Thomas Lanning MD.

Abdul Hamid Alraiyes MD.

47 years old AAM
Chief Complaints
Nausea
Vomiting
Abdominal Pain
CP
Past surgical Hx:
Lt AKA (1 year ago)
Rt AVF (radial artery)
Rt Big toe amputation
Lt IJ Dialysis catheter (3/10/2007)
Allergies:
Penicillin “rash”
Social History:
Resident at Cleveland Rehab
Denies any Hx of:
ETOH
Drug abuse
Ex- SMOKER

Family History:
DM
HTN
Medications:
Insulin aspart 5 units S.Q. Q AC
Lantus 20 units S.Q. QHS
Hydralazine 100mg P.O. Q8hr
Lisinopril 20mg P.O. QD
Lopressor 50mg P.O. BID
Norvasc 10mg P.O. QD
Renagel 800mg P.O. TID
Nephrocap 1 tab P.O. QD
Neurontin 300mg P.O. Q 8hr
Fluoxetine 20mg P.O. QD
Vancomycin 600mg I.V. with HD
Physical Exam:
V/S : 36- 120/56 - 62 – 17 - SPO2= 86% on RA
Pt is drowsy, dehydrated, not in distress
Skin: 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
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
Labs:
AG= 21
Serum Osmolality= 348 (275-290)
ABG= 7.048 / 41.8 / 75.1 / 11 A-a= 32 SAT= 86
FiO2 = 21%
119 – (86 + 12) = 21
Expected AG = 21 + [ 2.5 X (4.5 – 3.8] = 22.75
PCO2 = (1.5 X 12 ) + 8 +/- 2 = 28 - 24
PCO2 = (1.5 X 12 ) + 8 +/_ 2 = 28 – 24
ABG= 7.048 / 41.8 / 75.1 / 11

Metabolic Acidosis + Respiratory Acidosis

AG Excess / HCO3 deficit = 22 – 12 / 24 – 12 =~ 1
Labs:
Amylase= 102 Lipase=1082
LFT WNL ALP=242
CPP = 94 / 3 / 0.14
UA not done “Pt is anuric”
EKG: LVH
Cardiomegaly Bil pleural effusion
Small amount of ascites
Wall thickening of proximal Small bowel
in Lt upper abdomen
Mild renal atrophy
10 units R insulin x 2 I.V.
No I.V.F
naHCO3 tow Apm
Kayexalate 30 gram PO
CaCl 1 Amp
 Uncontrolled
blood sugar
Ketones
accumulation
Volume
contraction
DKA Starvation

Sepsis

MI
 Blood Sugar

1500
Axis Title

1000

500

Blood Sugar

Mon Mon Mon Mon Mon Mon Mon Mon Mon Mon Mon Mon
1 2 3 4 5 6 7 8 9 10 11 12
Blood Sugar 671 820 138 266 340 168 393 663 284 736 217 1140
•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.
•K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 4(Suppl 3):S1.
•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.)
 Osmolality

400
Axis Title

200

Osmolality

Mon Mon Mon Mon Mon Mon Mon Mon Mon Mon Mon Mon
1 2 3 4 5 6 7 8 9 10 11 12
Osmolality 312 320 248 273 266 243 255 277 244 245 260 348
 Hyperglycemia > 250
Anion Gap
Serum HCO3 < 20
Urine or Blood Ketones
+ NADH + NAD
 NPO
 INSULIN ( Bolus + Infusion)
 IVF
 Hyperkalemia / Hypokalemia
 ? NaHCO3
DKA + ESRD
INSULIN
INSULIN + ESRD
 INSULIN resistance 2 nd 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.
 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.
 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.
IVF
IVF
Hemo-dialysis
-Indications?
-Fluid removal?
 Indications?
• Metabolic Acidosis
• Hyperkalemia
• Uremia
• Decrease the Insulin resistance
• Low S O2 ? Pulmonary edema
Hyperkalemia?
• Usually no potassium replacement
• Check within 2 Hr after HD
• If AVF avoid the site of HD
• ESRD no osmotic diuretic effect.
Central I.V Access
Central I.V Access
NaHCO3?
 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