In fact, there is misdiagnosis and mistreatment in this case.
The patient is an 82-year-old man who has been suffering from diabetes for more than 40 years.
Gangrene of the foot has been experienced, and after treatment, it has stabilized, and the toe that was almost rotten has been saved.
People with diabetes often have high blood pressure. The patient has been suffering from hypertension for more than 30 years, eating antihypertensive drugs, and the blood pressure is stable, 110~140/60~70mmHg.
Most people with diabetes will have coronary heart disease. The elderly also have coronary heart disease and have lived in our cardiology department, but they have been controlled and stable.
Diabetics also have cerebrovascular disease. The elderly have suffered from cerebral infarction, so they sometimes live in neurology.
Diabetes can damage the kidneys, the elderly will also have decreased kidney function, and patients also have decreased kidney function.
A year before death, creatinine and urea nitrogen in the blood began to rise. Elevated creatinine is not particularly high, around 180 to 200 mol/L, but not low for an 81-year-old man.
In September of this year, the patient had "stomach" discomfort, anorexia, nausea, and could not eat, so he was hospitalized. The doctor suspected that it was a digestive tract disease, checked the patient's digestive tract barium meal, found no abnormality, and did symptomatic treatment. By this time, the patient's serum creatinine had risen to 292 mol/L. Because the patient's serum creatinine had also been elevated earlier, the doctor did not pay attention to it.
Just in time for the National Day holiday, the old man was discharged from the hospital and went home for the festival.
Just after the long holiday, the old man was sent to the rescue.
Recurrent episodes of ventricular tachycardia and ventricular arrest alternate, repeated episodes of "A-S syndrome" (cardiogenic ischemia), and repeated CPR rescue.
At this time, the blood potassium was as high as 7.5 mmol/L, and there was metabolic acidosis in blood gas analysis, as well as moderate anemia, and the ELECTROCardiogram also had obvious myocardial ischemia.
After asking for medical history, the patient ate lamb dumplings and bananas and oranges before the onset of the disease.
In the interval between rescue and recovery and heartbeat recovery, the old man will still have a short awakening, recognize us, and hold our hands.
However, the interval is so short that the nephrology department does not have the opportunity to do emergency dialysis of carotid puncture catheter, and can only be treated with internal medicine drugs.
After 8 hours of rescue, the patient died. Malignant ventricular arrhythmias due to chronic renal failure, hyperkalemia.
Look back at this case.
★ Diabetes can cause kidney damage.
Diabetes combined with hypertension, high blood lipids, atherosclerosis will also damage the kidneys, coupled with the elderly kidney function even if normal is reduced to the marginal state, under the heavy blow, kidney function damage will reach the end stage of kidney disease.
Renal hypofunction cannot be based on urine output alone.
Many people think that the kidneys are urinating, and the kidney function will be less urinating, and the reverse push is that the amount of urine is a lot of kidney function. Not really.
The kidneys also have the function of concentrating and diluting the amount of urine, and also exchange acids and bases, electrolytes, and regulate the excretion of metabolites. When the kidney function is not good, the amount of urine can be normal, but the quality is problematic, and toxic substances cannot be excreted.
Therefore, the kidney function is not good to a serious extent, it is called "uremia".
Elderly people have poor kidney function and cannot look at the level of serum creatinine alone.
Now many people know that poor kidney function depends on the level of creatinine in the blood. Because such substances as blood creatinine are not easy to excrete when the kidney function is not good, the level of blood creatinine reflects the condition of kidney function to a certain extent. However, the level of blood creatinine is also related to many factors, diet, muscle mass in the body, metabolism, etc., so it is more accurate to judge kidney function with "glomerular filtration rate".
However, the measured glomerular filtration rate is troublesome, so medically it is estimated by some formulas to judge renal function by "estimated glomerular filtration rate". For example, in this old man, when the blood creatinine is 292 mol/L, the estimated glomerular filtration rate is only about 20 ml per minute, according to the staging of chronic kidney disease is the 4th stage, and dialysis needs to be prepared. If you look at serum creatinine alone, you may feel that it is not too high.
Such patients can easily be aggravated by some triggers such as infections or improper diet.
★ In chronic kidney disease, renal hypofunction can present with many clinical manifestations.
Gastrointestinal symptoms and itchy skin are common.
Decreased kidney function, which causes a lot of metabolites and toxins to accumulate in the body, will stimulate various tissues and organs, causing symptoms of discomfort. Gastrointestinal symptoms are the earliest and most prominent. Patients can have anorexia, nausea, vomiting, diarrhea, bad breath, and stomatitis and mouth ulcers. Skin itching is also the most common complication.
Therefore, the doctor should comprehensively analyze the condition to explain the clinical symptoms.
Cardiovascular disease and electrolyte disorders are the most serious.
Cardiovascular disease is the most common complication and cause of death from chronic kidney disease. Uremia toxins can cause damage to the blood vessels, myocardium, pericardium of the heart, as well as other damage to the whole body, urine can not be excreted, water and salt are stored in the body, anemia, will lead to a decrease in heart function, failure.
Electrolyte disorders, like the hyperkalemia present in this patient, affect all kinds of electrical activity of cardiomyocytes, and various arrhythmias and malignant arrhythmias, including ventricular fibrillation and ventricular arrest, can be fatal in minutes.
For patients with kidney failure, diet is strictly controlled. The patient ate lamb stuffed dumplings before the onset of the disease, a high-protein, high-fat, and high-potassium diet, and ate high-potassium fruits such as bananas and oranges, and the sick kidneys were overwhelmed. On the basis of the original, coupled with severe arrhythmias induced by hyperkalemia, it eventually leads to death.