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Thomas Lanning MD.Abdul Hamid Alraiyes MD.

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47 years old AAM

Chief Complaints

Nausea

Vomiting

Abdominal PainCP

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Past surgical Hx:Lt AKA (1 year ago)

Rt AVF (radial artery)

Rt Big toe amputationLt IJ Dialysis catheter (3/10/2007)

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Allergies:Penicillin rash

Social History:

Resident at Cleveland RehabDenies any Hx of:

ETOH

Drug abuse

Ex- SMOKER

Family History:

DM

HTN

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Medications:Insulin aspart 5 units S.Q. Q AC

Lantus 20 units S.Q. QHS

Hydralazine 100mg P.O. Q8hr

Lisinopril 20mg P.O. QDLopressor 50mg P.O. BID

Norvasc 10mg P.O. QD

Renagel 800mg P.O. TID

Nephrocap 1 tab P.O. QDNeurontin 300mg P.O. Q 8hr

Fluoxetine 20mg P.O. QD

Vancomycin 600mg I.V. with HD

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Physical Exam:V/S : 36- 120/56 - 62 17 - SPO2= 86% on RA

Pt is drowsy, dehydrated, not in distressSkin: dry

Chest: Bil crackles, no wheezing + decreased air entry.

CVS: S1 + S2 + no M

ABD: soft, distended epigastric, tenderness, no rebound, BS+.

EXT: no edema , Lt AKA, Rt Big toe amputation, AVF on the Lt arm

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Labs:WBC = 10.9 , Hb= 12.6, Ht= 39.2, Plt= 184

Na= 119, K= 8, Cl= 86, CO2= 12

BUN= 103, Cr= 9.9 , Glucose=1140

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Labs:AG= 21Serum Osmolality= 348 (275-290)

ABG= 7.048 / 41.8 / 75.1 / 11 A-a= 32 SAT= 86

FiO2 = 21%

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119 (86 + 12) = 21

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Expected AG = 21 + [ 2.5 X (4.5 3.8] = 22.75

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PCO2 = (1.5 X 12 ) + 8 +/- 2 = 28 - 24

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PCO2 = (1.5 X 12 ) + 8 +/_ 2 = 28 24

ABG= 7.048 / 41.8 / 75.1 / 11

Metabolic Acidosis + Respiratory Acidosis

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AG Excess / HCO3 deficit = 22 12 / 24 12 =~ 1

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Labs:

Amylase= 102 Lipase=1082LFT WNL ALP=242

CPP = 94 / 3 / 0.14

UA not done Pt is anuric

EKG: LVH

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Cardiomegaly Bil pleural effusion

Small amount of ascites

Wall thickening of proximal Small bowel

in Lt upper abdomenMild renal atrophy

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10 units R insulin x 2 I.V.

No I.V.F

naHCO3 tow Apm

Kayexalate 30 gram PO

CaCl 1 Amp

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DKA

Uncontrolled

blood sugar

Volume

contraction

Ketones

accumulation

Starvation

Sepsis

MI

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Blood Sugar

0

500

1000

1500

AxisTitle

Mon

1

Mon

2

Mon

3

Mon

4

Mon

5

Mon

6

Mon

7

Mon

8

Mon

9

Mon

10

Mon

11

Mon

12

Blood Sugar 671 820 138 266 340 168 393 663 284 736 217 1140

Blood Sugar

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Ansari, A, Thomas, S, Goldsmith, D. Assessing glycemic control in patients with diabetes and end-stage renal failure. Am J Kidney Dis

2003; 41:523

Joy, MS, Cefalu, WT, Hogan, SL, Nachman, PH. Long-term glycemic control measurements in diabetic patients receiving hemodialysis. Am

J Kidney Dis 2002; 39:297.

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K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 4(Suppl 3):S1.

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Coronary-artery calcification is common and

progressive in young adults with end-stage renal

disease who are undergoing dialysis. (N Engl J Med

2000;342:1478-83.)

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Osmolality

0

200

400

AxisTitle

Mon

1

Mon

2

Mon

3

Mon

4

Mon

5

Mon

6

Mon

7

Mon

8

Mon

9

Mon

10

Mon

11

Mon

12

Osmolality 312 320 248 273 266 243 255 277 244 245 260 348

Osmolality

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Hyperglycemia > 250

Anion Gap

Serum HCO3 < 20

Urine or Blood Ketones

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+ NADH + NAD

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NPO

INSULIN ( Bolus + Infusion)

IVF

Hyperkalemia / Hypokalemia

? NaHCO3

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DKA + ESRD

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INSULIN

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INSULIN + ESRD

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INSULIN resistance 2nd

to uremia

1) Increased hepatic gluconeogenesis.

2) Reduced hepatic and/or skeletal muscle glucose uptake.

3) Impaired intracellular glucose metabolism.

4) abnormalities in phosphate and vitamin D metabolism

5) Anemia

Mak, RH, DeFronzo, RA. Glucose and insulin metabolism in uremia. Nephron 1992; 61:377.

McCaleb, ML, Izzo, MS, Lockwood, DH. Characterization and partial purification of a factor from uremic

human serum that induces insulin resistance. J Clin Invest 1985; 75:391.

http://www.utdol.com/utd/content/topic.do?topicKey=drug_a_k/38433&drug=truehttp://www.utdol.com/utd/content/topic.do?topicKey=drug_a_k/38433&drug=true

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Decreased insulin degradation

Decreased until GFR of 15-20 ml/min. Uremia will be higher and this will lead to an increase in

resistance to insulin when GFR 10 ml/min.

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INSULIN

No dose adjustment is required if the GFR is above 50 mL/min.

The insulin dose should be reduced to approximately 75% of baseline

when the GFR is between 10-50 mL/min. The dose should be reduced by as much as 50% when the GFR is less

than 10 mL/min.

in pt HD patients the insulin requirement in any given patient will depend

upon the net balance between improving tissue sensitivity and restoring

normal hepatic insulin metabolism.

Snyder, RW, Berns, JS. Use of insulin and oral hypoglycemic medications in patients with diabetes

mellitus and advanced kidney disease. Semin Dial 2004; 17:365.

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IVF

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IVF

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Hemo-dialysis

-Indications?

-Fluid removal?

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Indications?

Metabolic Acidosis

Hyperkalemia

Uremia

Decrease the Insulin resistance

Low S O2 ? Pulmonary edema

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Hyperkalemia?

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Usually no potassium replacement

Check within 2 Hr after HD

If AVF avoid the site of HD

ESRD no osmotic diuretic effect.

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Central I.V Access

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Central I.V Access

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NaHCO3?

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DKA + ESRD + Questions

1. Metabolic Acidosis could be from multiple sources.

2. Insulin doses

3. Importance of HD

4. Role of IVF

5. Role central venous pressure and (risk / benefit)

6. Treatment of Hyperkalemia / Hypokalemia

7. Role of HCO3

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