A man who did not know he had renal disease

A 45 year old man with diabetes and hypertension was admitted in the ward because of cardiac failure. After his admission, investigations showed that he had advanced renal failure. Subsequently he underwent two sessions of hemodialysis through a double-lumen femoral catheter. He never knew he had renal disease until this admission. He had been regularly reviewed by doctors for diabetes and hypertension in a government clinic near his house for about ten years. Four years ago, he had been referred to an ophthalmologist in a specialist government hospital and had undergone laser treatment for retinopathy.

The doctors attending to him during this admission feel that he may have end-stage renal disease and have recommended that he should undergo the creation of an AV fistula for the purpose of regular maintenance hemodialysis in the future.

Discussion

Is his kidney disease a recent development?

No. He must have had chronic kidney disease 4 years ago at the time when he was treated for diabetic retinopathy because there is a close association between these two microvascular complications.

If his chronic kidney disease had been detected 4 years ago, would it have benefited this patient?

Yes, it might have benefited him because, with early detection, we could have attempted to slow down the progression of renal failure and give him a longer period of life without renal replacement therapy.

What are the treatment options to slow down the rate of renal deterioration in diabetes?

Treating diabetes to achieve target blood sugar values, treating hypertension to target values and the use of medication that inhibit the renin-angiotensin system have been shown to delay the progression of renal failure in diabetes.

Why should one be cautious about using the serum creatinine value during this admission to label him as end stage renal failure?

During this admission he has cardiac failure and, consequently, reduced renal blood flow. His serum creatinine on admission will therefore be the result of both his chronic kidney disease and the acute renal injury secondary to cardiac failure. Only after the acute event (cardiac failure) has been treated will the serum creatinine truly reflect the impact of his chronic kidney disease. Hence, one should not use his initial serum creatinine to label him as end stage renal failure. A repeat serum creatinine, after one or two weeks of treatment, will be a better measure of his chronic kidney disease and the need for maintenance hemodialysis.