Diabetes Mellitus and Chronic Renal Failure
History: Cindy Mallon, an 8-year-old girl in previously good health, has noticed that, in the past month, she is increasingly thirsty. She gets up several times a night to urinate, and finds herself gulping down glassfulls of water. At the dinner table, she seems to be eating twice as much as she used to, yet she has lost 5 pounds in the past month. In the past three days, she has become nauseated, vomiting on three occasions, prompting a visit to her pediatrician.
Questions:
At the doctor’s office, blood and urine samples are taken. The following lab results are noted:
| blood glucose level = 545 mg/dl blood pH level = 7.23 | (normal = 50 – 170 mg/dl) (normal = 7.35 – 7.45) |
| urine = tested positive for glucose and for acetone / acetoacetate (i.e. ketone bodies) (normally urine is free of glucose and ketone bodies) | |
1. Why is her blood-glucose level elevated?
The years progress, and Cindy has considerable difficulty controlling her diabetes. She has been told that she has “brittle” diabetes, a form of the disease marked by wide swings in blood-glucose levels despite the best efforts at control. Cindy is advised by her physician that she is at risk for developing certain complications of diabetes.
2. What are the possible long-term complications of her disease?
In her mid-forties, Cindy began to show early signs of diabetic nephropathy (kidney disease), consisting of persistent proteinuria, hypertension, and gradually decreasing renal function as measured by chemical tests. She nonetheless felt fairly healthy over the next 10 years. At age 55, however, she has noticed becoming increasingly fatigued upon mild physical exertion and requiring more sleep than previously. In addition, she has generally felt nauseated most of the time, and in the past two weeks, has vomited on several occasions. She has increased swelling in her ankles, and is short of breath. She has also become less responsive over the past day or so. Laboratory tests reveal that her kidney disease is now progressing at a much faster rate:
Diabetes Mellitus and Chronic Renal Failure
BUN (blood urea nitrogen) = 56 mg / dl (normal = 10 – 20 mg / dl)
Urinary output = 25 cc / hour (normal = 50-60 cc / hour)
Cindy is advised by her physician that her kidneys are failing. She is informed about treatment options: hemodialysis vs. continuous ambulatory peritoneal dialysis (CAPD) vs. kidney transplant. In consultation with her physician, Cindy chooses to undergo hemodialysis. A checkup two weeks after beginning dialysis reveals the BUN has decreased to 35 mg / dl.
Although hemodialysis is fairly effective, it is not fool-proof. For example, patients with chronic renal failure, despite a regular schedule of hemodialysis, will experience disruptions in calcium and phosphate balance.
3. Failing kidneys have a harder time excreting phosphate, and thus blood-phosphate levels tend to rise. What effect will rising blood-phosphate levels have on blood calcium levels?
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