case study on chronic renal failure

1. CASE PRESENTATION ON CHRONIC RENAL FAILURE
BY:
PURANAM SOUMYA
Y18PHD0417
III/VI PHARM.D

2. CHRONIC RENAL FAILURE
▣ CONTENTS
INTRODUCTION
EPIDEMIOLGY
ETIOLOGY
PATHOPHYSIOLOGY
DIAGNOSIS
TREATMENT
DEMOGRAPHIC DETAILS
SOAP ANALYSIS
PHARMACIST INTERVENTION

3. INTRODUCTION
▣ DEFINITION - CHRONIC KIDNEY DISEASE (CKD) REFERS TO AN IRREVERSIBLE
DETERIORATION OR LOSS OF LARGE NUMBERS OF FUNCTIONING NEPHRONS AND
CAUSE LOSS OF THE EXCRETORY, METABOLIC AND ENDOCRINE FUNCTIONS OF THE
KIDNEY
▣ SERIOUS CLINICAL SYMPTOMS USUALLY DO NOT OCCUR UNTIL THE NUMBER OF
FUNCTIONAL NEPHRONS FALLS TO AT LEAST 70 TO75 PERCENT BELOW NORMAL.

4. RECENT DEFINITION
▣ KIDNEY DAMAGE FOR >3MONTHS WITH OR WITH OUT DECREASED GFR MANIFEST BY
EITHER
▣ PATHOLOGICAL ABNORMALITIES IN THE COMPOSITION OF BLOOD URINE OR
ABNORMALITIES IN IMAGING TEST
OR
▣ GFR < 60ML /MIN /1.73M2 FOR> 3MONTHS WITH OR WITHOUT KIDNEY DAMAGE

5. STAGING
THE DIFFERENT STAGES OF CKD FORM A CONTINUUM.
THE STAGES OF CKD ARE CLASSIFIED AS FOLLOWS :
STAGE 1: KIDNEY DAMAGE WITH NORMAL OR INCREASED GFR (>90
ML/MIN/1.73 M 2)
STAGE 2: MILD REDUCTION IN GFR (60-89 ML/MIN/1.73 M 2)
STAGE 3A: MODERATE REDUCTION IN GFR (45-59 ML/MIN/1.73 M 2)
STAGE 3B: MODERATE REDUCTION IN GFR (30-44 ML/MIN/1.73 M 2)
STAGE 4: SEVERE REDUCTION IN GFR (15-29 ML/MIN/1.73 M 2)
STAGE 5: KIDNEY FAILURE (GFR < 15 ML/MIN/1.73 M 2 OR DIALYSIS)
BY ITSELF, MEASUREMENT OF GFR MAY NOT BE SUFFICIENT FOR IDENTIFYING STAGE
1 AND STAGE 2 CKD,
BECAUSE IN THOSE PATIENT'S THE GFR MAY IN FACT BE NORMAL OR BORDERLINE
NORMAL. IN SUCH CASES,
THE PRESENCE OF ONE OR MORE OF THE FOLLOWING MARKERS OF KIDNEY DAMAGE CAN
ESTABLISH THE DIAGNOSIS :
 ALBUMINURIA (ALBUMIN EXCRETION > 30 MG/24 HR. OR
ALBUMIN:CREATININE RATIO > 30 MG/G [> 3 MG/MMOL])
 URINE SEDIMENT ABNORMALITIES
 ELECTROLYTE AND OTHER ABNORMALITIES DUE TO TUBULAR DISORDERS
 HISTOLOGIC ABNORMALITIES
 STRUCTURAL ABNORMALITIES DETECTED BY IMAGING
 HISTORY OF KIDNEY TRANSPLANTATION IN SUCH CASES

6. EPIDEMOLOGY
GLOBALLY, 8% TO 16% OF THE GENERAL POPULATION HAS CKD.
1.9 MILLION PEOPLE ARE UNDERGOING RENAL REPLACEMENT THERAPY.
PREVELANCE OF CKD INCREASES WITH AGE ; 30% IN GREATER THAN 70 YEARS OLD.
DIABETES AND HYPERTENSION ARE TWO IMPORTANT RISK FACTORS FOR CKD.
IN PATIENTS WITH TYPE 2 DIABETES, PREVELANCE OF 27%.
AMONG T1DM; 17% TO 25% OF PATIENTS DEVELOPED DIABETIC CHRONIC KIDNEY DISEASE (DCKD) AFTER 30 YEARS.

7. ETIOLOGY OF CRF
• CAUSES OF CHRONIC KIDNEY DISEASE (CKD) INCLUDE THE FOLLOWING :
• DIABETIC KIDNEY DISEASE
• HYPERTENSION
• VASCULAR DISEASE(ANGINA & MI)
• GLOMERULAR DISEASE(PRIMARY OR SECONDARY)
• TUBULOINTERSTITIAL DISEASE(NEPHRITIS AFFECTING THE INTERSTITIUM OF THE KIDNEYS)
• URINARY TRACT OBSTRUCTION OR DYSFUNCTION
• RECURRENT KIDNEY STONE DISEASE
• CONGENITAL DEFECTS OF THE KIDNEY OR BLADDER
• UNRECOVERED ACUTE KIDNEY INJURY

8. SYMPTOMS
• TIREDNESS
• WEAKNESS
• NOT SLEEPING WELL
• LESS DESIRE TO EAT THAN USUAL
• NAUSEA
• ITCHING
• SHORTNESS OF BREATH
• ALTERED TASTE
• ALTERED MENTAL STATE

9. NDD-CKD VS ESRD
• THE TERM NON DIALYSIS DEPENDENT CKD ALSO ABBREVIATED AS NDD-CKD IS A
DESIGNATION USED TO ENCOMPASSES THE STATUS OF THOSE PERSONS WITH AN
ESTABLISHED CKD WHO DO NOT YET REQUIRE THE LIFE SUPPORTING TREATMENTS FOR
RENAL FAILURE KNOWN AS RENAL REPLACEMENT THERAPY(INCLUDING MAINTENANCE
DIALYSIS OR RENAL TRANSPLANTATION)
• THE CONDITION OF INDIVIDUALS WITH CKD WHO REQUIRE EITHER OF THE 2 TYPES OF
RENAL REPLACEMENT THERAPY(DIALYSIS OR TRANSPLANTATION) IS REFERRED TO AS THE
END STAGE RENAL DISEASE (ESRD)

13. Complications
• ANEMIA: DUE TO LACK OF ERYTHROPOIETIN
• METABOLIC ACIDOSIS (SEVERE): DUE TO LACK OF NH3 PRODUCTION BY KIDNEYS WHICH IS INVOLVED IN ACID-
BASE BUFFER
• HYPERKALEMIA: DUE TO LACK OF EXCRETION
• PERICARDITIS: DUE TO UREMIA
• OSTEODYSTROPHY (OSTEITIS FIBROSA CYSTICA): DUE TO LACK OF 1,25-
DIHYDROXYCHOLECALCIFEROL AND ALSO SECONDARY HYPERPARATHYROIDISM
• FLUID OVERLOAD (ANASARCA): LACK OF EXCRETION AND NA+ RETENTION
• ENCEPHALOPATHY: DUE TO UREMIA
• HYPERTENSION: DUE TO ACTIVATION OF RAAS. HPT IS THE COMMON CAUSE OF DEATH DUE TO
MYOCARDIAL INFARCTION. MAINTAIN BP <130/80
• INFECTIONS: UREMIA PREVENTS DEGRANULATION OF THE NEUTROPHILS AND SO
• MYELOPEROXIDASE CAN’T BE RELEASED TO DESTROY BACTERIA
• BLEEDING TENDENCIES: DUE TO PLATELETS DYSFUNCTION FROM EFFECTS OF UREMIA

14. DIAGNOSIS
▣ BLOOD
▣ ↑ CREATININE AND BUN
▣ ELECTROLYTES: HYPERKALAEMIA, HYPERPHOSPHATEMIA, HYPOCALCAEMIA
▣ MONITOR BLOOD PH FOR METABOLIC ACIDOSIS
▣ ↓ CALCITRIOL LEVELS
▣ ↑ PARATHYROID HORMONE (PTH)
▣ ULTRASOUND: SHRUNKEN KIDNEYS AND FIBROTIC PARENCHYMA
▣ RENAL BIOPSY: SOMETIMES INDICATED TO DETERMINE THE UNDERLYING CAUSE

15. URINE ANALYSIS

16. TREATMENT
• ALTHOUGH CHRONIC KIDNEY DISEASE CANNOT BE CURED , IT IS POSSIBLE TO SLOW THE DAMAGE TO THE
KIDNEY IN MOST PATIENTS. DOCTOR MAY RECOMMEND ANY OF THE FOLLOWING:
• CONTROLLING PROTEIN IN THE URINE BY RESTRICTING THE AMOUNT OF PROTEIN IN THE DIET OR
MEDICATION.
• TAKING ACE INHIBITORS OR ANGIOTENSIN II RECEPTOR ANTAGONISTS TO SLOW THE PROGRESSION TO
CHRONIC RENAL FAILURE.
• REDUCING THE USE OF AND THE DOSAGES OF DRUGS THAT MAY BE TOXIC TO THE KIDNEYS.
• MANAGING THE COMPLICATIONS OF THE CHRONIC RENAL DISEASE SUCH AS FLUID OVERLOAD HIGH BLOOD
PHOSPHATE OR POTASSIUM LEVELS , LOW BLOOD LEVEL OF CALCIUM AND ANAEMIA

17. Non-pharmacological treatment
• ADMIT PATIENT ESPECIALLY IN STAGE OF EXACERBATION
• DIET: RESTRICT DIETARY PROTEIN TO< 40 G/DAY, RESTRICT NA+, K+, PO4-
• INTAKE, AVOID POTASSIUM CONTAINING FOODS E.G. BANANA
• WATER AND ELECTROLYTE BALANCE:
i. DAILY FLUID INTAKE = PREVIOUS DAY’S URINE OUTPUT + 600 ML (FOR INSENSIBLE LOSSES)
ii. STRICT FLUID INPUT AND OUTPUT CHART
• DAILY WEIGHING
• GENERAL HEALTH ADVICE E.G. SMOKING CESSATION
• • AVOID NEPHROTOXINS E.G. NSAIDS , HERBAL MEDICATION

18. PRECAUTIONS
• LOWERING HIGH BLOOD PRESSURE
• CONTROLLING BLOOD SUGAR AND LIPID LEVELS
• STAYING HYDRATED
• CONTROLLING SALT IN DIET
• QUITTING SMOKING
• UNDERGOING DIALYSIS A MEDICAL PROCESS THAT CLEANS BLOOD
• HAVING A KIDNEY TRANSPLANT
• COUNSELLING FOR YOU AND YOUR FAMILY ABOUT DIALYSIS AND/OR TRANSPLANT OPTIONS.

19. PREVENTION
• TO HELP REDUCE YOUR CHANCE OF CHRONIC DISEASE OF CHRONIC KIDNEY FAILURE TAKE THE FOLLOWING
STEPS:
1. GET A PHYSICAL EXAM EVERY YEAR THAT INCLUDES A URINE TEST TO MONITOR YOUR KIDNEY HEALTH
2. DO NOT SMOKE
3. MAINTAIN A HEALTHY WEIGHT.
4. DRINK WATER AND OTHER FLUIDS TO STAY HYDRATED.
5. PEOPLE WHO HAVE DIABETES ,PREVIOUSLY KNOWN KIDNEY DISEASE HIGH BLOOD PRESSURE ARE OVER
THE AGE OF 60 SHOULD BE SCREENED REGULARLY FOR KIDNEY DISEASE
6. PEOPLE WITH A FAMILY HISTORY OF KIDNEY DISEASE SHOULD ALSO BE SCREENED REGULARLY.

20. DISTINGUISHING ACUTE FROM CHRONIC RENAL IMPAIRMENT
• COMPARING ANY PREVIOUS MEASUREMENTS OF SERUM CREATININE WITH THE PATIENTS CURRENT BIOCHEMISTRY. PRE-
EXISTING CHRONIC RENAL IMPAIRMENTS CAN BE EXCLUDED IF A RELATIVELY RECENT PREVIOUS MEASUREMENT OF RENAL
FUNCTION WAS NORMAL.
• A HISTORY OF SEVERE MONTHS VAGUE ILL HEALTH NOCTURIA OR PRURITUS AND FINDINGS OF SKIN PIGMENTATION
ANAEMIA LONG STANDING HYPERTENSION OR NEUROTHERAPY SUGGEST A MORE CHRONIC DISEASE.
• RENAL ULTRASONOGRAPHY TO DETERMINE SIZE AND ECHOGENICITY OF THE KIDNEYS. IT IS NOTE WORTHY THAT RENAL SIZE
IS NORMAL IN MOST PATIENTS WITH ARF.
• ANAEMIA IS A MAJOR FEATURE OF CRF , BUT IT MAY OCCUR EARLY IN THE COURSE OF MANY DISEASE THAT CAUSE ARF.
• BONE DISEASE – EVIDENCE OF LONGSTANDING RENAL BONE DISEASE (EX: RADIOLOGICAL EVIDENCE OF
HYPERPARATHYROIDISM , GREATLY ELEVATED PARATHYROID HORMONE(PTH) LEVELS IS A DIAGNOSTIC OF CRF, BUT
HYPERCALCEMIA AND HYPERPHOSPHATEMIA MAY OCCUR IN BOTH ARF AND CRF.

21. DEMOGRAPHIC DETAILS
• NAME : SUJATHA STATUS : MARRIED
• AGE : 72 YEARS IP.NO : IP19019018
• SEX : FEMALE REG.NO : 202778191
• HEIGHT : 5.4 FEET WEIGHT : 45KG
• PLACE : GUNTUR DOA : 21/02/2021
• RELIGION : HINDU DOD : 26/02/2021
• DEPARATMENT : UROLOGY
• ECONOMIC BACKGROUND : POOR

22. SOAP NOTES
SOAP ANALYSIS :
A 72 YEARS OLD FEMALE PATIENT OF 45 KG’S WEIGHT, 5.4 FEET HEIGHT OF HINDU RELIGION WITH POOR ECONOMIC
BACKGROUND FROM GUNTUR HAVE ADMITTED IN E-WARD.
• SUBJECTIVE DATA :- LACK OF APPETITE, FEVER FOR 2 DAYS,
URINE CONTINUOUS FOR 10 DAYS.
• OBJECTIVE DATA :- ULTRASONOGRAPHY FOR ABDOMEN. SERUM CHLORIDE - 111MMOL/L.
SERUM BILIRUBIN - 2.5 MG/DL.
SERUM INDIRECT BILIRUBIN - 2.2 MG/DL. HAEMOGLOBIN - 9.5GM/DL.
• ASSESSMENT :- BASED ON SUBJECTIVE DATA (URINE CONTINUOUS FEVER) AND LABORATORY DATA OBTAINED THE PATIENT IS
ASSESSED TO BE SUFFERING FROM RENAL FAILURE.
• FINAL DIAGNOSIS :- CHRONIC RENAL DISEASE.

23. DAY NOTES
• DAY -1 :- O/E :- ECG - SINUS TACHYCARDIA.
LEFT VENTRICULAR HYPERTROPHY.
LABORATORY REPORTS:- FASTING BLOOD SUGAR - 115MG/ML.
SERUM CHLORIDE - 110MMOL/L.
BLOOD UREA - 43MG/DL.
SERUM CREATININE - 1.8MG/DL.
DAY - 2 :- ADVISED TEST :- BLOOD UREA - 2.
SERUM CREATININE - 1.2MG/DL.
SERUM CHLORIDE - 111MG/DL.
SERUM BILIRUBIN - 7.5MG/DL.
SERUM ALKALINE PHOSPHATE - 46U/L.

24. ULTRASONOGRAPHY OF ABDOMEN
• GRADE - 1 BILATERAL CHRONIC MEDICAL RENAL DISEASE.
• LARGE PATCH OF CONSOLIDATION AT LOWER LOBE OF RIGHT LUNG.
• ADVISED TEST :- SERUM PROTEIN - 5.5G/DL. PCV - 32%.
• CARDIOLOGY REPORT : SCLEROTIC AORTIC VALVE, NO AC/NO AR, NORMAL CHAMBERS.
• GRADE - 1 DIASTOLIC DYSFUNCTION.

25. VITALS
DAYS TEMPERATURE(IN
F)
PULSE
RATE(bpm)
REPSIRATORY
RATE(cpm)
BLOOD
PRESSURE(mm/H
g)
1 100 90 24 120/90
2 98.6 82 22 110/80
3 98.6 94 16 120/80
4 98.6 84 20 130/80

26. PLAN FOR TREATMENT
GOALS OF TREATMENT :-
• TO REDUCE BODY TEMPERATURE.
• TO REDUCE LACK OF APPETITE.
• TO REDUCE URINE CONTINUOUS.
• TO IMPROVE PATIENT CONDITION.

27. MEDICATION:
SL.NO BRAND NAME GENERIC NAME DOSE FREQUENCY ROA DAYS
1 INJ.PANTOP PANTORAZOLE 40mg BD IV 4
2 INJ.ZOFER ONDANSETRON 2mg BD IV 4
3 INJ.TAZACT PIPERACILLIN+
TAZOBACTUM
2.25mg BD IV 4
4 TAB. ZITHROMAX AZITHROMYCIN 250mg BD ORAL 4
5 NEB.DUOLIN
BUDECORT
salbutamol+
ipratropium+
bromide+
budesonide
1.25mg
0.5 mg
TID INHALATION 4
6 TAB.LEVOCET LEVOCETRIZINE 5mg BD ORAL 4

28. TREATMENT GIVEN
1. INJ. PANTOP - 40 MG - BD - IV
GENERIC NAME :- PANTOPRAZOLE.
PHARMACOLOGICAL CLASS :- PROTON PUMP INHIBITOR.
USES :- PREVENTS EXCESS ACID PRODUCTION IN STOMACH.
MOA :- IT WORKS BY INTERFERING WITH THE FINAL STEP OF ACID RELEASE IN THE STOMACH.
INDICATION :- TO TREAT STOMACH ULCERS.
SIDE EFFECTS :- HEADACHE, ALTERED SENSE OF TASTE, RUNNY NOSE AND COUGH.
ADR’S :- SKIN RASH, ANOREXIA, INJECTION SITE THROMBOPHLEBITIS.
CI :- ALLERGY
PREGNANCY CATEGORY :- B.

29. 2. INJ.ZOFER-40MG-BD-IV
GENERIC NAME :- ONDANSETRON.
PHARMACOLOGICAL CLASS :- SELECTIVE 5 - HT3 RECEPTOR.
USES :- TREAT NAUSEA, VOMITING.
MOA :- IT BLOCKS THE ACTION OF SEROTONIN IN THE BODY THAT CAN TRIGGER NAUSEA AND VOMITING'S.
INDICATION :- TO TREAT GASTRO - OESOPHAGEAL REFLEX DISORDERS.
SIDE EFFECTS :- HEADACHE, CONSTIPATION, FATIGUE, FEVER.
ADR’S :- INCREASED LIVER ENZYME LEVELS.
CI :- ALLERGY, APOMORPHINE.
DI :- AMITRIPTYLINE LINE, CARBAMAZEPINE, PHENYTOIN.
PREGNANCY CATEGORY :- A.

30. 3. INJ. TAZACT - 2.2 MG - BD - IV
GENERIC NAME :- PIPERACILLIN (400MG) + TAZOBACTAM (500MG).
PHARMACOLOGICAL CLASS :- BETA-LACTAMASE INHIBITOR.
USES :- BACTERIAL INFECTIONS, URINARY TRACT INFECTIONS, MICROBIAL INFECTIONS.
MOA :- PIPERACILLIN - IT WORKS BY INTERFERING WITH CERTAIN PROCESSES THAT HELP BACTERIA.
TAZOBACTUM - INHIBITS CHEMICALS PRODUCED BY BACTERIA.
INDICATION :- ANTIBACTERIAL AGENT.
SIDE EFFECTS :- DIARRHOEA, FEVER, NAUSEA, VOMITINGS.
ADR’S :- RASH, ITCHING OF SKIN.
CI :- ALLERGY.
DI :- LIVE CHOLERA VACCINE, OXYTETRACYCLINE, PROBENECID.
PREGNANCY CATEGORY : B

31. 4.
• TAB. ZITHROMAX- 250MG - BD - ORAL
GENERIC NAME :- AZITHROMYCIN.
PHARMACOLOGICAL CLASS :- MACROLIDE ANTIBIOTIC.
USES :- PNEUMONIA, NOSE AND THROAT INFECTIONS, SINUS, SKIN INFECTIONS.
MOA :- PIPERACILLIN - AZITHROMYCIN PREVENT BACTERIA FROM GROWING BY INTERFERING WITH THEIR
PROTEIN SYNTHESIS. IT BINDS TO THE 50S SUBUNIT OF THE BACTERIAL RIBOSOME, THUS INHIBITING
TRANSLATION OF MRNA.
INDICATION :- TO TREAT BACTERIAL INFECTIONS.
SIDE EFFECTS :- DIARRHOEA, FEVER, ABDOMEN PAIN, VOMITINGS. ADR’S :- DRY OR SCALY SKIN, ACID OR
SOUR STOMACH.
CI :- HYPERSENSITIVITY, LIVER DAMAGE.
DI :- ATORVASTATIN, AMIODARONE, DIGOXIN.
PREGNANCY CATEGORY :- B.

32. 5. TAB. LEVOCET - 5MG - BD - ORAL
GENERIC NAME :- LEVOCETIRIZINE.
PHARMACOLOGICAL CLASS :- ANTIHISTAMINE.
USES :- RUNNY NOSE, SNEEZING, REDNESS, ITCHING, TEARING OF THE EYES.
MOA :- IT WORKS BY BLOCKING THE ACTION OF A NATURAL SUBSTANCE PRODUCED BY BODY CALLED
HISTAMINE.
INDICATION :- TREAT ALLERGY SYMPTOMS SUCH AS WATERY EYES, RUNNING NOSE.
SIDE EFFECTS :- DIARRHOEA, SLEEPINESS, HEADACHE.
ADR’S :- DIFFICULTY IN PASSING URINE.
CI :- ALLERGY, KIDNEY DISEASE.
DI :- ALPRAZOLAM, CLOBAZAM, CODEINE.
PREGNANCY CATEGORY :- B.

33. 6.NEB. DUOLIN AND BUDECORT – 1.25MG/0.5MG - TID – INHALATION.
GENERIC NAME :- SALBUTAMOL + IPRATROPIUM/BROMIDE + BUDESONIDE.
PHARMACOLOGICAL CLASS :- ANTICHOLINERGIC, CORTICOSTEROID.
USES :- AIRWAY NARROWING, COPD.
MOA :- IT CAUSES BRONCHODILATION. IT WORKS BY RELAXING AND OPENING THE BLOCKED AIR PASSAGES.
INDICATION :- BRONCHODILATION, CONTROL OF WHEEZING.
SIDE EFFECTS :- SNEEZING, COUGH, VIRAL INFECTIONS.
ADR’S :- HEADACHE, TACHYCARDIA TREMOR.
CI :- HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY.
DI :- AMINOPENCILLINS, DIGOXIN22.
PREGNANCY CATEGORY :- B.

34. MONITORING PARAMETERS
• DISEASE SPECIFIC - MONITORING FEVER, URINE PASSAGE. MONITORING RENAL FUNCTION TESTS.
• DRUG SPECIFIC - MONITORING LIVER ENZYME LEVELS. MONITORING ADVERSE DRUG REACTIONS.
ABOUT DRUGS
• TAB. PANTOP SHOULD BE TAKEN WITH EMPTY STOMACH (ATLEAST HALF AN HOUR BEFORE FOOD).
• AZITHROMYCIN USUALLY TAKEN BY MOUTH WITH A GLASS OF WATER ONCE DAILY WITH OR
WITHOUT FOOD.
• LEVOCET SHOULD BE TAKEN WITH OR WITHOUT FOOD.
PATIENT COUNSELLING
• EAT A LOW PROTEIN DIET, LIMITING SALT, POTASSIUM, PHOSPHOROUS.
• AVOID FAST FOODS, FROZEN DINNERS, CANNED FOODS THAT ARE HIGHER IN SODIUM.
• USE OF SPICES, HERBS AND SODIUM FREE SEASONING IN PLAN OF SALT .
• AEROBIC EXERCISE.
• DECREASING MORE SALT INTAKE.

35. DIET FOR CKD PATIENTS
• BREAK FAST - 1.5 SERVING OF CEREAL + A GLASS OF MILK.
• MORNING SNACK - 1 BOWL OF FRUITS (PINE APPLE, STRAW BERRIES).
• LUNCH - A GOOD COMBINATION OF STARCH + PROTEINS AND FATS.
• AFTERNOON - 1 CORN BREAD + BEEF PATTY.
• DINNER - YEAST ROLL STEAMED CHICKEN + SQUASH + MARGARINE.
• PROTEIN RESTRICTION TO 0.6 - 0.8GM/KG/DAY MAY RETARD CKD PROGRESSION
• PHOSPHORUS RESTRICTION - PHOSPHOROUS LEVEL SHOULD BE KEPT IN THE NORMAL RANGE (<4.5MG/DL)
PREDIALYSIS.
• SALT AND WATER RESTRICTION.
• DISCHARGE MEDICATION
• TAB. PANTOP - 40MG - OD - ORAL - 7 DAYS.
TAB. ZITHROMAX- 250MG - OD - ORAL - 7 DAYS.
• TAB. LEVOCET - 5MG - OD - ORAL - 7 DAYS.

36. THANK YOU