Soapo case presentation for pharmacy students on acute kidney disease

1. DKA AND AKI ON CKD
GROUP 2

2. Group members
Lawrence Nana Bonso - UHAS20205114
Teye Grace - UHAS 20203664
Janice Esther Agbeblewu - UHAS20202288
Faustina Vuvor- UHAS20203311
Comfort Asiedu - UHAs20204662
Emmanuel Obeng Gyamfi- Uhas20201504
Mensah Albert Ekow- UHAS20200706
Ashiagbor Gloria Tsotsoo – UHAS20207018
Asamoah Joyce Aframa - UHAS20208033

3. Patient Profile
Patient Initials : V. K. Gender : Female Age: 57
DOA: 9th February, 2024 Ethnic origin: Akan
Hospital : Ho Teaching Hospital Occupation: Trader
Insurance: NHIS Ward: Female Medical

4. Patient Profile cont.
PMHx :
Previous admission o/a hyperglycemia
SHx:
Lives at Godokpe, trader
FHx:
Hypertension+ (daughter, son), Stroke+ (mother)
DHx:
On long term medications and herbal medications

5. PRESENTING COMPLAINT
Weakness in limbs for one week
HISTORY OF PRESENTING COMPLAINT
Client is a known hypertensive and a diabetic. She was rushed to ER
due to progressive weakness and complained of ill health some days
ago and has been visiting the facility without any improvement

6. Complaints
PRESENTING COMPLAINT
Weakness in limbs for one week
HISTORY OF PRESENTING COMPLAINT
Client is a known hypertensive and a diabetic. She was rushed to ER
due to progressive weakness and complained of ill health some days
ago and has been visiting the facility without any improvement

7. Findings
ON DIRECT QUESTIONING:
She has a headache, left-side body weakness, polyuria, polydipsia,
fever, vomiting, (once, copious, exacerbated on eating), urinary
incontinence and intermittent dry cough.
ON EXAMINATION:
She looked chronically ill, in no obvious pain or respiratory distress,
pale, febrile, anicteric and mildly dehydrated.

8. Findings cont.
CVS : Pulse was regular, S1 & S2 present, no murmurs
RS: Air entry reduced bilaterally, vesicular breath
Abdomen: Full, mwr, non-tender, no mass palpated, LS2K-, shifting
dullness-, bowel sounds present and normal
CNS: conscious and alert, GCS of 15/15
Allergies : no known allergies

9. Investigations
BLOOD FILM FOR MALARIA PARASITES
No malaria parasite seen
SERIAL COLLECTION
Urine collected: Straw colored

10. VITALS
VITAL NAME 06:11
PM(18-02-
2024)
10:54
PM(18-02-
2024
06:55
AM(19-02-
2024)
07:28 AM(19-
02-2024)
08:46
AM(19-02-
2024)
SpO2 98 % -
Non-
rebreather
mask-NRM
98 % -
Non-
rebreather
mask-NRM
100 % -
Non-
rebreather
mask-NRM
- 97 % -
Non-
rebreather
mask-NRM
Respiration
Rate
22 Per Min 22 Per Min 23 Per Min - 23 Per Min

11. VITALS CONT.
Blood
Pressure
111 mmHg
- 57 mmHg
132 mmHg
- 69 mmHg
141 mmHg
- 65 mmHg
- 118 mmHg
- 63 mmHg
Pulse 88 Per Min 88 Per Min 83 Per Min - 86 Per Min
Temperature 38.0
Celsius -
Axilla
36.5
Celsius -
Axilla
37.2
Celsius -
Axilla
- 37.4
Celsius -
Axilla

12. VITALS CONT.
Fasting
Blood Sugar
- - 12.9
(mixtard
18mls)
mmol/L
12.9(18iu of
mixtard
administered)
mmol/L
-
Random
Blood Sugar
- - - 10.0 mmol/L -

13. Investigations (Blood for C/S)
Organisms Antibiotics Results
Staphylococcus aureus Trimethoprim/Sulfamethoxazol
e
Sensitive
Gentamicin Sensitive
Cefotixin Sensitive
Levofloxacin Resistant
Clindamycin Resistant
Azithromycin Resistant

14. Liver Function Test
Parameter Result Unit Reference
range
Flag
Albumin 31.75 g/l 35.00-52.00 L
ALP 428.4 U/I 42.0-207.0 H
ALT 46.6 U/I 10-50.0 N
AST 98.6 U/I 5.0-34.0 H
GGT 103.6 U/I 9.0-36.0 H

15. Liver Function Test cont.
Bil total 12.8 µmol/l 3.40-25.75 N
Bil direct 8.7 µmol/l 0.00-10.30 N
Indirect bil 4.05 µmol/l 1.70-17.00 N
Total protein 74.6 g/l 62.0-85.0 N
Globulin 42.88 g/l 20.00-40.00 H

16. BUE + CREATININE – RENAL FUNCTION
TEST
Parameter Result Unit Reference
range
Flag
Urea 15.78 umol/L 2.10-7.10 H
Creatinine 142.55 umol/L 40.00-105.00 H
Sodium 125 L 135.0-150.0 L
Potassium 4.7 mEq/L 3.6-5.5 N
Chloride 91 L 96-108 L

17. FULL BLOOD COUNT
Parameter Result Unit Reference range Flag
WBC 23.25 10^3/uL 3.0-10.9 H
RBC 3.34 10^6/uL 3.9-5.5 N
HGB 9.4 g/dL 11.5-16.0 L
HCT 28.8 % 37.0-47.0 L
MCV 86.2 FL 80.0-95.0 N
MCH 28.1 pg. 27.0-34.0 L
MCHC 32.6 g/dL 31.0-35.4 N
PLT 307.0 10^3/uL 150-450 N
EOS% 0.0 % 0.0-6.0 N

18. FULL BLOOD COUNT CONT.
BASO# 0.03 10^3/uL 0.0-0.2 H
NEUT# 20.42 10^3/uL 2.0-7.5 H
LYMPH# 1.63 10^3/uL 1.0-4.0 N
MONO# 1.16 10^3/uL 0.20-1.00 H
EOS# 0.01 10^3/uL 0.00-0.50 N
IG# 0.26 10^3/uL 0.00-7.00 N
MONO% 5.0 % % %
LYMPH% 7.0 % 20.0-50.0 L
NEUT% 87.9 % 50.0-75.0 H
BASO% 0.1 % 0.0-1.0 N

19. URINE ROUTINE EXAMINATION
APPEARANCE - Cloudy
Urine Color - Straw
PH - 5.0
SPECIFIC GRAVITY - 1.020
LEUKOCYTES - Positive +++
NITRITE - Negative
BLOOD - Negative
PROTEIN - Trace
UROBILINOGEN - Normal
PUS CELLS - >30
EPITHELIAL CELL - 15
RED BLOOD CELLS (RBCs) - 0
CAST - Granular cast present (+)
CRYSTALS - Not seen
YEAST-LIKE CELLS - Not Seen
COMMENTS - Bacteria Present (+++)
KETONES - Trace
URINE GLUCOSE - Positive +++

20. CURRENT MEDICATIONS
Medications Dose/ Frequency Start Date End Date Reason for use
Tab Amlodipine 10mg daily 10-02-2024 23-02-2024 Hypertension
SC Enoxaparin
sodium
40mg daily 10-02-2024 12-02-2024 Prophylaxis for
deep vein
thrombosis
IV Ceftriaxone 2g daily 3/7 12-02-2024 14-02-2024 To treat urinary
tract infection
IV Clindamycin 300mg q.i.d 13-02-2024 16-02-2024 To treat sepsis
caused by
diabetic foot
ulcer

21. CURRENT MEDICATIONS CONT.
Tab Multivitamin Daily 10-02-2024 23-02-2024
Tab vitamin B1,
B6,B12
10-02-2024 23-02-2024
Mixtard 18 mane, 10 nocte 16-02-2024 18-02-2024 To manage
diabetes
IV Meropenem 500mg tds 14-02-2024 15-02-2024 To treat sepsis
caused by diabetic
foot ulcer
IV Gentamicin 40mg/ml in 2ml 17-02-2024 19-02-2024 To treat sepsis
caused by diabetic
foot ulcer

22. CURRENT MEDICATIONS CONT.
IVF Sodium
Chloride
0.9% in 500ml 09-02-2024
15-02-2024
10-02-2024
16-02-2024
For hydration
and to manage
DKA
IV Paracetamol IG Stat 09-02-2024 09-02-2024 To manage pain
Blood 2units 14-02-2024- 14-02-2024
IV ceftriaxone 2G Stat 09-02-2024 09-02-2024 For the
treatment of
diabetic foot
ulcer

23. Medical problems
1. Diabetic Ketoacidosis in a known DM PPT by sepsis from: Infected diabetic
foot ulcer & UTI
2. Acute Kidney Injury on Chronic Kidney Disease
Acute kidney disease sec to sepsis/dehydration
CKD sec to HPT nephrosclerosis/ Diabetic nephropathy
3. Diabetic Peripheral Neuropathy R/O PAD

24. Pharmaceutical care issues
•Inappropriate treatment of anemia
•Drug-drug interactions (Ceftriaxone and Enoxaparine)
•Inappropriate dosing of Insulin premix (70/30) and Soluble insulin
HM 100iu
•Inappropriate treatment of UTI
•Uninvestigated lipid profile
•Indication without treatment (Acidosis)
•Inappropriate use of Albertis regimen and Gentamicin

25. PHARMACEUTICAL
CARE PLAN (SOAPO)
OPTIMIZING THE MANAGEMENT OF DIABETIC KETOACIDOSIS AND
PERIPHERAL NEUROPATHY

26. Subjective data
•Polyuria
•Polydipsia
•Vomiting
•Foot ulcer
Objective data
•Dehydration
•High urine ketones

27. Assessment of diagnosis (DKA)
Diabetic ketoacidosis (DKA) is a condition associated with high blood
glucose (usually >18 mmol/L), which nonetheless, is unavailable to
the body tissues as a source of energy
It is a common cause of death among diabetes patients in Ghana and
often occurs in type 1 diabetes [patients but may also occur in type 2
diabetes.
The subjective data of polyuria, polydipsia, vomiting and objective
data of dehydration, and high urine ketones confirm the diagnosis of
DKA. (Standard Treatment Guidelines, 2017).

28. Assessment of diagnosis (DPN)
DPN is the most common complication of DM.
It involves presence of symptoms and signs of peripheral nerve
dysfunction in people with Diabetes after other possible causes have
been excluded.
The subjective data of foot ulcer confirm the diagnosis of the
Diabetic Peripheral Neuropathy (DPN).

29. Assessment of medications
Sodium chloride [NA | 0.9% 500ml Infusion.
According to the Standard Treatment Guidelines (2017), 500ml of 0.9% sodium
chloride infusion is appropriate to dilute the patient's blood glucose to a range
of 11 to 13 mmol/L before the initiation of insulin
Insulin Premixed (70/30) 100 iu/ml 10ml
Mixtard is suspension for injection that contains both insulin in two forms;a
soluble form, which acts quickly and an isophane form , which is absorbed
slowly during the day . This gives Mixtard a longer duration of action. The route
of administration and frequency is appropriate but the dosage is
inappropriate.(STG, 2017)

30. Assessment of medications
Clindamycin 300mg
Clindamycin, an antibiotic, suppresses protein synthesis by binding to 50S
ribosomal subunits; bacteriostatic or bactericidal depending on drug
concentration, organism and infection site.The use of this medication as well as
its dose and route of administration was appropriate for the treatment of
diabetic foot ulcers (British National Formulary)
Meropenem 500mg.
Meropenem is a Carbapenem antibiotic with a broad spectrum against Gram
positive and Gram negative bacteria and anaerobes. According to the BNF, pg
564 Meropenem is used for the treatment of sepsis. The dosage, route of
administration and frequency is appropriate

31. Assessment of medications
Insulin Soluble HM100iu
Insulin is a hormone secreted from the pancreatic B cells in response to glucose
and other stimulants such as amino acid, free fatty acids, gastric hormones,
parasympathetic stimulation and B adrenergic stimulation.
Insulin is used for the treatment of diabetic keto acidosis.(ADA, 2023)
The route of administration and frequency is appropriate but the dosage is
inappropriate.(STG, 2017).

32. Assessment of medications
Ceftriaxone IV 2g STAT
It is a third-generation cephalosporin with broad-spectrum gram-negative
activity. it exerts antimicrobial effect by interfering with synthesis of
peptidoglycan; bacteria eventually lyse because activity of cell-wall autolytic
enzymes continues while cell-wall assembly is arrested.
According to the BNF 84, the use of IV ceftriaxone 2G daily STAT for the diabetic
foot ulcer is appropriate. Hence, the dose and route of administration of
ceftriaxone was appropriate

33. PHARMACEUTICAL
CARE PLAN (SOAPO)
OPTIMIZING THE MANAGEMENT OF ACUTE KIDNEY INJURY ON
CHRONIC KIDNEY DISEASE

34. Subjective data
Vomiting, urinary incontinence, mild respiratory distress, pedal
edema, dehydration, severely pale
Objective data:
Creatinine 142.55 mol/l, urea 15.78mmol/l, Hb 8.9, Temp. 38.9,
eGFr 37mls/min 1.73

35. Assessment of diagnosis (AKI ON CKD)
Acute Kidney Injury (AKI) is a term that has now replaced the term Acute Renal
Failure (ARF). It describes a sudden decrease in renal function occurring over a
period of hours to days resulting in accumulation of nitrogenous waste products
and disruption of blood volume, electrolyte and acid-base balance.
According to the Kidney Disease Improved Global Outcome an elevated
creatinine above 105mmol/l and elevated urea above 7.10 indicates acute
kidney injury. Also, patients with eGFr between 30 -44mls/min/1.73m2 are
classified as having stage 3 chronic kidney disease according to the Kidney
Disease Improved Global Outcome (KDIGO) guidelines.

36. Assessment of diagnosis
ANEMIA
Anaemia is defined as decreased concentration of haemoglobin for the age and
sex of the individual.
According to the Standard Treatment Guideline, patients with Hgb less than
13g/dl in males or less than 12mg/dl in females are considered anemic.

37. Assessment of diagnosis
URINARY TRACT INFECTION
Urinary tract infection is defined as an infection in any part of the urinary
system. The objective data obtained from the Urine R/E showed the presence
of bacteria and high level of leukocytes in the urine sample.
According to the Standard Treatment Guidelines, Urinary tract infection (UTI) is
the presence of micro-organisms such as bacteria in the urine or tissues of the
normally sterile genitourinary tract.

38. Assessment of medications
Blood transfusion
Blood transfusion is the process of transferring blood products into a
person's circulation intravenously. Transfusions are used for various medical
conditions to replace lost components of the blood.
According to the Standard Treatment Guideline, blood transfusion is
recommended for patients with severe anemia that’s patients with an Hgb less
than 7.9. The patient had an Hgb of 8.9 hence the used of blood transfusion to
correct the anemia was inappropriate

39. Assessment of medications
IV Gentamicin 40mg/ml
Gentamicin is an antibiotic that belongs to a class of aminoglycosides. According
to the STG, Gentamicin is appropriate for the treatment of sepsis in patients
with diabetic foot ulcer. But, according to the KDIGO guideline, the use of
aminoglycoside ( gentamicin) is contraindicated in patients with acute kidney
injury.
This is because aminoglycosides such as gentamicin is nephrotoxic and this
injury is due to binding of positively charged aminoglycoside molecules to
negatively charged phospholipids in proximal tubular epithelial cells within renal
cortex, cellular uptake with formation of reactive oxygen species and alterations
in cell membrane transporters and cell death

40. Assessment of medications
IVF Sodium chloride 0.9% in 500ml
Infusion sodium chloride 0.9% in 500ml is an isotonic crystalloid solution that is
used to expand intravascular volume and return volume status to neutral fluid
balance( euvolemia) in volume depleted patients. The Kidney Disease Improved
Global Outcome recommends the use of 0.9% normal saline in AKI patients with
mild to severely dehydrated state. The dose, route of administration and
duration of therapy was appropriate.

41. Assessment of medications
IV Ceftriaxone 2g OD 3/7
Third-generation cephalosporin with broad-spectrum gram-negative activity; has
lower efficacy against gram-positive organisms but higher efficacy against
resistant organisms; highly stable in presence of beta-lactamase and exerts
antimicrobial effect by interfering with synthesis of peptidoglycan ; bacteria
eventually lyse because activity of cell-wall autolytic enzymes continues while
cell-wall assembly is arrested.
According to the BNF 84, the use of IV ceftriaxone 2G daily for complicated
urinary tract infection is appropriate for 7days. Hence, the dose and route of
administration of ceftriaxone was appropriate but the duration of therapy was
inappropriate.

42. Assessment of medications
Amlodipine 10mg daily
Amlodipine is a calcium channel blocker which inhibits transmembrane influx of
extracellular calcium ions across membranes of myocardial cells and vascular
smooth muscle cells without changing serum calcium concentrations; this
inhibits cardiac and vascular smooth muscle contraction, thereby dilating main
coronary and systemic arteries.
According to AHA/ACC, the use of Amlodipine 10mg daily for the treatment of
hypertension in a black patient with type 2 diabetes mellitus and chronic kidney
disease is appropriate.

43. Assessment of medications
IV Paracetamol 1g stat
Paracetamol is an analgesic that inhibits prostaglandin synthesis in the CNS and
works peripherally to block pain impulse generation; acts on the hypothalamus
to produce antipyresis.
According to NICE guidelines, the use of IV paracetamol for the treatment of
mild-moderate pain and fever is appropriate. The dose and route of
administration are also appropriate

44. Assessment of medications
SC ENOXAPARIN 40MG DAILY
Enoxaparin is a low molecular weight heparin ; antithrombotic that inhibits
factor Xa by increasing inhibition rate of clotting proteases that are activated by
antithrombin III.
According to AHA/ACC guideline, Enoxaparin is recommended for the
prophylaxis of deep vein thrombosis. Hence, the dose, route of administration
and frequency is appropriate.

45. Plan
GOALS OF THERAPY
To replace the fluid losses
To replace the electrolyte losses, especially potassium
To replace deficient insulin
To seek underlying cause and treatment appropriately
To slow the progression of neuropathy
To achieve and maintain a target-range Hb level of 11-12 g/dL
To control hypertension

46. Plan
To control blood glucose
To manage underlying causes
To prevent complications and further worsening of kidney function
To relieve symptoms such as fever and pain (See section on ‘Fever’ and ‘Pain
Management’)
To eradicate causative agent
To prevent complications
To identify patients with abnormalities of the genito-urinary tract

47. Plan (Recommendations)
Start Atorvastatin 20mg daily
Assess ASCVD risk of the patient
Lipid profile should be assessed
Initiate aspirin 75mg daily
Initiate potassium citrate tablet 1080mg daily to treat the acidosis
Consider changing the dose of Insulin Premix (70/30) from – to –
Consider changing the dose of Soluble insulin HM 100iu from 8iu to 10-20iu.

48. Plan (Recommendations)
Consider following the appropriate approach for sliding scale.
We recommend potassium citrate 1080mg to manage her metabolic
acidosis(pH-6.0) until her HCO3- is greater than 22mEq/L.
Replace IV gentamicin 40mg/ml in 2ml in 2ml with IV co-trimoxazole 960mg
twice daily. This is because the use of co-trimoxazole is safe in patients with
acute kidney injury compared to gentamicin for the treatment of diabetic foot
ulcer.

49. Plan (Recommendations)
Test for the haemoglobin levels for the patient. 200mg ferrous sulphate should
be given 12 hourly for 3-6months if the Hgb is below 12g/dl
Complete IV ceftriaxone therapy and carry out urine R/E test to confirm
complete eradication of the bacteria

50. Monitoring
MEDICATION EFFICACY SAFETY
Sodium chloride, IV Hydration Swelling, headache
Mixtard Reduction in blood
glucose levels
Hypoglycemia
co-trimoxazole Eradication of S. aureus skin rashes ,diarrhea ,
Meropenem Eradication of S. aureus Inflammation at injection
site

51. Monitoring
Vitamin B1. B6, B12
(NEUROBION)
To relieve neuropathic
pain.
nausea, diarrhea
Atorvastatin Reduction in LDL/C level myalgia,diarrhea,serum
transaminase level
Aspirin To bleeding,ulceration

52. Monitoring
Iron sulphate increase in HB lvevel
Ceftriaxone complete eradication of
bacteria
diarrhea, rash
potassium citrate To increase pH above 7.6 hyperkalrmia, abdominal
discomfort,diarrhea

53. COUNSELLING
Patient was advised to:
Maintain a diet rich in fibre and less in carbohydrates
Have regular testing for insulin and ketone bodies
Never skip an insulin dose and oral diabetes medications
Maintain hydration by drinking extra fluids
Have regular checkups of blood glucose levels

54. COUNSELLING
Take regular temperature and pulse checks
Advise on a balanced diet. Regular intake of leafy foods as well as fresh fruits
and vegetables, beans, liver, meat, eggs, fish
Nutrition: Give protein of high biological value at 40 g protein/day in adults.
Daily weighing
Beware of hyperkalemia - avoid potassium-containing foods e.g. bananas,
coconut

55. COUNSELLING
Avoid nephrotoxins e.g. NSAIDs, herbal medication
Daily intake of fluid of 600 ml over the previous day’s urine output for adults
(400 ml/m2 body surface area in children)
Restrict salt intake
Observe personal hygiene and proper cleaning after defecation

56. Role of the Pharmacist
1.I monitored for efficacy and toxicity of the medication .
2. I counseled the patient on the need to adhere to her medications.
3. I counseled the patient to observe for any reactions to the medications( rash,
diarrhea etc)

57. Outcome
Recommendations were accepted and implemented
The patient’s condition improved and was subsequently discharged.

58. References
Joint Formulary Committee. (2022). British National Formulary 83. BMJ
Publishing and the Royal Pharmaceutical Society.
Joseph T. Dipiro et al 2011, Pharmacotherapy, a pathophysiologic approach eight
edition, McGraw-Hill companies, New York.
Mary A. Chisholm-Burns et al 2019, Pharmacotherapy, principles and practice
fifth edition, McGraw-Hill education New York.
Standard Treatment Guidelines (2017) 7th Edition, Ministry of Health (GNDP)
Ghana Yamens Press Limited
American Diabetes Association. 10. Cardiovascular disease and risk
management: standards of medical care in diabetes—2020. Diabetes Care.
2020;43(suppl 1):S111–S134.

59. References
American Diabetes Association. 11. Microvascular complications and foot care:
standards of medical care in diabetes—2020. Diabetes Care. 2020;43(suppl
1):S135–S151.
Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2016 ACC Expert Consensus
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60. References
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO
2012 Clinical Practice Guideline for the Evaluation and Management of Chronic
Kidney Disease. Kidney Int Suppl. 2013;3:1–150.
Chronic Kidney Disease Surveillance System—United States Atlanta (GA),
Centers for Disease Control and Prevention. [cited 2020 Dec 29]. Available from:
https://nccd.cdc.gov/ckd
U.S. Renal Data System (USRDS). USRDS 2018 annual data report: Epidemiology
of kidney disease in the United States. National Institutes of Health, National
Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD, 2018.

61. References
Levey AS, Stevens LA, Schmid SH, et al. A new equation to estimate glomerular
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