Management of DM in Patients With CKD

Monitor blood pressure, serum creatinine, and serum potassium levels within 2 to 4 weeks after initiating or increasing the dose of an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB). ACEi or ARB therapy should generally be continued unless serum creatinine increases by more than 30% within 4 weeks of initiation or dose escalation.

According to FDA recommendations, metformin should not be used in men with a serum creatinine level ≥ 1.5 mg/dL or in women with a level ≥ 1.4 mg/dL, or in individuals over 80 years of age with decreased creatinine clearance. However, treatment with metformin is recommended in patients with type 2 diabetes (T2D), chronic kidney disease (CKD), and an estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m².

ADA/KDIGO Consensus Statements:

All patients with type 1 or type 2 diabetes and CKD should be managed using a comprehensive, individualized care plan developed collaboratively between healthcare professionals and the patient. This plan should focus on optimizing nutrition, physical activity, smoking cessation, and weight management. Evidence-based pharmacologic therapies should be implemented to preserve organ function, alongside additional treatments aimed at achieving intermediate targets for glycemic control, blood pressure, and lipid management.

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Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS)

Myocardial Infarction (MI)

Myocardial infarction is classified into five types based on the underlying etiology and clinical circumstances:

• Type 1 MI: Spontaneous myocardial infarction resulting from ischemia due to a primary coronary event, such as plaque rupture, erosion, fissuring, or coronary artery dissection.

• Type 2 MI: Myocardial ischemia secondary to an imbalance between oxygen supply and demand. This may occur in the setting of increased demand (e.g., severe hypertension) or decreased supply (e.g., coronary artery spasm, embolism, arrhythmias, or hypotension).

• Type 3 MI: Sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia and presumed new ECG changes or ventricular fibrillation before biomarkers can be obtained.

• Type 4a MI: Myocardial infarction associated with percutaneous coronary intervention (PCI), defined by an elevation in cardiac troponin (cTn) values >5 times the 99th percentile upper reference limit (URL), along with evidence of ischemia.

• Type 4b MI: Myocardial infarction associated with documented stent thrombosis.

• Type 5 MI: Myocardial infarction occurring in the context of coronary artery bypass grafting (CABG), with cTn elevation >10 times the 99th percentile URL and supporting clinical or imaging findings.

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Infarct Location and Clinical Implications

• Right Ventricular (RV) Infarction: Most commonly results from obstruction of the right coronary artery or a dominant left circumflex artery. It is characterized by elevated right ventricular filling pressures, which may be accompanied by severe tricuspid regurgitation and reduced cardiac output. RV infarction can significantly impair hemodynamics.

• Inferoposterior Infarction: Often leads to some degree of RV dysfunction in approximately 50% of cases and hemodynamic compromise in about 10–15%. In patients with inferoposterior infarction, elevated jugular venous pressure in conjunction with hypotension or shock should prompt consideration of RV involvement. RV infarction in the setting of left ventricular infarction markedly increases mortality risk.

• Anterior Infarction: These infarcts are typically larger and are associated with worse outcomes compared to inferoposterior infarctions. They usually result from obstruction of the left coronary artery, particularly the left anterior descending artery. In contrast, inferoposterior infarctions are commonly due to right coronary artery or dominant left circumflex artery occlusion.

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Acute Cholangitis

Cholangitis

Cholangitis was first defined in 1877 by Jean-Martin Charcot, who described the pathognomonic triad of fever, right upper quadrant pain, and jaundice. Today, cholangitis is defined as the presence of increased hepatic intraductal pressure along with concurrent infection of the obstructed bile ducts.

Chole: Derived from the Greek word “cholē,” meaning bile.
Angio: Comes from the Greek “angeion,” meaning vessel.
Cholangitis: Refers to a bacterial infection of the biliary tree.

The pathogens most commonly identified as causative agents of acute ascending cholangitis are gram-negative and anaerobic organisms. The most common pathogens include Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, and Citrobacter.

Iatrogenic introduction of bacteria often occurs following endoscopic retrograde cholangiopancreatography (ERCP) in individuals with biliary obstruction.

• Charcot's Triad: The classical triad (fever, right upper quadrant pain, and jaundice) has high specificity (95.9%) but low sensitivity (26.4%).

• Tokyo Guidelines (2018): The sensitivity of the Tokyo guidelines is 100%, with a specificity of 87.4%.

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Pseudo- Conditions in Medicine

 

The term ‘pseudo’ means ‘false’, ‘pretended’, ‘unreal’, or ‘sham’. Likely to be of Greek origin, pseudes means false. There are a number of ‘pseudo’ terms and syndromes that we see in the common practice. Even though the meaning of pseudo is unreal or sham, however several medical conditions/ syndromes are true entities as described above.

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Acute Pulmonary Embolism

"D" sign:

In a physiologically normal heart, LV pressure > RV pressure. When viewing heart in a parasternal short axis during systole the LV maintains a circular appearance, bowing the intraventricular septum into the right ventricle. A D-shaped left ventricle or flattening of the interventricular septum with a D-shaped configuration is a feature described with significant RV overload / right heart strain such as that occurring with complications of a sizable pulmonary embolic event.

McConnell's sign:

An echocardiographic finding of segmental right ventricular wall‐motion abnormality with apical sparing, is highly specific in acute pulmonary embolism and may guide rapid intervention when other testing is not feasible.

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Thyroid storm

 

Thyroid Storm

Thyroid storm is a rare and life-threatening condition characterized by an acute exacerbation of thyrotoxicosis, marked by elevated levels of free triiodothyronine (T3) or free thyroxine (T4) and suppressed thyrotropin (TSH). It presents with severe clinical symptoms and can lead to multiorgan failure, affecting various organ systems, including the central nervous system, cardiovascular system, hepatic system, pulmonary system, respiratory system, digestive system, and gastrointestinal excretory system.

Specific Strategic Steps for Treatment

• Therapy to control increased adrenergic tone: Beta-blocker
• Therapy to reduce thyroid hormone synthesis: Thionamide
• Therapy to reduce the release of thyroid hormone: Iodine solution
• Therapy to block peripheral conversion of T4 to T3: Iodinated radiocontrast agent, glucocorticoid, PTU, propranolol
• Therapy to reduce enterohepatic recycling of thyroid hormone: Bile acid sequestrant

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Urinalysis & Urine Sodium

     

Theophilus Protospatharius, a seventh-century physician, authored the first manuscript focused exclusively on urine, titled "De Urinis." In this work, he demonstrated that heating urine precipitated proteins, thereby documenting proteinuria as a disease state. Later, in the 12th century, the French scholar Gilles de Corbeil classified 20 different types of urine based on variations in urine sediment and color. He also introduced the "matula," a glass vessel that allowed physicians to assess the color, consistency, and clarity of urine.

Following includes the complete analysis of urine:

Visual exam

• Color. 

• Clarity

Dipstick test

• Acidity (urine pH). 

• Bilirubin. 

• Blood (hemoglobin). 

• Glucose. 

• Ketones

• Leukocyte esterase.

• Nitrites. 

• Protein

• Urine specific gravity test. 

Microscopic exam

• Crystals. 

• Epithelial cells. 

• Bacteria, yeast and parasites (infections). 

• Red blood cells (RBC). 

• Urinary casts: 

• White blood cells 

Fractional excretion of Sodium (FE Na).

• [(U Na x P Cr) / (P Na x U Cr)] x 100
• U = Urine, P = Plasma, Cr = Creatinine, Na = Sodium.
• Re-absorption and filtration accounted (Both).
• Should not be used with normal renal function.

Acute Kidney Injury (AKI)

• FE Na < 1%
• Urine sodium < 20 mEq/L.

Acute Tubular Necrosis (ATN)

• FE Na > 2%
• Urine sodium > 40 mEq/L.

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Capnography

CAPNOGRAPHY V/S PULSE OXIMETRYCAPNOGRAPHY 

• Provides a measure of ventilation – or concentration of CO2 exhaled air
• (aka end tidal CO2 or etCO2).
• Not effected by supplemental oxygen.
• Reflects breath-to-breath ventilation.
• Appear not normal if the patient has stopped breathing.
• Apnea or hypoventilation is detected immediately by capnography

PULSE OXIMETRY 

• Measures oxygenation or arterial blood oxygen saturation & pulse rate.
• Detects oxygen deficiency (hypoxia).
• May appear normal even if the patient has stopped breathing.
• Takes time to detect Apnea or hypoventilation.

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