---CK forum Q --by thrombolyser - studentmle

[ArchivalUser]

A 51-year-old man with a 4-year history of diffuse cutaneous systemic sclerosis is hospitalized for new-onset hypertension associated with anemia and thrombocytopenia. On admission, temperature was normal, pulse rate was 78/min, and blood pressure was 180/105 mm Hg. Neurologic examination was normal, and there was skin thickening over his face, chest, arms, hands, and legs. Lungs were clear to auscultation, and cardiac examination revealed a normal S1 and S2, an S4, and no S3. Abdominal examination was unremarkable. There was 1+ edema of both lower extremities.

Laboratory studies on admission:

Laboratory Studies
Hemoglobin

9.8 g/dL (98 g/L)
Platelet count

101,000/µL (101 × 109/L)
Blood urea nitrogen

32 mg/dL (11.43 mmol/L)
Creatinine

1.4 mg/dL (123.79 µmol/L)
Urinalysis

2+ protein; 3“5 erythrocytes/hpf; no casts

A peripheral blood smear showed 2+ erythrocyte fragments and schistocytes. At the time of admission, therapy with captopril, 6.25 mg every 8 hours, was initiated. Within 24 hours, this dose was increased to 25 mg every 8 hours.

Three days after admission, blood pressure is 140/95 mm Hg. The creatinine level is now 2.1 mg/dL (185.68 μmol/L). Complete blood count is unchanged, and repeat urinalysis reveals 2+ protein with no erythrocytes or leukocytes.

Which of the following is the most appropriate management at this time?

A Discontinue captopril; initiate calcium channel blocker therapy
B Continue to increase captopril dose
C Perform plasmapheresis
D Perform captopril renography

[ArchivalUser]

d??

[ArchivalUser]

i think 1 coz:
1-DOC for scleroderma is ca chan blocker
2-cr is going high=> uw step3 says stop acei in case of increased cr(dont recall the @ wht cr number)

[ArchivalUser]

Can I answer

[ArchivalUser]

CC? OR LOOK FOR STENOSIS...CBC IS UNCHANGED MEANS SCHISTOCYTE STILL THERE?

[ArchivalUser]

@ thrombolyser

Please Give us the answer

[ArchivalUser]

The most appropriate management for this patient is further increasing his captopril dose. This patient was hospitalized with scleroderma renal crisis. Angiotensin-converting enzyme (ACE) inhibitors are believed to be the most effective agents for preserving or improving renal function in scleroderma renal crisis. Therefore, continuation of these agents is indicated even if the creatinine level continues to increase and the patient requires hemodialysis, because improvements in renal function with this therapy have been reported even after 18 months of dialysis. One-year survival of scleroderma patients with renal crisis has been shown to increase from 15% to 76% with aggressive treatment using ACE inhibitors.

Discontinuation of captopril is contraindicated in this patient. Although his creatinine levels have increased, his underlying renal crisis is responsible, not the ACE inhibitor. In addition, his blood pressure has not been fully controlled. Plasmapheresis does not help to manage scleroderma renal crisis. Moreover, this therapy is contraindicated in patients taking ACE inhibitors. Flushing, hypotension, and gastrointestinal symptoms have been shown to develop during plasmapheresis in patients receiving ACE inhibitors, possibly due to increased kinin generation.

Captopril renography is not indicated because this patient does not have increased risk for bilateral renal artery stenosis. His increasing creatinine level is not unexpected and should not raise clinical suspicion for an underlying process in addition to scleroderma renal crisis.

[ArchivalUser]

very good ....and new concept.......looks like nephrology board qun...

[ArchivalUser]

mortality difference drives me........