CLINIC:
DATE OF VISIT:
DATE OF BIRTH:
ATTENDING PHYSICIAN:
Pediatric Renal Transplant
02/05/2009
03/24/1990
Minnie M. Sarwal, M.D., Ph.D.
IDENTIFICATION: XXXXX is an 18-year-old male patient with a history of end-stage renal
disease secondary to reflux nephropathy and bladder exstrophy. He also had a history of
multiple pseudomonal urinary tract infections. He is status post living related donor
renal transplant on 01/06/2009. He is 1 month status post his transplant. He also had a
history of a retroperitoneal hematoma while he was recovering from the transplant surgery
in the hospital. He was recently admitted to the hospital for acute pseudomonal
pyelonephritis on 01/20/2009 and discharged home on 01/30/2009. XXXXX presents to the
Renal Transplant Clinic today for a routine scheduled followup visit. His last clinic
visit was on 02/02/2009.
INTERVAL HISTORY: Since his last clinic visit, XXXXX has been doing well. His main
concerns at this time are that he is not happy catheterizing himself at least 10 times in
a day. It is really frustrating for him, and he is very upset about it, and he voices
his concerns that he cannot have a lifestyle with 10 times self-catheterizations in a
day. XXXXX's other complaints include his blood pressures. His blood pressures have
been really high, mostly in the 140s and 150s, at home, and he also has a history of
headaches, and he believes the headaches are mostly due to interrupted sleep at night.
He wakes up at least 4-5 times at night and self-catheterizes to void himself. He is
upset that these interruptions in sleep are causing a headache, and the first thing in
the morning when he gets up he gets a headache. He does not need to take medication but
he really feels uncomfortable. The headache is mostly in the frontal region and not
associated with nausea, vomiting, or visual changes or palpitations, or dizziness. He
did not measure blood pressures when he had headaches, so he does not know if these
headaches are related to his high blood pressures. The other major concern XXXXX had at
this time was swelling of his ankles. He started noticing swelling of both ankles,
especially around the end of the day. The swelling increases all through the day, and at
the end of the day the swelling is more. Otherwise, XXXXX denies forgetting any
medications. He has been doing well.
REVIEW OF SYSTEMS: Review of systems showed no history of change in weight, no history
of fevers, chills, dizziness, visual problems, runny nose, nosebleed, nausea, vomiting,
heartburn, abdominal pain, diarrhea, constipation, shortness of breath, cough, wheezing,
sore throat, swollen glands. No history of rash or itching, no history of weakness,
muscle cramps, excessive bruising, no history of anxiety, depression, no history of
excessive thirst or abnormal random blood sugars. Pertinent positives include high blood
pressures, headaches, ankle swelling. XXXXX also complains that he cannot take deep
breaths. If he takes a deep breath, his musculature on the abdomen is painful, and if he
takes long walks or hikes he gets abdominal pain all the way around his abdomen, but not
anywhere inside. He drinks at least 2.5 to 3 liters in a day, and voids at least every
2-1/2 to 3 hours, depending on his feel. He catheterizes himself depending on his feel
to urinate. He voids at least 350-400 mL of urine each time, and averaging about 350 mL.
MEDICATIONS:
His current medications include:
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Prograf 8.5 mg p.o. in the morning and 8 mg in the evening.
CellCept 750 mg twice a day; that comes to 426 mg/sq m per dose.
Magnesium 2 tablets twice a day.
Pepcid 20 mg twice a day.
Valcyte 450 mg once a day.
Ciprofloxacin 1 tablet at night.
Detrol 6 mg at 6 p.m. once a day.
Amlodipine 10 mg twice a day.
Reglan 5 mg three times a day.
Sodium bicarbonate 3 tablets three times a day.
Colace 1 tablet twice a day.
MiraLax p.r.n.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 64.8 kg; it has come down from 66 kg on February 02, 2009. Height
172.1 cm. Blood pressure 143/76.
GENERAL: Active, alert, not in acute distress. He has apparently been very emotional
about self-catheterizing himself and has been crying.
HEENT: Within normal limits.
CHEST: Clear breath sounds bilaterally.
HEART: S1 and S2 heard. No murmurs.
ABDOMEN: Soft. It has been a little tender on his left side and also on the place where
he had his renal transplant in the right lower quadrant, and he would not let us touch
his abdomen much. He has mild tenderness in the suprapubic region. No CVA tenderness
noted at this time. Of course, he had his bilateral nephrectomies done.
GENITALIA: Deferred at this time.
EXTREMITIES: Full range of motion. Ankle edema noted bilaterally. Pitting edema noted
bilaterally.
SKIN: No lesions.
NEUROLOGIC: Neurologically intact.
LABORATORY STUDIES: His most recent labs are from today: Total WBC 5.1, hemoglobin 8.2,
hematocrit 24.2, platelets 289,000. Sodium 145, potassium 5.7, chloride 110, bicarbonate
23, BUN 24, creatinine 2.17, glucose 88, anion gap 12, calcium 9.8, phosphorus 3.3,
magnesium 2. Prograf 6.4. Urinalysis: Clean catch showed a specific gravity of 1.009,
glucose negative, ketones negative, blood trace, pH 7.5, protein negative, nitrites
negative, leukocyte esterase negative, RBC 4-5, WBC 0-2, bacteruria negative. CMV DNA
PCR done on 02/03/2009 is negative. Last urine culture on 02/02/2009 showed no growth.
Recent renal ultrasound was done on 02/02/2009 and showed stable moderate pelviectasis,
normal renal ultrasound. The urinary bladder is normal in shape, contour and wall
thickness. There is a small amount of echogenic layering sediment in the posterior
bladder wall. The transplant kidney in the right lower quadrant demonstrates normal
cortical echogenicity and corticomedullary differentiation. There is stable, moderate
pelviectasis, and the transverse dimension of the renal pelvis is
1.68 cm. There is mild dilatation of the proximal ureter, measuring 7 mm. Normal blood
flow on waveforms are seen in the main and intralobular artery and main renal vein of the
transplant kidney. Resistive indices in the intralobular arteries ranged from 0.58 to
0.72. The velocity in the renal artery ranged from 0.57 to 0.63 per second. The renal
artery resistive indices are within normal limits.
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ASSESSMENT AND PLAN: XXXXX is an 18-year-old male patient with a history of end-stage
renal disease secondary to reflux nephropathy, status post bilateral native
nephrectomies, status post living related donor renal transplant on 01/06/2009, from his
dad, status post retroperitoneal hematoma evacuation on 01/10/2009. Apparently his main
issues have been self-catheterization for 10 times a day, which is frustrating XXXXX
totally, and he is not happy with his lifestyle. We have tried talking to Dr. Kennedy
and his nurse, Cathy, in regard to his voiding habits year-old see if we can help him
reduce the number of self-catheterizations in a day, but apparently we could not talk to
Dr. Kennedy as he was in the OR. We will followup with Dr. Kennedy.
1. RENAL: Regarding his renal function, his creatinine has been persistently at 2.2,
and it is coming down slowly, 2.14 to 2.17. We anticipate some more decrease in his
serum creatinine as he goes further away on his transplant. His potassium is a little
bit high, but we did not make any changes at this time. Otherwise, no other electrolyte
abnormalities at this time. He needs to be on magnesium, as well as sodium bicarbonate,
to prevent acidosis and also hypomagnesemia. He is on Prograf and CellCept for his
immunosuppression. Target levels for Prograf are between 10-12, and his level is 6.4
today. The plan is to give an extra 1 mg p.o. now and then increase the Prograf dose to
8.5 mg twice a day.
2. UROLOGY: In terms of his urology, XXXXX will make an appointment with Urology, and
then we will come up with a plan regarding his self-catheterization.
3. CARDIOVASCULAR: He is pretty hypertensive at this time. Our goal blood pressures
for XXXXX are around the 120s, but definitely note above 130, so we plan to start him on
atenolol 25 mg twice a day, along with amlodipine 10 mg twice a day. XXXXX does not like
a Catapres patch on him, so we started him on atenolol.
4. INFECTIOUS DISEASE: He cannot take Septra, as his creatinine has been persistently
high, so we plan inhaled pentamidine for him. He is going to get next inhaled
pentamidine on 02/10/2009 at 6:30 p.m. in the day hospital. He continues to be on
Valcyte 450 mg once a day, and he continues to be on ciprofloxacin for his urinary tract
infection prophylaxis.
5. GASTROINTESTINAL: XXXXX's constipation has improved, so he continues to be on the
current regimen of Colace 1 tablet twice a day and MiraLax p.r.n. as needed, and
continues to be on Reglan 5 mg three times a day.
Our plan is to follow him up in a week from now, and we will repeat a Prograf level the
day after tomorrow.
The case was discussed in detail with Dr. Sarwal.
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