6.4_ashley_fallbeispiel

Renal Case Studies
Cologne January 2011

Case 1.

Mr NT is a 40-year old man, diagnosed with testicular teratoma.
Weight
Before commencing treatment, a Cr-EDTA scan shows he has a GFR of 107 ml/min He is subsequently treated with: Prednisolone, Vincristine, Methotrexate, Bleomycin, Adriamycin, Cisplatin One week later, a routine set of blood tests shows Urea On his next admission, Mr. N.T. was given his chemotherapy as per protocol. Two days later, he was pyrexial with a temperature of 39.8o C. His full blood count revealed that he was neutropenic, WBC count = 1.3 x 10-9 (normal range 3.7 – 11.0 x10-9 ), Neutrophil count = 0.1 x 10-9 (normal range 1.5 – 7.5 x 10-9 ). He was prescribed empirically the following drugs:- Gentamicin IV His biochemistry over the following days was as follows:- Comment on the antibiotic therapy he has been prescribed. Do you need to intervene?? Case 2

Mr. D.K. is a 76 year-old man admitted to general surgical ward for repair of abdominal aortic
aneurysm.
HPC One week history of intermittent abdominal pain, backache and breathlessness. Pulsating
Referred as an emergency by General Practitioner. Angiogram shows dissecting aortic aneurysm - needs urgent repair. PMH Hypertensive for the last 20 years. Partial seizure epilepsy since childhood. Declining renal function secondary to hypertension. Married with 2 children - lives with wife Serum Creatinine 140 µmol/L (49 - 92 µmol/L) At operation Mr.D.K. experiences a major haemorrhage and collapses in theatre. He is resuscitated and taken to ITU where he is commenced on inotropes and cefotaxime IV 2g TDS. Urine output has dropped to about 10 ml/hour Temp 380C , BP 130 / 75, WBC count 15.8 x 109/L Describe the factors which influence drug removal during haemodialysis and Comment on the patient's prescription above. What changes you would DAY 7 Mr. D.K. is well enough to be discharged from ITU. He has not recovered any renal function so is transferred to a renal ward to receive intermittent haemodialysis. Do you need to amend his drug doses again? Case 3
Mrs BH is a 43 year old woman, admitted with a 3 day history of fever, rigors, night sweats, and
general malaise. On examination she was noted to have splinter haemorrhages under her
fingernails and she had developed a new heart murmur. She had recently had a tooth extracted.
Previous Medical History
Diagnosed with lupus nephritis at age 31.
Reached end stage renal failure 3 years ago.
She now has haemodialysis, for 4½ hours, 3 times a week.
Temperature 38.2oC BP = 135/90 mmHg
Serum biochemistry
Normal range
An echocardiogram revealed vegetation on the mitral valve. Blood cultures were taken, which subsequently grew Streptococcus viridans. A diagnosis of infective endocarditis was made, and Mrs BH was admitted to the medical ward for intravenous antibiotics. She was empirically prescribed:- Benzylpenicillin IV 1.2g every 4 hours + When the results of the blood cultures were known, amoxicillin 2g every 8 hours was added to her antibiotic regimen. Do you want to make any dosage adjustments for this patient? Sensitivities showed Mrs. BH had acquired a resistant strain of Strep. viridans, and the microbiologists advise that a new antimicrobial agent, “Streptoban”, be added to her current drug therapy. There is no immediate data on appropriate dosing in haemodialysis but the following information about Streptoban is available:- • The molecular weight is 370 daltons, • 85% of the oral dose is excreted unchanged in the urine, • Plasma protein binding is about 15%, • The normal intravenous dose for a healthy adult is 1g BD. What is the likely clearance of Streptoban by intermittent haemodialysis? Haemodialysis gives an effective GFR of approximately 10 ml/min Dosing in Renal Failure = Daily Dose x [(1 - Feu) + (Rf x Feu)] Feu - Fraction excreted unchanged in the urine. Rf - Extent of renal impairment as a fraction of renal function. Mrs. N.R. is a 43-year old woman, admitted for treatment of a severe case of shingles (herpes zoster). PMH Diagnosed as having adult polycystic kidney disease at age of 39. Reached end stage renal failure 4 years ago. Has been on automated peritoneal dialysis, 10 hours overnight, 5x / week, ever since. BP = 135/84 Daily fluid allowance = 500ml Her initial serum biochemical and haematological profile is:- Sodium It is decided she requires intravenous aciclovir. Q1. What dose would you recommend, and how would you administer it? If Mrs. NR was on intermittent haemodialysis, what dose of aciclovir would you If Mrs. NR was on CRRT, what dose of aciclovir would you recommend?

Source: http://www.aminfo2009.de/aminfo2011/downloads/vortraege/6.4_Ashley_Fallbeispiel.pdf