (low pCO2)
Hyperalaemic
Renal auss is also important as is catheter and monitoring fluid balance.
Provided by T. Whitfield, 2012