Question

A 65-year-old man with diabetes and coronary heart disease, and chronic kidney diseases, who had been admitted
with pulmonary congestion, shortness of breath, patient has pedal edema.
On the investigation: His serum creatinine, blood urea nitrogen, potassium and phosphate are elevated whereas
Serum calcium is low.
A. Why this patient has pulmonary edema despite of no history of respiratory diseases. Explain in details.
B. Explain the presence of low calcium and high phosphate level and correlate it to the impaired
activation of vitamin D and its consequences on parathyroid function, and mineralization of bone
in persons with chronic kidney diseases CKD.
This patient was discovered later to have liver cancer and the treatment plan is to start him on
Cancer chemotherapeutic (radio-contrast agents).
C. Do you think it is safe to use radio-contrast agents for this patient? Justify.

Answer 1

In the present acse study, patient has complaints of ,

• diabetes
• coronary heart disease
• chronic kidney diseases
• pulmonary congestion
• shortness of breath
• patient has pedal edema.
• Lab examination revealed elevated serum creatinine, blood urea nitrogen, potassium and phosphate
• Low Serum calcium

QUESTION 1

• Other than respiratory problems, the coronary artery dises also can contribute pulmonary edema
• Due to accumilation of fatty deposits or plaques, the arteries that supply blood to your heart muscle can become narrow
• This will lead to left ventricular systolic and/or diastolic impairment
• plaques or blood clot forms in narrowed arteries, blocking blood flow and damaging part of your heart muscle
• As a result of heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs.
• this will in turn leads to increse in the pressure in the blood
• fluid is pushed into the alveoli in the lungs
• This will result in pulmonary edema

QUESTION 2

• Vitamin D is needed to absorb calcium and it is produced by kidney
• In patients with kideny disese ability to activate vitamin D is decreased , this also inturn result in decreasd calcium levels
• kidney along with parathyroid gland maintains normal calcium and phospahate level in the body
• Since in CKD phospatase elimination decreses and accumilation of serum phosphate occurs
• The phosphate builds up in your body and binds to calcium. This causes your calcium levels to decrease
• Parathyroid hormoneis a chemical messenger which is very important in controlling the level of calcium in the blood.
• calcium level changes stimulates  calcium-sensing receptor (CaSR) on the surface of parathyroid cells
• If the level of calcium in the blood falls, the parathyroid glands normally produce more PTH, which pulls some calcium from the bones into the blood, normalising the level and cause hyperparathyroidism.
• thus PTH activation results  increasing calcium absorption from food, but also takes calcium out of the bones.
• This leads to demineralization of bones

QUESTION 3

• Since the patient have chronic kidney disese use of adio-contrast agents is not safe
• Use of  radio contast agent can result incontrast-induced nephropathy (CIN)
• The patient also have coronary artery dises so immedaiate evcauatin agent by dialysis also is complicated
• So it is recommened to use lowest dose possible of the newer macrocylic, ionic agents