Need Help-Case Study-Medicine


Need Help-Case Study-Medicine

Case Study-Medicine

Instructions to Writer:

  • Before approaching ANY of the following questions, familiarize and maximize your understanding to the clinical case in the below box. ALL questions are RELATED TO the clinical case.
  • With respect to EACH of the following questions, read carefully EACH word in the question, focus on and then answer EXACTLY the central core of the question by REVIEWING THE UPDATED LITERATURE EVIDENCE. It is absolutely important to provide a review summary based on updated literature evidence (preferably from publications within the recent 5 years in renowned nephrology journals (or other highly related journals in the field of renal disease management).
  • An EXTREMELY high-quality, concise, to-the-key-point summary of evidence from sound literature review is expected. Type the answer in paragraph in the space provided (named under “Literature Review Summary” below each Question.
  • Statements in literature review summary have to be well-referenced in APA 6th Style.
  • There is ABSOLUTELY NO need in the literature review summary to define medical terms. Do NOT restate well-known standard values in the field of nephrology. Every words must have value in presenting important evidence from literature.
  • All statistical numbers will NOT be counted as words.
  • The audience of this document are professional medical doctors with Doctor of Medicine Degree. So Professional writer is expected. Writing should be highly knowledgeable.
Clinical Case and Medical History:

Mr. Chan, a married 43-year-old male with a BMI of 32 kg/m2, is a known patient with chronic kidney disease (CKD) since 2011. He has a long history of repeated admissions for recurrent glomerulonephritis precipitated by IgA nephropathy. Severely obese though, he has no diabetes mellitus, yet with hyperlipidemia for the recent 10 years, and resistant hypertension for the recent 5 years. Of note, there was a recent relapse of IgAN this year in January 2016. At that time, he was admitted for diffuse proliferative IgAN with osteomyelitis at the sixth cervical vertebra following laminoplasty to the cervical spine stenosis. Although treatment was effective with a pulse dose of methylprednisolone, oral prednisolone, cyclophosphamide and vancomycin, his renal function further declined, as evidenced by a decrease in the estimated glomerular filtration rate (eGFR) from 19 mL/min/1.73 m2 to 16 mL/min/1.73 m2 at the time of discharge.

This time Mr. Chan was admitted for the management of acute mesangiopathic glomerulonephritis. Laboratory investigations (such as histopathology examination on renal biopsy samples) suggested that the primary cause of this insult was associated with class III IgA nephropathy. On admission, he was afebrile, complaining of dizziness, fatigue, oliguria for three days and decreased oral intake for two days. Lethargy and mild pedal edema were noted. His vital signs were as follows, blood pressure at 163/102 mmHg, respiration rate at 17 breaths/min and heart rate at 102 beats/min.

Owing to his moderate hyperkalemia, he was arranged to have temporary hemodialysis through placement of a temporary double lumen catheter at the right internal jugular vein. He was also asked to consider renal replacement therapy (namely haemodialysis and peritoneal dialysis) for his long-term management.

On admission, important laboratory results were listed as below.

24 urine collection: output: 302 ml; 3.8 g of proteinuria (i.e. nephrotic range of proteinuria)

Routine blood profile: Normal white cell and platelet level. Hemoglobin (Hb): 10 g/dl (Reference range: 13-17); Hematocrit (Hct): 31% (40-52); Blood urea nitrogen (BUN): 55 mg/dl (8-21); Serum Creatinine (Cr): 1485 μmol/L (80-115); K+: 6.7 mmol/L (3.5-5.1); Albumin: 34 g/L (34-54); Phosphate: 1.66 mmol/L (0.8-1.4); Estimated glomerular filtration rate (eGFR): 14 mL/min/1.73 m2 (stage 5 of end-stage renal failure)

Studies of serum complements: complement 3 and 4 normal

Serum IgA: 599 units (78-391)

Serology testing (antinuclear antibody, anti-glomerular basement membrane and anti-neurophil cytoplasmic antibodies, hepatitis panel, rapid plasma reagin, protein electrophoresis) normal or negative

Lipid panel: LDL elevated 4.8 mmol/L (<2.59 mmol/L)

Urinalysis: Haematuria with dysmorphic erythrocytes and 4+ proteinuria

 

  1. Describe the pathophysiology behind “acute mesangiopathic glomerulonephritis that is precipitated by IgA nephropathy” to explain the related patient laboratory values and presenting signs and symptoms. Give a brief highlight on the definitive diagnostic criteria and the principle(s) of treatments/management.
Literature Review Summary: (130-150 words excluding references)

 

 

Note: (Odd ratio, hazard ratio, or other statistical reporting data should be provided; any identified relations to the above case should be highlighted.)

 

  1. Describe the relationship between IgA-mediated glomerulonephritis (IgAN) and end-stage renal disease (ESRD) (and how do they correlate in terms of probability). Compare and contrast the epidemiology, incidence rate, morbidity and mortality rate of IgAN who transit to ESRD in Hong Kong, China, and other parts of the world. Describe main predictors for determining the rate of progression from the initial diagnosis if IgAN to ESRD. Describe prognosis, risk factors for complications for the patient group who have been shown with recurrent IgA-mediated glomerulonephritis.
Literature Review Summary: (180-200 words excluding references)

 

 

Note: (Odd ratio, hazard ratio, or other statistical reporting data should be provided; any identified relations to the above case should be highlighted.)

 

  1. Describe the unique challenges and the corresponding managements of peritoneal dialysis on obese patients (in particular, risk of peritoneal dialysis inadequacy, etc). (Preferably supplemented with Hong Kong experience/ research support, if not in Asian or other parts of the world are acceptable)
Literature Review Summary: (220-250 words excluding references)

 

 

 

Note: (Odd ratio, hazard ratio, or other statistical reporting data should be provided; any identified relations to the above case should be highlighted.)

 

 

 

  1. Describe the perceived experience and the objective Quality of Life of obese patients who undergo peritoneal dialysis.
Literature Review Summary: (100-120 words excluding references)

 

 

 

Note: (Odd ratio, hazard ratio, or other statistical reporting data should be provided; any identified relations to the above case should be highlighted.)

 

  1. What are the existing modality(ies) of peritoneal dialysis (e.g. CCPD, NIPD) most effective or preferred for obese end-stage renal disease patients? How do the treatment outcomes differ across these modalities (provide controversial evidence if appropriate)? What are the advantages and disadvantages of these modalities in the management of these patients from the point of nephrology? (250 words)
Literature Review Summary: (150-180 words excluding references)

 

 

 

Note: (Odd ratio, hazard ratio, or other statistical reporting data should be provided; any identified relations to the above case should be highlighted.)

 

  1. Minimal residual kidney function contributes significantly to solute removal and dialysis adequacy. Compounded by the unique challenges of peritoneal dialysis in obese ESRD patients, describe how each of the risk factors (namely, resistant high blood pressure, diet control on salt intake and fluid balance, sedentary life-style, obesity, hyperlipidemia with increased low-density lipoprotein) that might lead to poor outcomes of peritoneal dialysis by accelerating the loss of residual renal function. Describe how beneficial outcomes on these patients are supported by literature by controlling these risk factors. (Odd ratio, hazard ratio, or other statistical reporting data should be provided.)
Literature Review Summary: (280-300 words excluding references)

 

 

 

Note: (Odd ratio, hazard ratio, or other statistical reporting data should be provided; any identified relations to the above case should be highlighted.)

 

 

 

  1. Provide literature evidence to support the following assertion.

A number of inaccurate preconceptions to the renal replacement modality- peritoneal dialysis (PD) has been identified by joint discussion with the patient and his family. Patient misunderstood that peritoneal dialysis inadequacy can be resolved by setting higher dialysis goal such as adopting a PD regimen with frequent PD exchanges. To achieve a desirable Kt/V, patient’s desire to opt for continuous ambulatory peritoneal dialysis (CAPD) might not be feasible, instead automated peritoneal dialysis (APD) might be needed, preferably in the form of continuous cycler peritoneal dialysis (CCPD). Considering the obesity of patient and the severe intra-abdominal pressure that might be uncomfortable, risk of catheter leak (despite technically pre-sternal catheter can be inserted rather than the traditional PD catheter on the abdomen), peritoneal dialysis inadequacy is likely.

Inadequate dialysis might lead to poor treatment outcomes such as increased morbidity, mortality, and the need to transfer back to HD. There has been a percentage of PD patients transferring back to haemodialysis (HD) due to PD inadequacy.

Literature Review Summary: (280-300 words excluding references)

 

 

 

Note: (Odd ratio, hazard ratio, or other statistical reporting data should be provided; any identified relations to the above case should be highlighted.)

 

Reference:

 

Need Help-Case Study-Medicine

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