Kidney Issues: A Comprehensive Guide for Patients and Families

Q: Kidney Issues: A Comprehensive Guide for Patients and Families

Hello： Currently, your family member's creatinine levels have returned to normal range. <br>The recent decline in kidney function is likely due to acute kidney injury, but regular monitoring is still necessary. <br>Dietary restrictions are not required at this time. <br>The exact

Kidney problems

Hello Doctor,
My family member (female, 29 years old) has long-term chronic health issues.
She has been diagnosed with refractory epilepsy for 23 years and is currently taking the following medications: Depakote 700mg, Vimpat 100mg, Keppra 1000mg, and Lamictal 30mg.
Additionally, she has been on psychiatric medications for 2 years: Zolpidem 7.5mg, Lorazepam 0.5mg, and Olanzapine 10mg.

This past week, she experienced severe constipation, and her neurologist prescribed Lactulose.
She has a history of elevated ammonia levels, is a carrier of hepatitis B, and her mother passed away from liver cancer.
She was hospitalized on July 24 for cellulitis and again on July 31 due to unexplained sepsis, which led to acute respiratory failure requiring intubation in the ICU.

On August 7, her creatinine (Cr) was 0.48/11, and upon discharge from the ICU, it was 0.9.
However, on August 14, it rose to 2.78, then 3.27 on August 17, and 2.87 on August 19.
An ultrasound revealed a 2 cm cyst, with left kidney measuring 13.2 cm and right kidney 14.3 cm.
By August 25, her Cr was 1.988, and she was discharged with a Cr of 1.58.
During her hospitalization, there was no proteinuria, but there was hematuria (1-2+), and she experienced abnormal menstrual bleeding that has persisted for over a month.
The doctors advised her to drink more water but did not provide any treatment for the bleeding.
I am unsure if she had oliguria while in the ICU, but after discharge, her daily fluid intake was approximately 2500-3000 cc, with urine output of 3000-4000 cc.
In the last three days before discharge, her fluid intake decreased to around 2000-2500 cc.
The doctors prescribed steroids, but it is unclear if this was specifically for her kidneys, as the discharge medications were only for two days, and there was no follow-up appointment scheduled.
The doctors did not provide information regarding the steroids, so she stopped taking them after finishing the course.
On September 1, her Cr was 1.479, and on September 7, it was 1.15 (no proteinuria, no hematuria).
On September 14, her Cr was 1.14, but her pancreatic enzymes were elevated.
Symptoms include fluctuating high blood pressure (around 120/80), severe headaches, nausea, vomiting, fatigue, drowsiness, and polyuria.
Recently, her urine color has changed to a lighter shade, and this week it has become darker.
During the day, her fluid intake is between 1500-2000 cc, but her urine output is only half of that.
Today, it suddenly decreased further; after consuming 1500 cc during the day, her urine output was less than 500 cc, although nighttime urination (about 400-500 cc) and morning urination (400-500 cc) contribute to a total volume that seems adequate.

After being referred to another doctor, no treatment was provided, and the advice remained to drink more water.
I have several questions:
1.
The doctors have been unable to identify the cause of her renal failure (they believe it is not acute and not pre-renal or post-renal, suspecting it may be immune-related, but only the globulin to albumin ratio is abnormal, and electrophoresis is normal).
Is it acceptable to not treat or conduct further tests in this situation? Should I consider changing doctors?
2.
The fluid intake during the day does not correlate with her output.
Is it truly beneficial for her to drink large amounts of water? (She has mild lower extremity edema that leaves an indentation when pressed.)
3.
Since I have been managing her diet due to her kidney issues, her electrolyte levels have remained normal, except for hemoglobin levels consistently between 9-10 without recovery.
Should I continue dietary management? Initially, the doctors said it was unnecessary, later advising to reduce potassium intake, and after the referral, they mentioned only monitoring protein intake.
I have been controlling her diet; is it necessary to avoid malnutrition while ensuring a balanced intake?
4.
Her kidney dysfunction has persisted for over a month; does this classify as chronic kidney failure? I have read conflicting information online regarding the timeline for chronic kidney failure, with some sources stating one month and others three months.
Given her slow recovery, is there still a possibility for her to return to normal function?
5.
The doctor suggested that she may have had pre-existing chronic kidney failure followed by acute kidney failure, but her previous Cr levels were between 0.4-0.5, with no proteinuria or hematuria.
6.
The attending physician mentioned that myocarditis could be causing her renal failure, but the echocardiogram showed normal results.
7.
The sizes of her kidneys are inconsistent and enlarged, yet doctors at both hospitals have not conducted any examinations regarding this.
Is this considered normal?
I am truly confused and worried about my family member, who is so young and may have to face the prospect of dialysis in the future.
Please take the time to respond.
Thank you!

Li, 30~39 year old female. Ask Date: 2017/09/14

Dr. Wu Hongjie reply Internal Medicine

Hello: Currently, your family member's creatinine levels have returned to normal range.
The recent decline in kidney function is likely due to acute kidney injury, but regular monitoring is still necessary.
Dietary restrictions are not required at this time.
The exact causes of the lower extremity edema and the acute kidney injury cannot be determined from your description.
Additionally, myocarditis cannot be ruled out even if the echocardiogram is normal.
The difference in size between the two kidneys is within acceptable limits.
It is recommended that your family member continue to monitor kidney function at the hospital and manage any pre-existing chronic conditions.
Wishing you safety and health.
Sincerely, Dr.
Wu Hong-Jie, Chief of Nephrology, Taoyuan General Hospital, Ministry of Health and Welfare.

Reply Date: 2017/09/14

More Info

Understanding kidney issues, especially in the context of chronic illnesses, can be quite complex and overwhelming for patients and their families. Your family member's case presents several important aspects that need to be addressed, and I will do my best to provide a comprehensive overview based on the information you've shared.

1. Identifying the Cause of Kidney Dysfunction: It appears that the medical team has struggled to pinpoint the exact cause of the acute kidney injury (AKI) your family member experienced. Given the history of chronic illness, including epilepsy and liver issues, it is crucial to consider all potential contributing factors. The fact that the doctors suspect an immune-related issue is significant, as autoimmune conditions can lead to kidney damage. If the current medical team is not providing satisfactory answers or treatment options, seeking a second opinion from a nephrologist (kidney specialist) may be beneficial. A nephrologist can conduct more specialized tests, such as kidney biopsies or advanced imaging, to better understand the underlying pathology.

2. Fluid Management: The discrepancy between fluid intake and urine output is concerning. While hydration is essential, excessive fluid intake in the presence of kidney dysfunction can lead to fluid overload, which may cause symptoms like edema (swelling) and hypertension. The mild lower extremity edema you mentioned suggests that the kidneys may not be effectively managing fluid balance. It is essential to monitor her fluid intake closely and adjust it based on her urine output and any signs of fluid retention. Consulting with a nephrologist about an appropriate fluid management plan is advisable.

3. Dietary Considerations: Nutrition plays a critical role in managing kidney health. While it is essential to ensure adequate nutrition, certain dietary restrictions may be necessary depending on her kidney function and lab results. Since her potassium levels have been normal, strict potassium restriction may not be necessary unless advised by her healthcare provider. However, monitoring protein intake is crucial, especially if there is any indication of proteinuria (protein in the urine). A registered dietitian specializing in renal nutrition can provide personalized dietary recommendations that balance nutritional needs while protecting kidney function.

4. Chronic Kidney Disease (CKD) Diagnosis: The classification of kidney dysfunction as acute or chronic depends on the duration and underlying cause. If her kidney function has been impaired for over a month, it may be classified as chronic kidney disease (CKD), especially if there are persistent changes in creatinine levels. The prognosis for recovery depends on the underlying cause of the kidney injury and the extent of damage. Regular follow-up with a nephrologist is essential to monitor her kidney function and adjust treatment as necessary.

5. Underlying Conditions: The possibility of pre-existing CKD before the acute episode is plausible, especially if there were previous episodes of elevated creatinine levels. The absence of proteinuria and hematuria does not rule out CKD, as some forms of kidney disease may not present with these symptoms initially. Continuous monitoring of kidney function is crucial to determine if there is a progressive decline.

6. Heart-Related Issues: The suggestion that myocarditis could be contributing to kidney dysfunction is an important consideration. Cardiac health can significantly impact renal function, and if heart function is compromised, it can lead to decreased kidney perfusion and subsequent injury. If cardiac evaluations have returned normal, it may be worth exploring other potential causes of kidney dysfunction.

7. Kidney Size and Structure: Variations in kidney size can occur for various reasons, including congenital anomalies, compensatory hypertrophy (enlargement of one kidney due to the absence or dysfunction of the other), or underlying pathology. If the medical team has not addressed this concern, it may warrant further investigation, especially if there are significant size discrepancies.

In conclusion, navigating kidney health issues requires a multidisciplinary approach, including nephrology, nutrition, and possibly cardiology. It is essential to advocate for thorough evaluations and appropriate management strategies. Regular follow-ups, lab tests, and imaging studies will be crucial in monitoring her condition and adjusting treatment as needed. Your concerns are valid, and seeking further clarification and support from healthcare professionals is essential for ensuring the best possible outcomes for your family member.

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