In patients with terminal renal failure, left ventricular hypertrophy (LVH) is extremely common. It is found in approximately 60 to 80% of patients starting renal replacement therapy.  In renal failure, both preload and afterload are increased because of hypervolemia and increased peripheral vascular resistance respectively .

1. Case Presentation On
Chronic Kidney Disease
With Left Ventricular
Hypertrophy
Presented By
Percy Arpitha. B
Pharm.D III Yr
12Y01T0019
1

2. DEMOGRAPHIC DATA
NAME: xxx
AGE: 59yrs
GENDER: Male
I.P. NO: 9259/14
D.O.A: 29-1-15
D.O.D: Not Known
WARD: Delux ward
CONSULTANT: Dr. V. Pakki Reddy
2

3. SUBJECTIVE
3

4. CHIEF COMPLAINTS
C/O swelling of legs and face and
SOBPAST MEDICAL HISTORY:
 Type II DM & HTN since 5 yrs
 Left hemiplasia
 CKD since 3 yrs
PAST MEDICATION HISTORY:
 Metoprolol succinate - OD
 livogen[ferrous fumarate &folic acid] –
BD
 Dutrol [gliburide+metforminHCL] – OD
 Nodosis [sodium bicarbonate]
 Nephrocaps [vitamin B complex]
4

5. Torsemide 20mg
Calcitriol -0.5mcg
PAST SURGICAL HISTORY: Nil
PERSONAL HISTORY AND HABITS: smoker
FAMILY HISTORY: Nil
5

6. OBJECTIVE
6

7. GENERAL EXAMINATION
PHYSICALEXAMINATION
Date 29-1-15 30-1-15 31-1-15
11.45 AM 4.30PM 8.00PM 8.10PM
Temp N N
B.P in mm
of Hg
130/90 150/100 170/100 150/100 140/90
P.R 88/min
R.R 26/min
7

8. SYSTEMEXAMINATION
CVS : S1 S2 +
P/A examination : Soft
DIAGNOSTIC INVESTIGATIONS
COMPLETE BLOOD PICTURE
8

9. TEST 28-1-15 NORMAL VALUE
Hb 7.1 g/dl 13-17 g/dl
PCV 20.3 41-49 %
MCHC 35.2 31-35 gm/dl
RBC 2.45 million/cumm 4.5-5.5 million/cumm
MCV 83 76-96 fl/cell
MCH 29.2 25-34 pg/cell
TLC(WBC) 5500 cells/cumm 4000-11000cells/cum
Differential Leukocyte
Count
Neutrophils 66% 40-80%
Lymphocytes 30% 20-40%
Eosinophils 03% 0-6%
Monocytes 01% 2-10%
Platelet count 2.46 lakhs/cumm 1.5-4.0 lakhs/cumm 9

10. RENAL FUNCTION TESTS
TEST 7-1-15 28-1-15
CREATININE 4.2 mg/dl 8.2 mg/dl 0.6-1.6 mg/dl
BLOOD SUGAR TEST
TEST 7th 29th 30th Normal values
Blood sugar
(fasting)
109 60-110mg/dl
Blood
sugar(random)
162 148 80-160mg/dl
10

11. ELECTROLYTES
28th 29th Normal value
Sodium 136 135-145mEq/l
Potassium 5.6 3.5-5.5mEq/l
Chloride 101 98-105mEq/l
Serum calcium 8.1 8.4-10.2 mg/dl
URINE ANALYSIS
Albumin :+++(three plus)
Sugar : Nil
Deposit cells : 3-4 pus cells/HPF
2-3 epithelial cells/HPF
Ketone : Negative 11

12. 2 D ECHO CARDIOGRAM
 EF: 31%
 Left ventricle : Dilated , global hypokinesis
 Aortic valve : sclerotic
Impression
 LA, LV – dilated
 RWMA +
 Global hypokinesis
 Severe LV dysfunction
 Mild MR/ TR/ PAH, trivial AR
 No PE, LV clot
12

13. 13
Global hypokinesis
Condition where in the heart is generally very weak all
through along with mild to severe blockages of the coronary
arteries and all parts of heart (ventricles, walls, membranes,
and arteries etc. are weakened and function abnormally
Regurgitation
Blood flow in the opposite direction from normal, as the
backward flowing of blood into the heart or between heart
chambers.
Types
 Aortic regurgitation
 Mitral regurgitation
 Pulmonic regurgitation
 Tricuspid regurgitation

14. 14
Aortic regurgitation
From aorta into the left ventricle

15. 15
Mitral regurgitation
From left ventricle to left atrium

16. 16
Pulmonic regurgitation
From pulmonary artery into right ventricle

17. 17
Tricuspid regurgitation
From right ventricle into right atrium

18. ASSESMENT

19. Based On Subjective And Objective
Evidence The Patient Is A Known Case
Of Chronic Kidney Disease And Newly
Diagnosed To Have
Left Ventricular Hypertrophy
19

20. PLANNING
20

21. Day 1
11.30AM
DRUGPRESCRIBED DOSE FREQUENCY
1 TabMega CV
AMOXICILLIN+CLAVULANICACID
650mg BD
2 Tab.Revelamer
SEVELAMERCARBONATE
400mg OD
3 Tab.CyraD
REBEPRAZOLE+ DOMPERIDONE
20mg+30mg-1tab OD
4 Tab.Atocor
ATORVASTATIN
20mg OD
5 Tab.Reneplus
AscorbicAcid-60mg+Biotin-300mcg+CalciumPantothenate-
10mg+FolicAcid-10mg+MethylCobalamin-
1500mcg+Niacinamide-20mg+Pyridoxine-20mg+Riboflavin-
3mg+Thiamine-2mg
1 tab OD
6 Tab.Calcitriol
VITAMIN-D
0.25mcg OD

22. Day 1
4.30PM
ON EXAMINATION DRUGPRESCRIBED DOSE FREQUENCY
1 B.P170/80
C/O shortnessof breathclass-IV
orthopnea
IV Lasix
FUROSEMIDE
20mg BD
2 Neb.Duolin(IPRATROPIUM
BROMIDE+L-SALBUTAMOL)&
budecort(BUDESONIDE)
OD
3 Tab. Isolezin
ISOSORBIDE
DINITRATE+HYDRALAZINE
HYDROCHLORIDE
20mg+37.
5mg
BD
Day 2 ON EXAMINATION DRUGPRESCRIBED DOSE FREQUENCY
1 No feveror vomiting
B.P150/90
Tab. ShelcelCT
ELEMENTALCALCIUM+CALCITRIOL
500mg+0.25mcg OD
2 Tab. Clonazep
CLONAZEPAM
0.5mg OD

23. 29-1-15
 Heamodialysis done with Rt IJC
HD- 11/2 hour
UF-300 ml
Heparin-RIGID
BF-160ml/min
DF-300ml/min
30-1-15
1 unit-PCV
23

24. A vascular access lets large amounts of
blood flow continuously during
hemodialysis treatments to filter as much
blood as possible per treatment.
Arteriovenous fistula
Arteriovenous graft
Venous catheter
24

25. 25
Arteriovenous
Fistula
 created by connecting one
of the arteries to one of the
veins in your lower arm.
 allows repeated access
 may take several months
to form.
 may not clot as easily as
other methods.
 most effective dialysis
access and the most
durable.

26. 26
Arterio
venous graft
 Uses a synthetic tube
implanted under the skin
in your arm (graft)
 May be used if you have
very small veins.
 A graft does not need to
develop as a fistula does
 Compared with fistulas,
grafts tend to have more
problems with clotting or
infection

27. 27
venous catheter
 A tube may be used
temporarily if you
have not had time to
get a permanent
access.
 The catheter is
usually placed in a
vein in the neck,
chest, or groin.
 Because it can clog
and become infected,
this type of catheter is
not routinely used

28. Left Ventricular Hypertrophy
In patients with terminal renal failure, left
ventricular hypertrophy (LVH) is extremely
common. It is found in approximately 60 to
80% of patients starting renal replacement
therapy.
In renal failure, both preload and
afterload are increased because of
hypervolemia and increased peripheral
vascular resistance respectively .
28

29. 29
Pre existing hypertension renal
function
Pressure overload Na+ and water
retension,
anemia
volume overload
Hemodynamic burden

30. 30
Hemodynamic burden
To compensate
Frank starling increase recruits
neurohumoral
Mechanism muscle mass
mechanism
volume- force of
contraction
weakening of
contractility
muscle of heartVentricular dysfunction( hypertrophy, dilation , fibrosis)

31. 31
Pharmacological Management
 Treating high blood pressure
Angiotensin-converting enzyme (ACE) inhibitors &
Angiotensin II receptor blockers (ARBs) - widen, or
dilate, blood vessels to lower blood pressure,
improve blood flow and decrease the workload on
the heart.
Thiazide diuretics - eliminate sodium and water,
thereby reducing blood volume
Beta blockers - slow your heart rate, reduce blood
pressure
 Treating sleep apnea
 Aortic valve repair or replacement
 Cholesterol-lowering medications

32. 32
Non Pharmacological Treatment
Lifestyle changes can help lower your blood
pressure and improve left ventricular
hypertrophy symptoms.
Weight loss
Limit the amount of salt in your diet.
Drink alcohol in moderation, if at all.
Exercise regularly.

33. 33
The best way to help prevent left ventricular hypertrophy
is to maintain healthy blood pressure.
Monitor high blood pressure
The target for healthy blood pressure is less than 130/80
mm Hg.
Make time for exercise.
Regular exercise helps lower blood pressure and keep it
at normal levels.
Watch your diet.
Avoid foods that are high in fat and salt, and eat more
fruits and vegetables. Avoid alcoholic beverages or drink
them in moderation
Quit smoking if you're a smoker
Giving up smoking improves your blood pressure and
overall health.

34. 34
Drug - drug interactions
Furosemide – hydralazine hydrchloride/ isosrbide dinitrate (minor)
 Enhanced diuretic response to furosemide
 Hydralazine induces increase in renal blood flow, which increases the
plasma clearance (and diuretic effect) of furosemide.
Drug - food interactions
With grape fruit juice ;
Atorvastatin – increase bioavailability of atorvastatin resulting in increased
risk of myopathy and rhabdomyelosis
Budesonide – result in 2 fold increase in systemic exposure of budesonide
possibly increased cortisol suppression
With food ;
Furosemide & hydralazine – decreased exposure & efficacy
Clonazepam – caffine : decrease sedative effect

35. Reference
1.Fauci.S.A,Kasper.D.L,Longo.D.L,Braunwald.E,Hauser.
S.L,Jameson.J.L et.al.17th ed.USA:Mc Graw Hill
companies;2008.
2.Colledge.N.R,Walker.B.R,Raltson.S.H.Davidsons
principles and practice of medicine.21st
ed.US:elsevier;2010
3. http://www.mayoclinic.org/diseases-conditions/left-
ventricular-hypertrophy/basics/prevention/con-20026690
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