CASE PRESENTATION ON CHRONIC KIDNEY DISEASE AND URINARY TRACT INFECTION

CASE PRESENTATION ON CHRONIC
KIDNEY DISEASE AND URINARY
TRACT INFECTION
PRESENTED BY:-
CHANDANA C
III PHARM D
06 - SSCP

CHRONIC KIDNEY DISEASE
DEFINITION:-
Chronic kidney disease (CKD) is defined by a
reduction in the glomerular filtration rate (GFR) and/or
urinary abnormalities or structural abnormalities of the renal
tract.
 CKD refers to an irreversible deterioration in renal function
that usually develops over a period of years.
 Initially, manifests only as a biochemical abnormality but,
eventually, loss of the excretory, metabolic and endocrine
functions of the kidney leads to clinical symptoms and
signs of renal failure.

ETIOLOGY:-
 Diabetes mellitus
 Interstitial diseases
 Glomerular diseases
 Hypertension
 Reno vascular disease
 Unknown
CLINICAL FEATURES:-
 Polyuria and nocturia
 Proteinuria
 Haematuria
 Hypertension and fluid overload
 Uraemia
 Anaemia
 Electrolyte disturbances

URINARY TRACT INFECTION
Urinary tract infection refers to the presence
of organisms in the urinary tract together with symptoms
and signs, of inflammation.
 Refers to presence or absence, of functional or structural
abnormalities within the urinary tract.
 Infections of the urinary tract can be divided into two
general anatomic categories :
a) Lower tract infection (Urethritis, cystitis)
b) Upper tract infection (pyelonephritis)
DEFINITION:-

ETIOLOGY:-
 Escherichia coli (80%)
 Gram negative enteric bacteria such as Klebsiella and
Proteus species.
 Gram positive enterococci and Staphlyococcus
saprophyticus.
 Pseudomonas aeruginosa, Enterobacter and Serratia
species.
CLINICAL FEATURES:-
 Abrupt onset of frequency of micturition and urgency
 Burning pain in the urethra during micturition(dysuria)

 Suprapubic pain during and after voiding
 intense desire to pass more urine after micturition, due to
spasm of the inflamed bladder wall(strangury)
 Urine that may appear cloudy and have an unpleasant
odour
 Non-visible or visible haematuria.

PATIENT DEMOGRAPHIC DETAILS:-
 PATIENT NAME:- RAMA.......
 AGE:- 74 years
 GENDER:- Male
 BMI :- Normal (19.6)
 IP no.:- 19090456
 UNIT:- Nephrology and Urology
 WARD:- GNW MALE
 DOA:- 21-9-2019
 DOD:- 2-10-2019

CHIEF COMPLAINTS ON ADMISSION:-
C/o Uncontrolled urination since 1 day
Fever, cold, cough since 2 days
Frequent urination since 6 months

PATIENT HISTORY:-
 PAST MEDICAL HISTORY:- k/c/o Type II Diabetes mellitus,
Hypertension since 7 years
 PAST SURGICAL HISTORY:-CAD s/p CABG at age of 68yrs
 PAST MEDICATION HISTORY:- Prolomet XL 50(1-0-1), Human
mixtard(1-0-1), Plagerine-A 150(0-1-0), Rozavel 20(0-0-1),
Clonazepam(0-0-1/2), Lubrex eye drop
 SOCIAL HISTORY:- Nothing significant
 FAMILY HISTORY:- Nothing significant
 ALLERGIES:- Nil known allergies
 DIET:- Mixed diet

GENERAL PHYSICAL EXAMINATION :-
 CVS:- S1S2 heard
 RS:- B/L NVBS
 CNS:- Concious and oriented
 P/A:- Soft and abdominal distension present
 GRBS:-331mg/dl
 BP:- 200/100 mmHg
 HR:- 66 bpm
 RR:- 24 bpm
 Temp.:- 98.2° C
 SPO2:- 96%

PROVISIONAL DIAGNOSIS:-
 CHRONIC KIDNEY DISEASE
 URINARY TRACT INFECTION
 ACUTE PULMONARY EDEMA

SUBJECTIVE EVIDENCE OBJECTIVE EVIDENCE
 C/o Uncontrolled
urination since 1 day;
 Fever, cold, cough since
2 days;
 Frequent urination
since 6 months
 k/c/o Type II Diabetes
mellitus, Hypertension
 CAD s/p CABG
 Sodium:-132mmol/L
 Chloride:-92mmol/L
 Blood urea nitrogen:-
151mg/dl
 Serum creatinine:-3.5mg/dl
 Uric acid:-9.7mg/dl
 RBC:-3.48milli/cumm
 Hb:-10.2g/dl
 Urine glucose:-1%
 Hematocrit:-30.2%
 Neutrophills:- 76.5%
 Eosinophils:-0.8%
 Lymphocytes:-11.6%
 Monocytes:-11.1%
 Non specific ST abnormality
 abnormal ECG

OBJECTIVE EVIDENCE:-
 ULTRA SOUND ABDOMEN AND PELVIS:-
 Diffuse urinary bladder wall thickening with fine echoes of
concern for cystitis.
 B/L relatively small kidneys with subtle increase in cortical
echoes- grade- II/III medical renal disease.
 Both kidney shows increase in cortical echotexture with
maintained CMD – grade-I parenchymal disease.
 Mild thickening of urinary bladder wall with mucosal irregularity
and freely floating internal echoes noted in urinary bladder-
cystitis
 RETROGRADE URETHROGRAM:-
 Evidence of short segment smooth narrowing near the anterior
end of the penile urethra for 2.2cm-suggestive of stricture

FINAL DIAGNOSIS:-
 CHRONIC KIDNEY DISEASE
 URINARY TRACT INFECTION
 ACUTE PULMONARY EDEMA
 COPD
 URETHRAL STRICTURE
k/c/o
 TYPE II DIABETES MELLITUS
 ACCELERATED HYPERTENSION
 CAD s/p CABG

TRATMENT CHART:-
BRAND
NAME
GENERIC NAME DOSE FREQUEN
CY
ROA Number of
days
Inj.Auxifast Cefoperazone+sulba
ctum
1.5g 1-0-1 IV 1-5
Inj.Retamol Paracetamol 1g 1-1-1 IV 1-2
Inj.Lasix Furosemide 5mg/hr onflow IV 1-12
Inj.Heparin Heparin 5000u 1-1-1 IV 1-12
Tab.Clopilet Clopidogrel 75mg 0-1-0 PO 2-5
Tab.Ecospri
n AV
Atorvastatin+aspirin 150/20
mg
0-0-1 PO 2-5
Inj.Pan Pantoprazole 40mg 1-0-1 IV 1-12
Inj.Emeset Ondansetran 4mg 1-1-1 IV 1-3
Tab.Amlong Amlodipine 5mg 1-0-0 PO 2-12

BRAND NAME GENERIC NAME DOSE FREQUE
NCY
ROA No. of
days
Tab.Cardivas Carvedilol 3.125mg 1-0-1 PO 2-12
Inj.Human
Actrapid
Soluble insulin 2
Inj.Levoday levofloxacin 10mL 1-0-0 IV 3-12
Tab.Nexito Escitalopram
oxalate
5mg 1-0-1 PO 6-12
Lubrex eye drop Carboxymethylcel
lulose
0.5%w/v 1-1-1-1 6-12
Neb.Duolin Levoalbuteral+ipr
atropium
1-1-1 3-12
Tab.Angiplat Nitroglycerin 2.5mg 1-1-0 PO 8-12
Inj.Etrax XL Ceftrixone 1.5mg 1-0-1 IV 9-12
Neb.Foracort Formoterol+Bude
sonide
1.5mg 1-0-1 11-12

PROGRESSION:-
 Day-1 (21-9-19)
c/o breathing difficulty, general weakness, abdomen discomfort,
throat pain since 1 day; constipation since 2 month  cremaffin
BP:-200/100mmHg ; PR:-100bpm ; SPO2:-95% ; I/O:-300/200mL
 Day-2 (22-9-19)
c/o breathing difficulty
BP:- 140/80mmHg ; PR:- 80bpm ; SPO2:-100% ; RS:- B/L
Ronchi+,basal crepti+ ; serum creatinine:-2.5mg/dl ; BUN:-82 mg/dl;
I/O:- 1875/2490mL
 Day-3 (23-9-19)
c/o Sleeping disturbance
BP:- 150/80mmHg ; PR:- 90bpm ; I/O:-950/1550mL

 Day-4 (24-9-19)
c/o cough
BP:- 110/80mmHg ; PR:-80bpm ; I/O:- 1200/1600mL
 Day-5 (25-9-19)
Vitals stable ; I/O:- 1600/1150ml ; BUN:-151mg/dl ; serum
creatinine:-3.5mg/dl ; uric acid:-9.7mg/dl
 Day-6 (26-9-19)
Vitals stable ; P/A:-soft B/S+ ; I/O:-1600/2250mL
 Day-7 (27-9-19)
Acute pulmonary edema
RS:- B/L ronchi+ basal crepti+ ; vitals stable ; I/O:- 1300/1900mL

 Day-8 (28-9-19)
GC fair ; BP:- 120/80mmHg ; I/O:- 1550/2600mL
Adv. CST
 Day-9 (29-9-19)
BP :- 130/90 mmHg ; PR :-105bpm ; RS :- B/L Ronchi+
P/A:- Soft B/S + ; CVS :- S1S2 + ; SPO:- 97% on 2 L of oxygen
support ; I/O:- 1450/2200mlL
 Day-10 (30-9-19)
C/o general weakness ; BP :- 140/80mmHg ; RS :- B/L Ronchi + ;
SPO2 :- 90% RA ; I/O:- 1450/1800mL
 Day-11 (1-10-19)
Vitals stable ; afebrile ; RS :- B/L NVBS
Adv. CST

THERAPEUTIC GOALS:-
 To maintain normal blood glucose levels , blood pressure to
control accelerated hypertension.
 To treat risks factors of cardiovascular disease
 To control further complication
 To reduce cystitis cause .
 To reduce urethral stricture.
 To reduce complications related due to COPD
 To control respiratory failure caused due to pulmonary
edema.
 To reduce infection and maintain good health.

TREATMENT OPTIONS:-
 Calcium channel blockers :- amlodipine and nifedipine.
 Beta blockers :- carvedilol ,nebivolol and labetalol.
 Insulin Human mixtard.
 Antibiotic :- Ciprofloxacin , norfloxacin , cefalexin and
levofloxacin.
 Eye drops:- carboxymethylcellulose .
 B2 sympathomimetic bronchodilators:- formoterol ,
salmeterol.
 Corticosteroid:- budesonide.

TREATMENT OPTIONS ( continued…)
 Anti-cholinergic Bronchodilators:- ipratropium bromide.
 Nitrates:- nitro-glycerine.
 Anti-emetic :- ondansetron, palonosetron, dolanosetron.
 Proton pump inhibitor :- pantoprazole , rabeprazole
 Anti-pyretic:- paracetamol/ acetaminophen.
 HMG COA reductase inhibitor:- atarvosatitin

DISCHARGE MEDICATION:-
BRAND NAME GENERIC NAME DOSE FREQU
ENCY
ROA NO. OF
DAYS
Tab.Levoday Levofloxacin 500mg 1-0-1 PO 3days
Tab.Angiplat Nitroglycerin 2.5mg 1-1-0 PO Till review
Tab.Ecosprin AV Atorvastatin+Aspirin 150/20 0-0-1 PO -
Tab.Lasix Furosemide 40mg 1-0-0 PO -
Tab.Amlong Amlodipine 5mg 1-0-0 PO -
Tab.Nebicard Nebivolol 5mg 1-0-1 PO -
Tab.Etizolam Etizolam 0.25mg SOS PO -
Tab.Ketofix Cefixime 200mg 1-1-1 PO -
Syp.Cremaffin Liquid paraffin+Mg(OH)2 20ml 0-0-1 PO -
H.Actrapid Soluble insulin 25u 1-1-0 SC -
H.Mixtard NPH+Soluble 15u 0-0-1 SC -
Lubrex eye drop Carboxymethylcellulose 1-1-1-1 -
Tab.Silotime D Silodosin+dutasteride 8+0.5mg 0-0-1 PO -

PROBLEMS IDENTIFIED:-
 Diuretics:- patient has low level of electrolytes
 Where diuretics may cause more deficiency in electrolytes
levels which may lead to severe hyperthermia .
 HbA1c test is not performed to monitor the average blood
glucose level of blood
 Lipid profile tests are not performed.

 Bilirubin levels are not checked to determine the complication
related to constipation
 Administration of aspirin, heparin,clopidogrel though patient
has anaemia.
 Use of antiplatelet and anticoagulant may cause increased risk
of bleeding and anaemia
 Patient already has abnormal ECG ( i.e. non-specific ST
abnormality )where, administration of diuretics and albuterol
may lead to more ECG complications.

PHARMACIST INTERVETION:-
 Diuretics can be replaced by calcium channel blockers where
they will maintain the cardiac health and prevent the loss of
electrolytes caused by the diuretics , lead to prevention of
risks of hyperthermia.
 Check HbA1c levels.
 Check and monitor of bilirubin levels.
 Check lipid profile test.

MONITERING PARAMETERS:-
 HEMATOLOGY
 URINE ROUTINE
 ULTRASOUND ABDOMINAL PELVIS
 RETROGRADE URETHROGRAM
 ECG
 LIVER FUNCTION TEST
 LIPID PROFILE TEST
 GLUCOSE TEST

PATIENT COUNCELLING:-
 About disease:-
 Explain to patient about the disease
 Educate the patient about the complication of disease
 Explain to patient about cause of disease and risk factors of
the disease.
 About Medications:-
 Take regular medications as prescribed by the doctors
 Don’t miss or double the dose
 Advice about the drug interactions , ADR
 Advice about route and frequency of administration.

 About life style modifications:-
 Regular health check-up
 Advice for Exercise or yoga
 Prevent of excessive consumption of protein.
 Consume low potassium fruits like papaya, Kiwi .
 Consume cranberry juice.
 Consume low fat content food
 More electrolytes consumption
 Reduce amount of spices in daily diet
 Consume less amount of caffeine.

CASE PRESENTATION ON CHRONIC KIDNEY DISEASE AND URINARY TRACT INFECTION

CASE PRESENTATION ON CHRONIC KIDNEY DISEASE AND URINARY TRACT INFECTION

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