Lao Yang (pseudonym) was in a wheelchair and was pushed into the consultation room of Hu Ying, chief physician of the Department of Nephrology of Zhejiang University Second Hospital.
Half a month ago, he felt pain all over his body, he tried the home remedies in Tulang nearby, ate for half a month not only did the pain as usual but also vomited up and down diarrhea, went to the local hospital to check, and turned into uremia! After hemodialysis, he went back and forth to various hospitals for medical treatment, and this time he chose to come to Zhejiang Er.
Dr. Hu Ying carefully examined the test list and found that Lao Yang's renal function index (blood creatinine) a month ago was 120 μmol/L, although it exceeded the upper limit of normal (normal value 40-106umol/L), but it was not too bad, but the test sheet in front of him showed that blood creatinine was as high as 700 μmol/L, reaching the level of uremia, consider acute renal failure.
Folk remedies are the first object of suspicion, coupled with Lao Yang after taking the drug and pull and vomit, insufficient blood volume caused by the kidneys are relatively ischemic, and the kidney function deteriorated even more severely. The next laboratory test also confirmed Director Hu's speculation that secondary factors such as immunology were ruled out one by one, and Lao Yang's diagnosis considered acute renal failure (drug-induced, prerenal), and the home remedies were immediately discontinued, and it was necessary to strengthen the rehydration to correct volume depletion.
After rehydration, kidney protection and other treatments, just when Lao Yang's urine output gradually increased, the level of kidney function improved significantly. Hu Ying also found several abnormal indicators on the test form; electrolytes and blood uric acid. The test results showed that the phosphorus of Lao Yang was 0.35 mmol/L (normal value 0.81-1.45 mmol/L), blood potassium was 3.0 mmol/L (normal value 3.5-5.5 mmol/L), and blood uric acid was 166 (normal value 208-428 umol/L).
According to common sense, patients with renal failure due to excretion disorders, potassium, phosphorus and uric acid in the body are difficult to excrete, these indicators should be elevated, Lao Yang's test list is just the opposite, biochemical shows low potassium, low phosphorus, even uric acid are significantly low, and vomiting diarrhea are better and have not improved, why is this?
During the rounds, Director Hu asked about Lao Yang's joint pain. Speaking of pain, Lao Yang had a stomach to say.
Over the years, his whole body joints and bones have been painful, he does not know how many hospitals he has traveled to, how many departments he has seen, but the diagnosis he has obtained are various: senile arthritis, gouty arthritis, rheumatic polymyalgia, intercostal neuritis, spinal nerve entrapment syndrome, osteoporosis... After eating a lot of Chinese medicine and Western medicine, the pain became more and more serious, and later had to rely on a wheelchair to move.
For nearly a year, he regularly went to do a kind of "neural radiofrequency ablation surgery", it takes several thousand yuan to do it once, he can feel the pain relieve a little, and it doesn't take long to be old and a post, the money does not know how much it costs, this time if it is not to eat this new home remedy, it will not be acute kidney failure.
Speaking of this, Old Yang sighed: "Director Hu, you can cure my kidneys, it is already very good not to do hemodialysis, this bone pain, I really don't hold out any hope!" ”
When hu Ying flipped through the medical records, she saw that Lao Yang had viral hepatitis B, and found the familiar drug name in the previous eight years of anti-hepatitis B treatment data: adefovir dipivoxil. Director Hu has a bottom in his heart, Lao Yang's whole body joint pain problem, now it is a crooked beating, find the right doctor!
Hu Ying arranged further examinations for Lao Yang, which confirmed her judgment, Lao Yang's urinary phosphorus excretion rate was as high as 115% (normal value was less than 30%), the urine amino acid test was strongly positive, and the ECT results of the whole body bone showed that there were multiple radioactive concentrations throughout the body (pictured), and from the image film, it was as if the bones had turned black. The location of the distribution coincided with the location of Lao Yang's usual pain. Director Hu gave the final diagnosis: drug-induced Fanconi syndrome (caused by adefovir dipivoxil), hypophosphorus metabolic bone disease, acute renal failure.
After the diagnosis was confirmed, Hu Ying reformulated Lao Yang's treatment plan: adefovir ester was discontinued, entecavir was used to fight hepatitis B virus, and phosphorus and potassium supplementation were strengthened.
Three months later, full of red light, refreshed Old Yang returned to Director Hu's clinic, this time, Old Yang was walking, the results of the review were satisfactory: blood creatinine returned to the baseline level of 118umol/L, blood potassium, blood phosphorus and uric acid are normal, and the whole body pain that has plagued Old Yang for many years has also subsided!
In fact, in patients who have similar experiences with Lao Yang, there are at least nearly 100 cases of Fanconi syndrome caused by drugs in the Department of Nephrology of Zhejiang University Second Hospital, and adefovir dipivoxil is the most common type of drugs.
By damaging the proximal epithelial cells of the renal tubules, the drug causes reabsorption disorders of potassium, phosphorus, glucose, uric acid and other substances, resulting in the loss of these substances from the urine. Calcium and phosphorus are an important component of bones, and long-term hypophosphatemia can affect bone metabolism. More than half of patients present with bone pain that is difficult to correct, and they tend to travel to other departments and are easily misdiagnosed.
According to the incomplete statistics of the Single Center of the Second Hospital of Zhejiang University, these patients visited an average of 2.8 departments before the diagnosis was confirmed, and the average diagnosis time reached 2.3 years. Inappropriate analgesic treatments can further impair kidney function and ultimately affect the patient's health.
Text | Nephrology Hu Ying
Figure | Partly from the network
Audit | Chen Guozhong Hu Ying
Editor-in-charge | Zhu Junjun