CV-CVS-Nephro CV-CVS-Nephro ConferenceConference

Presented by F1 潘恆之Commented by Dr.謝宏昌2012/04/18

CASE 1: 8480511CASE 1: 8480511CASE 2: 21508337CASE 2: 21508337CASE 3: 8853407 CASE 3: 8853407

CASE 1: 8480511CASE 1: 8480511

General DataGeneral DataAge: 40-year-oldGender: FemaleEthnic: TaiwaneseMarital status: Married

Past historyPast historyHypertensionSystemic lupus erythematous

with lupus nephritisChronic kidney disease, lupus

nephritis relatedVasculitis related enteritisHypothyroidism

2012/04/10 Nephro OPD◦ Hydroxychloroquine sulfate(200mg)--1# QD◦ Ultracet tab -------------------------------1# BID◦ Prednisolone(5mg) ---------------------- 4# QD ◦ Amlodipine (5mg) ------------------------1# QD ◦ Isosorbide-5-mononitrate(60mg) ---- 0.5# HS

2012/04/10 Rheuma OPD◦ Etoricoxib (60mg) ------------------------1# QD ◦ Esomeprazole mups (40mg) ------------1# QD ◦ Sennoside A+B calcium (12mg) --------1# HS◦ Cobamamide (250mcg) ------------------1# BID ◦ Prednisolone (5mg) -----------------------2# QD

Medication historyMedication history

Personal HistoryPersonal HistoryAllergy to SulindacShe denied smoking, alcohol, or

betel nut chewing.

Family historyFamily history

Younger sister: SLEFather: lung cancerGrandmother: Arrythmia

Course Course 2011/02/08 ~ 2011/03/15 Admission

2011/03/22 Nephro OPD

UrosepsisAcute on chronic kidney disease

◦ On FDL for H/D◦ Arrange Hickman insertion and AVF creation

Discharge on 03/15

2011/03/31 Nephro OPD

Ga

S/S: local heat and swelling around left AVF◦Cefuroxime 1# BID x 7 days

S/S: local heat and swelling around left AVF◦Vancomycin 1g st, Dicofenac, Neo-

cortisone cream◦Return to CVS OPD on 05/30

Course Course 2011/05/30 CVS OPD

2011/07/11 CVS OPD

S/S: left forearm swelling ◦Arrange Duplex of AVF

2011/06/13 CVS OPDS/S: left forearm swelling

◦Consider repair the stenotic basilic vein◦Arrange revision of A-V shunt with intering

Graft

S/S: no local swelling, heat nor tenderness around AVF◦Arrange Duplex of AVF for follow up

Course Course 2011/10/22 ~ 2011/11/12 Admission

2012/03/06 Nephro OPD S/S: Left forearm swelling, severe pain over

the left hands for 2 months◦Arrange Duplex of AVF

Sepsis due to catheter related infection◦Remove Hickman catheter on 10/24◦Try AVG => AVG malfunction was noted on

10/26◦Arrange Duplex of AVF*◦Arrange AVG transposition and l’t Hickman

insertion *

◦Discharge on 11/12

Course Course 2012/03/14~2012/03/30 Admission

Left index finger cellulitis ◦ Give empiric antibiotics: Oxacillin◦ Arrange antegrade venography*◦ Arrange reposition of the left basilic ven and interposition with intering graft*

Discharge on 03/30

2012/04/10 Nephro OPD S/S: no local swelling, heat nor tenderness

around AVF

Discussion

DiagnosisDiagnosisLeft forearm swelling due to arteriovenous

graft-antero cubital vein junction stenosis, status post repransposition of the left basilic vein and interposition with intering graft on 2012/03/22

End-stage renal disease, favor lupus nephritis related, under regular hemodialysis QW135

HypertensionLeft ovarian cyst and multiple uterine

myoma

DiscussionDiscussion

CASE II: 21508337CASE II: 21508337

General DataGeneral DataAge: 56-year-oldGender: FemaleEthnic: HakkaneseMarital status: MarriedAdmission date: 2011/10/31

Chief ComplaintChief ComplaintPoor appetite for one month

Present IllnessPresent Illness This 55-year-old female has history of

hypertension, chronic kidney disease and asthma.

She had experienced progressive anorexia for almost a month. General malaise, nausea, vomited with food content, dyspnea on exertion, orthopnea, abdominal pain, dysuria and insomnia were also mentioned. She denied fever, chills, tarry stool, bloody stool, diarrhea, headache or dizziness.

Besides, she also suffered from left arm weakness for 2+ months.

She had tried Chinese herbal medicine for renal function deterioration since 2 weeks before admission. However, the symptoms persisted and progressed, so she went to our ER for help. Under the impression of chronic kidney disease related uremic symptoms, she was admitted to our ward for further management.

Past historyPast historyHypertensionChronic kidney diseaseAsthma

Personal HistoryPersonal HistoryNo known allergy history to drug

or foodShe denied smoking, alcohol, or

betel nut chewing.

Family historyFamily history

No family history of diabetes mellitus, hypertension, malignancy, chronic kidney disease or other systemic diseases.

Physical ExaminationPhysical ExaminationBH: 148cm BW: 44.96kg Vital signs: BT:36.6 ℃ HR:97/min RR:20/min BP: right arm -- 229/104 mmHg left arm – 52/41 mmHgGeneral appearance: fair lookingConsciousness: alert but disoriented,

E4V4M6HEENT: conjunctiva: not pale, sclera:

anictericChest: symmetrical expansion, bilateral

clear breathing sounds.Heart: regular heart beats, no audible

murmurs.

Abdomen: soft and flat normal bowel sounds, no local tendernessBack: No knocking pain over bilateral flank area Extremity: freely movable, no deformity bilateral lower legs grade I pitting edema left radial artery pulse decrease left hand light tough sensation decrease MP of upper arms-- L/R: 4+/5 MP of hands – L/R: 5/5Skin: no rash, no petechiae nor ecchymosis fair skin turgor

Hemogram

unit 10/30

WBC /uL 10400

RBC million/uL

3.72

Hemoglobin

g/dL 9.9

Hematocrit

% 30.8

MCV fL 82.8

MCH pg/cell 26.6

RDW % 17.2

Platelets 1000/uL 238

Segment % 88.3

Lymphocyte

% 8.0

Monocyte % 2.9

Eosinophil % 0.5

Laboratory FindingsLaboratory FindingsBiochemistry

10/30

BUN 69.5

Creatinine 8.56

ALT 27

Alk-P 141

Na/K/Cl 136/5.9/113

Ca/P 8.7/5.3

Albumin 3.91

Total protein 6.6

Sugar 140

PH 7.191

PCO2 29.3

PO2 69.4

HCO3 11.0

Sa% 90.1

11/02

T-protein(U)

250.6 mg/dL

Creatinine(U)

242.86 mg/dL

24hr U/O 200 ml

24hr TP(U) 501.2 mg

24hr Ccr 3.94 ml/min

Urinalysis 11/01

Color Yellow

Turbidity Cloudy

Sp. Gravity 1.015

pH 5.5

Leukocyte Negative

Nitrite Negative

Protein 3+(1000)

Glucose Negative

Ketone Negative

Urobilinogen

0.1

Bilirubin Negative

Blood Negative

RBC 1

WBC 7

Epi. 11

2011/10/30 CXR2011/10/30 CXR

2011/11/02 Cardiac 2D 2011/11/02 Cardiac 2D echoechoIVS: 19 mm; LVEDD: 34 mm; LVESD: 14 mm;

PW:15 mm; EF by M-mode: 87 %Pericardial effusion: nil, tamponade: nilLV systolic function: adequateVavular lesions: TR -- Vmax: 4.0m/s, max gradient: 64 mmHgAsynergy: no regional wall motion abnormality

Conclusion: Thick IVS & LVPW, mild MR, TR&PR, pulmonary hypertension maybe due to CRF (group 5)

2011/11/03 Kidneys echo2011/11/03 Kidneys echo

Left / Right : 7.1 cm / 7.1 cm Both kidneys are small in size with irregular contour. The cortical echogenicity is increased with inadequate thickness. The pelvocalyceal systems are not dilated. There is an echo-free lesion (1.2 X 0.6 cm) with posterior wall enhancement over the lower pole of right kidney. No obvious evidence of renal stone or mass is noted.

Imp: Parenchymal renal disease

2011/11/03 Peripheral 2011/11/03 Peripheral Doppler of Upper ExtremitiesDoppler of Upper Extremities

Brachial Forearm Ankle Right Systolic BP, sensor PTA 203 針頭 220 Left Systolic BP, sensor PTA 111 87 206

Conclusion: Proximal left subclavian dumped flow, favored proximal

left subclavian atery significant stenosis. Left vertebral

dumped flow, suspect left vertebral ostium stenosis lesion. Asymmetric brachial systolic BP.

2011/11/05 Hickman 2011/11/05 Hickman insertion and left distal insertion and left distal forarm AV fistula creationforarm AV fistula creationLeft distal forearm radial-cephalic AV

fistula anastomosis Post-OP thrill(+/+++), bruit(++/+++),

cephalic vein is engorged well to upper arm. wrist radial artery pulsation: YES, strong, hand numbness:NO, finger tips cyanosis: NO

Comment: Need further intervention for proximal subclavain artery lesion to assist this AV fistula maturation.

2011/11/10 TCD/CCD2011/11/10 TCD/CCDB-Mode Finding: Moderate, hypoechoic, heterogeneous,

circumscribed atherosclerotic change at both CCAs. R't CCA 19- 51%, L't CCA 29% diameter stenosis. Doppler Findings: Decreased flow at left extracranial VA. TCD Diagnosis: Focal stenosis at both MCAs. Proximal stenosis at L't VA or L't subclavian steal syndrome should be considered. R't intracranial VA increased flow due

to compensation.

2011/11/16 CTA of Brain2011/11/16 CTA of Brain1. Multiple small hypodensities in left corona radiata, suggesting lacunar infarct.2. High grade stenosis of left subclavian artery with abrupt occulsion just proximal to the orifice of the vertebral artery. The left vertebral artery is perfused by the retrograde filling of the right vertebral artery via vertebrobasilar junction. 3. Mild hypoplasia of left vertebral artery.

2011/11/16 CTA of Brain2011/11/16 CTA of Brain4. Atherosclerotic calcification with focal stenosis of right CCA (<50%)5. Atherosclerotic calcification in bilateral ICAs and right VA.6. Irregular contour of bil. MCA, ACA, and left VA suggestive of atherosclerosis.

2011/11/16 CTA of Brain2011/11/16 CTA of Brain Arterial stenosis measurement: CCA: Rt:<50% Lt:0% Extra-ICA: Rt:0% Lt:0%; Intra-ICA: Rt:0% Lt:0% ACA: Rt:<50% Lt:<50%, MCA: Rt:<50%

Lt:100% PCA: Rt:0% Lt:0% Extra-VA: Rt:0% Lt:0%, Int-VA: Rt:0% Lt:<50% BA: 0%

IMP: Left subclavian artery occulsion with steal phenomenon. Hypoplasia of left VA. Focal stenosis of right CCA ( 〈 50%). Atherosclerosis of intracranial arteries.

2012/01/19 Peripheral 2012/01/19 Peripheral Doppler of Lower ExtremitiesDoppler of Lower Extremities

Segmental blood pressures: ABI: Right 1.11 normal

Left 1.08 normal A mild to mod narrowing at Rt distal ATA

2012/02/09 P.T.A2012/02/09 P.T.AOsital to proximal segment of left

subclavian artery with atherosclerotic change and near total occlusion.

Total occlusion after vertebral a. branch.Collaterals via left vertebral a. to distal left

subclavian artery Pressure gradient between AO-subclavian

was 60-100 mmHg

Conclusion: Left subclavian artery stenosis and occlusion(see text), s/p PTCA failed.

2012/03/15 CTA of Left 2012/03/15 CTA of Left Upper ExtremitiesUpper ExtremitiesGreat arteries: - Segmental stenosis (66%, 2.3cm) of proximal left subclavian artery. - Segmental CTO of mid/distal left subclavian artery with collaterals to contribute the small left axillary artery (2.7mm, id). - R/O thrombus in the pulmonary trunk (se4im34). - Dilated pulmonary trunk (4.3cm, od) - SMA ostium occlusion with colalteral from IMA via Riolan artery.

MedicationMedicationAmlodipine 5mg/tab -------------- 1 PC

QDClonazepam 0.5mg/tab ----------- 1 PC

HSColchicine 0.5mg/tab ------------ 1 PC

QDImipramine 25mg/tab ------------- 1 PC

HSAspirin 100mg/cap -----------------1 PC

QDCilostazol 50mg/tab ---------------1 PC BID

DiagnosisDiagnosisLeft subclavian artery stenosis

and left vertebral artery hypoplasia.

End-stage renal diseaseHypertensionAsthma

DiscussionDiscussion

CASE III: 8853407 CASE III: 8853407

General DataGeneral DataAge: 49-year-oldGender: FemaleEthnic: TaiwaneseOccupation: Counselor

Past HistoryPast HistoryHypertensionEnd stage renal disease, s/p

CAPD during 1995~2002, complicated with CAPD peritonitis, shift to H/D since 2002

Peptic ulcer disease

MedicationMedicationFamotidine (20mg) ------------------------ 1#

QODBisoprolol hemifumarate(1.25mg) ----

0.5# QDIrbesartan (300mg) -----------------------

0.5# QODAlprazolam (25mg) ------------------------ 1#

HSMetoclopramide (5mg) ------------------ 1#

QD

Personal HistoryPersonal HistoryNo known allergy to drug or foodSmoking: deniedAlcohol: deniedBetel nut chewing: deniedNo recent travel historyNo contact history

Family historyFamily history

Father: hypertension, strokeMother: hypertension, ESRD

Course Course 2010/10/11 ~ 2010/10/25 Admission (SKH)

2010/10/28 ~ 2010/11/16 Admission

Left AVF infection ◦ On FDL for H/D◦ Remove left AVF

Transffered to LinKou CGMH on 10/25

2010/11/29 CVS OPD

Ga

Arrange right AVF creation*Discharge on 11/16

S/S: local heat, swelling with painful sensation around

right AVF◦Arrange duplex of AVF*◦Arrange revision of AV shunt with intering

jump graft*

Course Course 2011/03/28 CVS OPD

2012/03/15 CVS OPD

S/S: Persistent swelling with intermittent ischemic pain over right hand, bruit (++, mild steal)◦Give Cilostazol 1# BID x 14 days◦Arrange Duplex of AVF *◦Arrange Antegrade Venography*◦Arrange Percutaneous Transluminal

Angiography*S/S: Progressive right upper limb swelling

with limited ROM and intermittent ischemic pain over right hand, favor venous hypertension related◦Arrange Antegrade Venography*

Course Course

2012/03/29~ CVS & Nephro OPDS/S: Still mild swelling over right upper limb and intermittent ischemic pain with cyanosis change over right handFavor mixed problem of venous hypertension, steal and big fistula flow are noted

Discussion

DiscussionDiscussion