Most likely diagnosis
1. As per the case study, the woman is of 80 years old and suffering from various diseases. However, chronic kidney disease is the most likely diagnosis. The patient is suffering from the type two diabetes mellitus since 10 years. Therefore, she has the chance of chronic kidney disease. From her medical report, it is seen that the amount of potassium, creatinine, HbA1c are very high. The normal range of HbA1c is 19-40 mmol/Mol (Gillett et al. 2015). As per the result, it is seen that the rate of HbA1c of the woman is 51 mmol/Mol. The range is very high therefore; the woman is at high risk. Another problem of the woman is that she suffering from the tachycardia. It can be a side effect of the high risk of type 2 diabetes mellitus. Chain and Gregory (2016) mention that the normal value of creatinine is 48-80 umol/L. From the various tests, it is found that the rate of creatinine is much higher that is 168 umol/L. Moreover, the level of urea is also high that is 13.8 mmol/L than the normal range that is 1.7-8.3 mmol/L.
2. From the each of the diagnostic test, the biochemical findings are achieved. From the risks of the type two diabetes mellitus, the patient gained various serious health issues like tachycardia, hypertension, disorientation and extreme weakness. The level of the potassium increased 5.7 mmol/L whereas the normal range of potassium is 3.7-5.4 mmol/L. The patient has the chance of attacked by the renal disease and chronic kidney disease. Moreover, the patient has the chance of renal failure. For this purpose, the mdrd formula test is done for the estimation of glomerular filtration rate. The e-GFR rate is 27 ml/min/ 1.73 sq.m. However, the normal range is >90 ml/min/ 1.73 sq.m. Therefore, it is seen that the result is much lower than the normal value of the e- GFR. The patient is belonging to the 4th stage of the chronic kidney disease and the function of kidney is being impaired. The rate of the ferritin is 273.1 ug/L. The normal range is 4.6-204 ug/ L (Kelkitli et al. 2016). The patient may suffer from chronic anemia due to insufficient production of red blood cells.
Potassium is important for the nerve and muscle cell function that helps to control the heart rate. When the potassium level in blood goes above the normal range, it is known as the hyperkalemia. Plasma ferritin indicates the total amount of iron that is stored in body. The deficiency of ferritin shows the symptoms of the iron deficiency anemia. The higher rate of urea can cause poor condition of homoeostasis and impaired electrolytes due to chronic kidney disease. (Tobias et al. 2014). Moreover, the protein catabolism rate increases and the patient suffer from the acute glomerulonephritis, polycystic kidney disease, chronic nephritis and nephrosclerosis. Higher rate of creatinine indicates the symptoms of the renal health, as it is the byproduct of the muscle metabolism (Wang et al. 2017).
3. As mentioned by Logue et al. (2013), creatinine refers to the waste product of normal muscle breakdown. Kidney filters the byproduct creatinine from blood in urine and reabsorb little amount of creatinine. When the amount of reabsorption rate goes higher, abnormalities are seen in the patient like the problems of kidney and the kidney may damage. The GFR rate always depends on the age, sex, race and size. The glomerular filtration rate is estimated by the creatinine clearance that is the good estimation. Mindikoglu et al. (2014) opined that the sample collection for the creatine clearance test is very vital and important. Wrong sample collection can differ the result of the creatinine clearance test. From this interpretation and result, it is clear that the result of creatinine clearance test of the patient who is the woman of 80 years old is normal. However, the other parameters of the patient show that she has higher risk of renal disease and kidney failure.
Biochemical findings and their clinical significance
Creatinine Clearance = (U×V)/ P mL / Min
U = Urine creatinine concentration (µmol/L)
V= Urine flow rate (m L / min or (L/24h / 1.44)
P= plasma creatinine concentration (µmol/L)
Urine creatinine concentration = 8.3mmol x 1000 = 8300 µmol/L=
U×V= 8300 x 1950ml /1.44m L/ min= 8300 x 1.354.1= 11238.2
Creatinine clearance= (11238.2/ 168) µmol/L= 66.89 mL/min
This test is suggested t6o check the accuracy of kidney function. It detects the problems of the kidney function and blood flow of kidney. The test is done to check the heart and kidney problem of a patient, who is suffering from diabetes mellitus type 2. This will also help to check the effects of the toxic drugs on kidney function. According to Logue et al. (2013), the 120 mL/min is the normal value of creatinine clearance and 1.73 m2 is the normal value of body surface area (BSA). BSA helps to check the body fat of a person. When the rate of creatinine clearance decrease than the normal value, it indicates various health issues like diabetes, heart failure, malfunction of kidney, shock, chronic kidney failure and dehydration.
4. In view of Chen et al. (2016) the age, sex and diet affects the rate of serum creatinine production.
The diet should contain fewer amounts of carbohydrate and protein. Moreover, the water also should be restricted as the renal function decreases. With the increasing age the function of the kidney starts to decrease. Therefore, the patient should take the modified diet. Moreover, the patient has hypertension and tachycardia, therefore, the intake of sodium and potassium should be restricted. The serum creatrinine sensitivity for early detection of the kidney disease is deprived and not a strong predictor for the analyzing the older people like the patient of 80 years old. The individuals who have higher muscle mass with normal renal function can have the false increased serum creatinine level. The modified diet may include the cystatin C that is a lower molecular weight. The basic protein helps to filter and metabolize tubular reabsorption with the small amount of the excreted urine.
Females and older people produce lower amount of creartinine in comparison to the male and the young people. However, the production rate differ from person to person and in people of different age group. The Due to usage of this basic protein, the serum creatinine production rate does not affected by the age and sex. The person who uses this basic protein gets the advantage of age and sex. The main important thing that affects the rate of serum creatinine production is the body mass index and the body fat (Tuot et al. 2015). Therefore, the calculation of the waist hip ratio is necessary to check the body fat. The body weight should be proportional with the serum creatinine production that is decreased with the increasing age. The increase rate of the serum creatinine increases the problem of renal function. To avoid the error in calculation of the serum creatinine production, the sample of mid urine collection period serum creatinine should be used.
Creatinine clearance calculation and implications
5. Serum creatinine concentration helps to diagnose the impairment of the glomerular filtration. Cystatin C in recent days helps to diagnose the renal functional problems. It is independent of the age, sex and diet. Moreover, the body fat and body mass index also less important factor for the persons who use the cystatin C as the basic protein. Cystatin C is a protein that is encoded by CST3 gene. Physicians mainly use the CST3 as the biomarker of the kidney function (Mindikoglu et al. 2014). However, it is very costly to use and takes long time. The molecular weight of cystatin C is very low. At the time of glomerular filtration, the cystatin C is removed from the blood stream. Sometimes, the physicians use the cystatin C in diabetes for the early detection. Cystatin C is effective for the elderly persons mainly. This is the sensitive marker of the glomerular filtration and help in early indicator of the impaired function of kidney. However, the measurement of Cystatin C alone has not shown the estimation of the kidney function. Body composition influences the cdystatin C. Cancer; thyroid dysfunction can affect the function of the cystatin C. Woo et al. (2014) mentioned that kidney dysfunction develop the risk of the cardiovascular disease and death. However, the function of kidney is related with the cardio vascular system. Therefore, the renal problems can affect the cardio vascular system and may be the cause of the heart failure. It is necessary to mention that the increase rate of the cystatin C can cause of death. Therefore, it should be used in limited rate to avoid the risk of death. This would not link with the kidney function. BMI can influence cystatin C. Non renal factors do not affect the function of the cystatin C. Moreover, it helps to detect and monitor the kidney disease in the service users with the hepatic disease. Cystatin C can correlate the appearance of the microalbumin. Kidney does not eliminate the dosing medication.
References
Chain, K. and Gregory, A., 2016. Use of Electrocardiogram as Part of the Preparticipation Examination. Pediatric annals, 45(1), pp.e26-e29.
Chen, S., 2013. Retooling the creatinine clearance equation to estimate kinetic GFR when the plasma creatinine is changing acutely. Journal of the American Society of Nephrology, pp.ASN-2012070653.
Chen, X., Wei, G., Jalili, T., Metos, J., Giri, A., Cho, M.E., Boucher, R., Greene, T. and Beddhu, S., 2016. The associations of plant protein intake with all-cause mortality in CKD. American Journal of Kidney Diseases, 67(3), pp.423-430.
Gillett, M., Brennan, A., Watson, P., Khunti, K., Davies, M., Mostafa, S. and Gray, L.J., 2015. The cost-effectiveness of testing strategies for type 2 diabetes: a modelling study.
Kelkitli, E., Ozturk, N., Aslan, N.A., Kilic-Baygutalp, N., Bayraktutan, Z., Kurt, N., Bakan, N. and Bakan, E., 2016. Serum zinc levels in patients with iron deficiency anemia and its association with symptoms of iron deficiency anemia. Annals of hematology, 95(5), pp.751-756.
Logue, J., Walker, J.J., Leese, G., Lindsay, R., McKnight, J., Morris, A., Philip, S., Wild, S., Sattar, N. and Scottish Diabetes Research Network Epidemiology Group, 2013. Association between BMI measured within a year after diagnosis of type 2 diabetes and mortality. Diabetes care, 36(4), pp.887-893.
Mindikoglu, A.L., Dowling, T.C., Weir, M.R., Seliger, S.L., Christenson, R.H. and Magder, L.S., 2014. Performance of chronic kidney disease epidemiology collaboration creatinine?cystatin C equation for estimating kidney function in cirrhosis. Hepatology, 59(4), pp.1532-1542.
Tobias, D.K., Pan, A., Jackson, C.L., O’reilly, E.J., Ding, E.L., Willett, W.C., Manson, J.E. and Hu, F.B., 2014. Body-mass index and mortality among adults with incident type 2 diabetes. New England Journal of Medicine, 370(3), pp.233-244.
Tuot, D.S., Lin, F., Shlipak, M.G., Grubbs, V., Hsu, C.Y., Yee, J., Shahinian, V., Saran, R., Saydah, S., Williams, D.E. and Powe, N.R., 2015. Potential impact of prescribing metformin according to eGFR rather than serum creatinine. Diabetes care, 38(11), pp.2059-2067.
Wang, X.L., Zhang, T., Hu, L.H., Sun, S.Q., Zhang, W.F., Sun, Z., Shen, L.H. and He, B., 2017. Comparison of Effects of Different Statins on Contrast-Induced Acute Kidney Injury in Rats: Histopathological and Biochemical Findings. Oxidative Medicine and Cellular Longevity, 2017.
Woo, K.S., Choi, J.L., Kim, B.R., Kim, J.E. and Han, J.Y., 2014. Clinical usefulness of serum cystatin C as a marker of renal function. Diabetes & metabolism journal, 38(4), pp.278-284.
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