Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
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17 days at the VA – day 17
1 Dec2009
55 yo man with SC disease and membranous nephritis. He is taking an ACE inhibitor to decrease his urine protein and delay progression of renal disease. We saw these labs
| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 133 | Cl | 107 | BUN | 27 |
| K | 5.1 | HCO3 | 19 | creat | 1.2 |
This was the last day of my tour at the VA. So instead of making this a puzzle, I will tell you what we did. You can consider your options before you read what follows:
Serum osms 283
Urine osms 351
Urine Na 101
Urine K 13
Urine Cl- 96
We did not obtain an ABG because we felt the diagnosis was crystal clear.
TTKG was low at 2.1 confirming low aldosterone effect
Urine anion gap was positive +18 confirming renal acidosis
ACTH stim test was normal
So we made a diagnosis of type IV RTA. We consulted renal, and they decided to withhold the ACE inhibitor for 2 weeks, checking a urine protein/creatinine now and then. They will reassess this complex problem at that time, i.e., the patient needs and ACE-I to decrease proteinuria, but the ACE-I induces a type IV RTA.
I hope my nephrology readers will provide a commentary on how they would handle this problem.
Related posts:
- 17 days at the VA – Day 3
- 15 days at the VA – day 2
- 17 days at the VA – day 14
- 17 days at the VA – Day 1
- Another hyperkalemia – my explanation
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4 Responses to 17 days at the VA – day 17
Pro Nephros
December 1st, 2009 at 10:18 pm
People with sickle cell disease can get tubular hyperkalemia even without an ACE-I. This being said, I personally would not consider a K of 5.1 a good enough reason to stop the ACE-I. I would put the patient on oral sodium bicarbonate tablets or Shohl's solution, and add furosemide or torsemide if necessary, in order to keep the ACE-I.
Happy Hospitalist
December 2nd, 2009 at 12:19 am
I think the need for decreasing proteinuria with ACEi trumps the mild hyperkalemia and acidosis from IV RTA. Never seen someone die from that.
cory
December 2nd, 2009 at 6:40 am
The Potassium is within normal range and the sodium and bicarb are very minimally down.
Why do anything other than continue meds?
ErnieG
December 2nd, 2009 at 8:05 pm
The labs don't seem worrisome. You have clear evidence ACE-I prevents progression of renal disease in proteinuric states, his acidosis is minimal, and there seem to be no clinical problem with his electrolyte abnormality. Membanous nephropathy can lead to dialysis with close to 20% mortality in the first year; type IV RTA almost never leads to severe life threatening acidosis or severe hyperkalemia leading to dysrhythmia.. Are you treating the patient, or treating yourself?