Nephrology

PCP submission

55 yrs old M with CHF, CKD and HTN coming for follow up after hospitalization.

Pt was readmitted at the hospital on 1/4/2021 for SOB, DOE, respiratory failure

Hospital records reviewed: 1/4/2022 HF with LVEF 40-50% as of echo done on 1/2022. prior to that his LVEF was less 50-60% so he is deteriorating. This is the second time in 2 months that the pt. has been hospitalized for similar problems. Had occasions where QT interval was prolonged. According to pt’s hospital discharge notes – he had elevated Kappa and Gamma light chain elevated electrophoresis study for which he was referred to Hematologist also advised 24 hrs Urine electrophoresis ( which is pending) I don’t know at this point why they did electrophoresis . During routine blood tests in the clinic his serum proteins and CBC levels did not show anything – his WBCs was elevated 11.2 (repeat hospitalization and chronic comorbidities may be the cause) .

Recent lab tests done in the clinic on 1/28/2021 showed CKD stage 4. GFR 16 and creat 3.28, electrolyte levels were normal. Pt never been dialysed.

Hospitalization 12/12/2021: suspected hyperaldosteronism due to persistent hypokalemia and HTN.

I am not initiating tests for hyperaldosteronism now because that will delay care with the specialist and his K levels were WNL ( low normal) during his recent blood tests.

His blood pressure today was >150/90

Pt was given referrals to nephrology and cardiologist, which he has not yet followed up with.

Is there anything else we can do while patient awaits to be seen by Nephrologist and cardiologist?

Specialist response

Thanks for sharing this case. I suggest the following-

1. Confirm not taking OTC NSAIDS or PPI (h2 blocker ok).
2. Confirm following 2 gram sodium diet.
3. Ideally should monitor body weight daily and should be on a sliding scale diuretic dose depending on weight. This can be achieved by first establishing target weight (the lowest weight at which patient is not feeling dizziness/orthostatic) and then typically if weight increases by >2 lbs on consecutive days then at least 50% rise in daily diuretic dose till patient comes back to target weight 3. confirm not a tobacco user.
4. Check urine bence jones proteins on spot specimen. Kappa, lambda elevations per se are not significant unless Kappa/Lambda ratio is elevated.
5. Check hepatitis panel, renal doppler, PTH, vitamin D, calcium, phosphate, iron panel.
6. Patients like this with cardiorenal syndrome are difficult to manage and are at high risk for recurrent hospitalizations. Home visiting nurses can be helpful for closer monitoring.
7. If serum bicarb is below normal then start sodium bicarb 650 mg daily.
8. In addition to general nephrology (or through general through) he should also be referred to transplant nephrology. He is at risk for kidney disease. progression and requirement of dialysis
9. Check chem-7, magnesium, hg q 4-6 weeks. Intervals for other lab checks like PTH will depend on the results from initial Tess.

Forgot to mention checking urinalysis with sediment and urine microalb/cr ratio.