a case study on Acute Kidney Injury.pptx

Case study analysis of acute kidney injury: clinical presentation, diagnosis, and management strategies and along with disease information.

1. A Case Presentation on Acute Kidney Injury Presented by:- P J Hemanth Reddy Pharm D 3rd year 19Y01T0018 CESCOP,KNL.

2. SOAP NOTES: Subjective Evidence:- Name: xxxxx Age:60 years Gender: male IP.no:93217 Ward: general medicine Consultant Doctor: Dr. Kantha Reddy, Mbbs Chiefs complaints:- ℅ Back pain with Vomiting immediately after food intake since three days and it is associated with abdominal discomfort. ℅ Difficulty in micturition since three days.

3. Past Medical history:- K/C/O HYPERTENSION - on treatment Amlodipine 5mg , Torsemide 5mg . H/O Burning Micturition three years back on treatment of Nitrofurantoin 100mg. Personal History and Habits:- Diet: Mixed Alcoholic/Smoker: Smoker Sleep: Normal. Appetite: Normal Bowel and Bladder habit: Abnormal Objective evidence:- 2D Echo: Concentric Left ventricular hypertrophy and Left ventricular Diastolic dysfunction & normal LV systolic function.

4. Ultra sound: Bilateral grossly enlarged kidney with multiple cysts. Laboratory findings: Contents Values Reference Serum creatinine 7.8mg/dl 0.6-1.5 mg/dl GFR 36 ml/min 80-125 ml/min Serum potassium 4.5mg/dl 3.5-5.5 mg/dl serum sodium 132mmol/L 135-155mmol/L Blood urea nitrogen 90mg/dl 10-50mg/dl Blood pressure 160/100 mmHg 131/86 mmHg

5. Assessment:- The patient was already a know case of Hypertension & History of Burning Micturition. And newly diagnosed to have Acute Kidney Failure.

6. Acute kidney failure Definition: Acute kidney injury is a rapid reduction in kidney function over a day to weeks causing an accumulation of nitrogenous waste and other metabolites in the blood and decrease in GFR with Increase in serum creatinine levels. Epidemiology:- The incidence of AKI has grown by more than fourfold in the United States since 1988 and is estimated to have a yearly incidence of 500 per 100,000 population, higher than the yearly incidence of stroke. Community acquired AKI - < 1%

7. Hospital acquired AKI - (7-20%) ICU acquired AKI- (35-70%) Etiology:- Multi organ dysfunction Decreased blood flow to the kidneys Heart diseases Liver failure Anaphylaxis Severe dehydration Nephrotoxic drugs Blockage in kidney and urinary tract due to blood clots, kidney stones and other metabolic waste products. Bladder cancer,colon cancer, cervical cancer.

8. Risk factors:- Age Diabetes High blood pressure Blockage in blood vessels Heart failure Liver diseases Kidney diseases Certain cancers and their treatments Alcohol consumption and smoking

9. Pathophysiology:-

10. Clinical presentation:- Decreased urine output Fluid retention, causing swelling of legs Shortness of breath Fatigue Confusion Nausea Weakness Irregular heartbeat Chest pain or pressure

11. Diagnosis:- Blood urea nitrogen Serum creatinine Serum potassium Serum sodium Glomerular filtration rate Urine analysis Ultra sound X-ray Abdominal CT- scan Abdominal MRI

12. Standard treatment:- Replacement of fluids Normal saline (0.9%) Hypotonic saline (0.45%) Mannitol 20% w/v Furosemide 10-20mg/hour Inj. Sodium bicarbonate 50-100 ml of 4.2 % Inj. Calcium gluconate 10ml of 10% over 5 minutes

13. Planning: S.No Brand name Generic name Indication Dose ROA Frequency and (Start - end date) 1 Tazomac Piperacillin + Tazobactum Antibiotic 2000+ 250mg IV BD (D1-D4) 2 Pantop Pantoprazole PPI 40mg IV BD (D1-D4) 3 Nodosis Sodium bicarbonate Antacid 500mg PO OD (D1-D4) 4 Shelcal Calcium + Vitamin- D3 Nutritive agent 500mg 250 IU PO OD (D1-D4) 5 Ondem Ondansetron Antiemetic 4mg IV BD (D1-D4)

14. 6 Potklor Potassium chloride Electrolyte 10ml/ 1000mg PO BD (from D 4) 7 Nefrosave Taurine + Acetylcysteine Mucolytics 50mg + 150mg PO OD (D1-D4) 8 Ultracet Paracetamol + Tramadol Analgesic 325mg + 37.5mg PO BD (D3-D4) 9 Clavam Amoxicillin + Clavulanic acid Antibiotic 500mg + 125mg PO TID (D3-D4)

15. Progress chart : Day Vitals Treatment Day-1 Temp- 98°F Bp- 160/100mmHg PR-82 bpm RR- 22cpm Serum creatinine-7.8mg/dl Serum potassium-4.5mg/dl serum sodium-132mmol/BUN -90mg/dl GFR- 36ml/min 2D echo: Concentric LV hypertrophy, LV Diastolic dysfunction & normal LV Systolic function. Rx 1.Inj Tazomac 4.5 mg IV stat 2.5mg IV BD 2.Inj pantop 40 mg IV BD 3.Tab Nodosis 500mg PO BD 4.Tab Shelcal 500mg+250IU PO OD 5.Inj Ondem 4mg IV BD 6.Tab Nefrosave 650mg PO OD

16. Ultra sound of kidney: Bilateral grossly enlarged kidney with multiple cysts. Day-2 Temp- 99.3°F PR-82 bpm RR-22 cpm BP- 150/110 mmHg Rx Continue same therapy Day-3 Temp-97.6°F PR- 85 bpm RR- 21 cpm BP-150/90 mmHg BUN- 90 mg/dl serum creatinine- 6.9 mg/dl Rx CST 7.Tab ultracet 362mg PO BD 8. Tab Clavam 625mg PO TID

17. Day-4 Temp- 97°F PR-84 bpm RR-23 cpm BP-160/110 mmHg Rx CST 9. Syp potklor 10ml with glass of water PO BD Mechanism of action: TAZOMAC: Piperacillin/ Tazobactum: It shows bacteriocidal effect against both gram +ve and -ve bacteria by inhibiting bacterial spectrum formation and cell wall synthesis. ADR: Rash, constipation, Diarrhoea, Nausea, Headache,Fever. Sodium bicarbonate: Increases plasma bicarbonate levels and buffers excess hydrogen ion concentration and rises blood pH, there by reversing the Clinical manifestations of acidosis. ADR: skin ulcers, metabolic Alkalosis.

18. Ondansetron: It works by blocking 5HT3 receptors peripherally on vasal nerve terminals and centrally in the chemo receptor trigger zone (CTZ), there by preventing vomiting. ADR: Constipation, Diarrhoea, Headache,Fever. NEFROSAVE: Acetylcysteine: It is sulfhydryl compoundcompound and acts to increase synthesis of glutathione in the liver. Glutathione subsequently acts as an antioxidant and facilitates conjugation to toxic metabolites. Taurine: It is an antioxidant, suppressing the toxicity of hypochlorite and hypobromite produced physiologically. ADR: Rash, Diarrhoea, Nausea, vomiting, constipation. POTASSIUM CHLORIDE: Is an electrolyte replenisher, participates in several physiological processes in the body including the transmission of nerve impulses, the maintenance of normal renal function and intracellular tonicity, and the contraction of skeletal, cardiac and smooth muscle

19. ADR: Over consumption leads to Hyperkalemia, Cardiac arrest, Abdominal pain, Nausea, Vomiting. ULTRACET: Paracetamol/Acetaminophen: It acts by inhibiting prostaglandin synthase activity in CNS. Tramadol: It exerts it's effect through binding of parent drug and M1 metabolite (O-desmethyl-tramadol) and mu-opioid receptor and through weak inhibition of norepinephrine and serotonin reuptake. ADR: Pruritis, Constipation, Diarrhoea, Nausea, Vomiting, Headache. CLAVAM: Amoxicillin: It is an analog of Ampicillin, is semi synthetic antibiotic that inhibits the biosynthesis of cell wall mucopeptide. Clavulanic acid: Support respiratory and cardiovascular function. ADR: Skin rash,Diarrhoea, Nausea, Vomiting, Headache, Wheezing.

20. Pantoprazole: Pantoprazole covalently binds to the H+,k+ - ATPase enzyme system at secretory surface of gastric parietal cells and suppress the gastric acid production. ADR: Abdominal pain, Diarrhoea, Headache.

21. Pharmacist Interventions: Rationality: The given treatment was found to be Rational. Possible Drug Interactions : Gatifloxacin + Human Insulin = Concurrent use of fluoroquinolones and Ant Patient counseling: Regarding Disease: Acute kidney injury is the sudden abruption in kidney function. Regarding Drugs: Tab Nodosis- Should be taken Orally, twice a day. Tab Nefrosave- Should be taken Orally, once a day. Tab Ultracet- should be taken Orally, thrice a day. Tab Clavam- Should be taken Orally, thrice a day. Syp Potklor- 10ml of syrup should be taken Orally with glass of water twice a day.

22. Lifestyle Modifications: Quitting smoking. Lowering Salt intake (<2.3gm/day). Undertaking an exercise program compatible with cardiovascular health and tolerance, aiming for at least 30min,5 times per week. Maintain healthy body weight (BMI- 20to25). Monitor Blood pressure regularly. Be hydrated, by drinking water regularly. Reference: Textbook of Harrison’s principles of internal medicine by Jameson fauci 20th edition Page no- 2099. https://www.micromedexsolutions.com/micromedex2/librarian/ssl/true https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes/syc-20369048 Textbook of Clinical Pharmacy and Therapeutics by Roger Walker and Cate Whittlesea , 5th edition. Page no- 255 to 271