Case 4: An 80-year-old woman was admitted with a diagnosis of hypertension, cong
ID: 55381 • Letter: C
Question
Case 4: An 80-year-old woman was admitted with a diagnosis of hypertension, congestive heart failure, anemia, possible diabetes and chronic renal failure. She was treated with diuretics and IV fluids and released 4 days later. Her lab results are shown below (2/11 and 2/15).
Five months later, she was re-admitted for treatment of repeated bouts of dyspnea. She was placed on a special diet and drugs to control her hypertension and was discharged. It was felt that she had not been taking her medication as prescribed and she was counseled regarding the importance of regular doses.
Test
2/11
2/15
7/26
7/28
BUN, mg/dL
58
*
*
61.0
Creatinine, mg/dL
6.2
6.2
6.4
6.0
Uric Acid
10.0
*
*
9.2
BUN/Creatinine
#
*
*
#
Glucose
86
80
113
*
* means the test was not done
# means you need to calculate the number
1..Note that this patient’s admitting diagnosis is “possible diabetes.” If this patient had truly been a diabetic with an elevated blood glucose and positive ketone, what effect would this have had on the measured values for creatinine? Explain.
Test
2/11
2/15
7/26
7/28
BUN, mg/dL
58
*
*
61.0
Creatinine, mg/dL
6.2
6.2
6.4
6.0
Uric Acid
10.0
*
*
9.2
BUN/Creatinine
#
*
*
#
Glucose
86
80
113
*
Explanation / Answer
Diabetes is one of the major contributing factors to kidney diseases. Diabetes causes injury to microcirculation of the kidneys. The small blood vessels get damaged and kidneys cannot filter blood properly. This leads to retention of more water and salt by the kidneys. Elevated blood urea nitrogen and serum cretinine are late signs of diabetic kidney disease. Anemia and hypertension are commonly associated with this condition.
However, the blood glucose appears to be normal at this stage because damaged kidneys cause less breakdown of insulin, and hence diabetic with renal diseases experience transient normal blood glucose levels.
Urine albumin to creatinine ratio is measure to assess kidney damage. Normally, urine contains large amounts of creatinine but little or no albumin. Even a small increase in the ratio of albumin to creatinine indicates kidney damage.
Healthy kidney excretes creatinine in the urine, and hence plasma creatinine levels are very low, less than 1mg/dl. Impairment of kidney functions lead to accumulation of creatinine in serum. The higher is the blood creatinine level, the lower is the glomerular filtration rate, and the worse is the condition of kidneys. Creatinine level of 6 indicates reduction of GFR from 15 to 20% of the normal.
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