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Critical Pathway: Chronic Renal Failure
Regents Online Degree Program
Critical Pathway: Chronic renal failure
Chronic renal failure is often occasioned by chronic kidney disease, immune disorder, trauma among other conditions. It does not have any specific symptoms and might include feeling unwell generally and experiencing a reduced appetite. It is diagnosed following screening of individuals who are identified to be at risk of kidney problems, like individuals with diabetes or high blood pressure and others who have blood relative with chronic kidney disease. It always seems complex when trying to come up with the right diagnosis for a patient.
M.A. is a 60-year-old man who has a stage V chronic kidney disease mainly as a result of diabetic nephropathy and a 12-year of type 2 diabetes. He has symptomatic peripheral vascular insufficiency, and 3 years ago he had undergone coronary artery bypass 3. Within the ten months that passed, Mr. M.A. had been undergoing hemodialysis 3 days in a week for 3.5 hours via left arm arteriovenous fistula. For the last 3 days he had undergone dialysis following his scheduled dialysis on the day of visit.
Three months before Mr. M.A. was admitted, he had developed a non-healing left foot ulcer and a critical lower limb ischemia. Several attempts such as vascular intervention to restore sufficient limb blood flow did not produce a positive result, and after two-month he had to undergo a transmetatarsal amputation. After the surgery the patient found that he was developing surgical wound infection, which called for a repeated debridement as well as intravenous vancomycin administration.
According to his wife Mr. M.A. was also showing some signs of continuous confusion and had been having visual hallucinations, claiming to be seeing things that never existed in real life. Such signs began some 2 weeks before he was admitted as an intermittent episode. However, the wife could identify any triggering events or temporal pattern for the episodes. Some 2 days which have passed these signs have been more persistent. Such confusion had never been seen from Mr. M.A. As much he was somehow forgetful in the previous years he was still able to take care of himself and perform simple tasks.
As a patient he was receiving medication of atorvastatin, atenolol, aspirin, gabapentin, insulin and the recent medication was vancomycin. For several years the patient had been taking 300mg of gabapentin 4 times in a day and this was effectively controlling his diabetic neuropathic pain. Administering of vancomycin was done during hemodialysis as per the blood levels. His wife made sure that he followed his mediation and dialysis regime strictly.
Mr M.A. was somnolent and a febrile but arousable. Some of his critical signs included:
Height- 4 feet
Weight- 120 lbs
Pulse rate of 60 beats/min (regular).
Blood pressure of 138/88 mm Hg
Respiration rate of 14 breaths/min
Temperatures 98.1 (oral)
Oxygen saturation while breathing room air of 98%
Left metatarsal stump wound was healing
Euvolemic without pericardial rubs
Waking up periodically
Lab results included the following:
White blood cells
5.7 x 109/L
3.5 -- 109/L
225 x 109/L
150-450 X 109/L
Blood urea nitrogen
50 mg / dL
When head MRI was done it revealed mild brain atrophy without mass lesion, hemorrhage, or ischemia. Revelation of electroencephalography was that nonepileptogenic, mild bitemporal slowing. Mr. M.A. was put on a full dialysis session, and 2 hours after dialysis as well as prior to dosing, the level of gabapentin were 27.0 ?g/Ml. This is due to the fact that circulating gabapentine is an eliminating efficiency at the time of dialysis. Such a level shows the tissue rebound and reveals that the predialysis level of this patient was clearly elevated.
Causes of the Patient's altered mental status
Patients with multiple comorbid conditions are at risk of altered mental status and it can be facilitated by various acute illnesses. Sometimes, it can be the sole symptoms of systemic infection. Consequently, some of the infections like urinary tract infections and pneumonia is suppose to be included within the differential diagnosis and then ruled out. But Mr. M.A.
was a febrile, did not have urinary or respiratory symptoms, and was just recently when he was treated with antibiotic. Meaning that it is not likely that infection was the cause of these problems.
Stroke is known to be associated with hallucinations and intermittent symptoms of altered mental status, particularly when there are no focal neurologic deficits, implying that it is not likely for stroke to be the cause of these problems. Parkinson-like motor disorder or Parkinson disease is associated with Lewy Body Dementia (LBD). Those patients who are experiencing LBD use to show complex hallucinations and fluctuations in alertness in people. It is known that hallucinations may bring a movement disorder and dementia.
As much as LBD may seem to be consistence with the problem of Mr. M.A., the sudden start as well as fast progression would be extremely uncharacterized in LBD, ruling out its possibility. Following Mr. M.A. having history of adherence to regular dialysis in addition to non-presence of uremia's physical signs indicate that hallucinations and decrease alertness are not a result of uremia. Again, during initiation of dialysis he was uremic but failed to demonstrate the same symptoms.
It is important to note that in recent weeks, the patient was given multiple agents such as contrast agents for computed tomography and magnetic resonance plus postoperative and preoperative antibiotics. Therefore, the potential and likely cause of the patient's problem could have been medication toxicity, particularly in the setting of renal failure. On the day of his admission, the patient underwent dialysis, and there was an immediate improvement of his hallucinations but came back again during the dialysis sessions.
Mr. M.A. has been known to have Type 2 diabetes which is a chronic condition that always affects the manner in which the body of a person metabolizes glucose (sugar), which is the main source of fuel. It was once known as non-insulin dependent diabetes or an adult-onset. When a person is diagnosed with type 2 diabetes, it means that the body either is failing to produce enough insulin that helps in maintaining a normal glucose level, or the body is resisting the effects of insulin (a hormone that helps in regulating the movement of sugar into the body cell), (Ahern J, Kruger DF., 1989). Though the condition is untreatable, it can be managed by eating well, doing exercises as well as maintaining a healthy weight.
Following continuous changes that are taking place within the health care system as well as public policy, there has been a shift in the treatment of renal chronic related acute settings like hospitals, towards outpatient managed care organizations and facilities. The need to achieve a cost-effective treatment is on the rise. Health care professionals specializing in the care of people with renal chronic and other similar illnesses are increasingly being recognized as an important group even in the manner in which they carefully attend to these patients. In the attempt to promote health and prevent occurrence of these related disorders, the health care provider have realized the need for self-management. The patients as well as those who take care of them are trained and educated on how to manage themselves or those who they take care of without necessarily having to visit health facility everyday.
Mr. M.A. has also undergone surgery, has wound infection and undergone dialysis. What provided clues for active infection and do away with substantial electrolyte abnormalities and hypoglycemia was an electrolyte panel with measurement concentration of glucose as well as a CBC. Even though there was unlikely of seizure following the history of the patient, useful corroborative information could be based on electroencephalography. MRI of the head can be used to evaluate structural abnormalities like mass lesion and brain atrophy. Elimination of gabapentin takes place from the urine, and accumulates in blood if you are a patient with renal failure. When gabapetin is excessively accumulated it may cause different neurologic toxicities, such as coma and hallucination. Therefore the level of gabapentin should be obtained. It would be of little help to consider arterial blood gas since the patient does not manifest respiratory signs and symptoms of oxygen saturation and labored breathing when the breathing room air was 98%.
Generally, gabapentine is usually well absorbed and has not been identified to exhibit batch-to-batch variations in it bioavailability. While in the blood stream, it is not bound by protein, (Luer MS, Hamani C, Dujovny M, et al. (1999). Therefore having co-administered medications that tend to bind serum protein is not supposed to have an effect on the gabapentin circulation level. Since gabapentin is usually not metabolized hepatically, it should not be affected by variations of the hepatic cytochrome system activities and any…
Sources Used in Documents:
Ahern J, Kruger DF, Gatcomb P, Petit W, Tamborlane W.,(1989). The Diabetes Control and Complications Trial (DCCT): the trial coordinators perspective. Diabetes Educ 15:236 -- 281
Bassilios N, Launay-Vacher V, Khoury N, et al. (2001) Gabapentin neurotoxicity in a chronic haemodialysis patient. Nephrol Dial Transplant.
Blum RA, Comstock TJ, Sica DA, et al.(1994). Pharmacokinetics of gabapentin in subjects with various degrees of renal function. Clin Pharmacol Ther;56(2):154-159
Brawek B, Loffler M, Dooley DJ, Weyerbrock A, Feuerstein TJ.(2008) Differential modulation of K (+)-evoked (3)H-neurotransmitter release from human neocortex by gabapentin and pregabalin. Naunyn Schmiedebergs Arch Pharmacol.:376(5):301-307
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