Ravindran, 53 years old Indian gentleman, a company driver

UPM 15011
● With a long history of T2DM, HPT and newly diagnosed ESRF currently on HD
● Came to ResQ HPUPM with a complaint of worsening generalised body itching for the
past 1 week.

HOPI
He was previously well until 1 month ago,
1. Sudden severe pain over the right big toe for 1 day
● Associated with fever, wet and blackish discolouration of the sole
● Mr Ravin mentioned that he has a long history of abnormal sensation of the lower
limbs where he has muscle cramps and reduced sensation.
● There were hard thick skin formed (callus) at the sole and recently there were
cracks over the area with bleeding
● The toe requires amputation done at HPUPM (04/08/2021)
● Before the amputation, the patient was having shortness of breath, pedal edema
and abnormal vital signs.
● Hence, the patient was subjected to HD (1, 4 regime) before going to the OT.
● Following that patient was well and was on regular HD via femoral catheter 2
times per week.
● However, the patient defaulted the treatment for 2 weeks as he mentioned that
he is feeling much better than before.

Date Creatinine trend

Before OT 02/08/2021 797

(eGFR 7 mL/min/ 1.73 m2)

Regular HD 05/08/2021 503

09/08/2021 646

12/08/2021 579

Last HD before default 16/08/2021 500

On current hospital admission 02/09/2021 974

(eGFR 5 mL/min/ 1.73 m2)

2. Generalised body itchiness x 1/52

● It was worse on his back and his thighs
● Presences of small and palpable rashes
● Not relieved by any oral medications (loratadine / antihistamine)
● Worsens upon scratching, at night
● Denied of any F/D allergy, recent insect bites, not induced by furry animal
contact, worse upon bath or touching fiberglass
 ● Progressively worsening that it disturbs his sleeps for x 3/7
● On the day of admission: the itchiness persisted and making him restless and in
desperate of rapid relief, he brought himself to ResQ HPUPM

However, no fever, chills or rigor, vomiting, abdominal pain, flank pain or bony pain, diarrhea,
muscle weakness, no changes in appetite or weight, no shortness of breath, chest pain or lower
limb swelling. Good urine output, no hematuria and no lower urinary tract symptoms such as
dysuria, urinary frequency, urinary urgency. No constitutional symptoms such as LOW, LOA or
night sweats.

Upon admission, it was found that the patient’s creatinine and urea was high with RBS of 27.8
mmol/L and was subjected for emergency haemodialysis via femoral catheter.

During the HD, the patient suddenly developed:

3. Chest pain
S - left sided
O - acute
C - heavy, compressing in nature
R - not radiating
A - shortness of breath
T - persistent lasted for more than 30 minutes
E - lying flat
S - 8/10

ECG was done but there are no STEMI changes. Following one sublingual GTN, the chest pain
resolved.
PMH

1. T2DM

Diagnosis ● 30 years ago, he was asymptomatic

● Voluntary screening after doing an abnormal reading (8
mmol/L) from dextrostix at home

Control and compliance ● Under follow up with HKL nephrologist

● Latest HbA1c: 6.5 %
● SMBG: ranges from 4.0 - 12.0 mmol/L
● Currently only on sc insulin
○ 8 units of actrapid TDS and
○ 8 units of insulatard pre bed
● Diet:
○ Never skip his meals
○ Balanced diet
○ Avoid snacking and sugary drinks

Complications ● Macrovascular
○ No episodes of sudden limb weakness or chest pain
prior to current admission
● Microvascular
○ Nephropathy:
○ Neuropathy:
■ abnormal sensation - episodes of muscle
cramps
■ Newly diagnosed ESRF started on HD via
femoral catheter (1, 4 regime)
○ Retinopathy: done laser 2 times at HKL
● Diabetic foot (aside from the amputation done)
○ Multiple hospital admission at HKL due to recurrent
unilateral leg swelling extending up to his right thigh
○ Associated with fever with progressively worsening
pain
○ u/s showed no evidence of arterial disease (PAD)
○ Recently he was told that he has charcot foot on his
left foot

2. HPT
○ Diagnosed 5 years ago
○ No hospital admission due to hypertensive crisis
○ Performs self monitoring blood pressure at home (normal reading)

DH
1. SC insulin (actrapid and insulatard)
2. Oral anti-hypertensive
FH
● His father died at the age of 55 years old with NKMI due to severe lung infection while
his mother died of oral carcinoma at a young age
● He is the 8th out of 9 siblings.
● He has a strong family history of CVS disease (2 of his siblings died due to cardiac
disease and another brother died in his sleep).
● No family history of renal disease.
● Unsure of any other disease / malignancy.

SH
● Lives with wife and children (2 daughter and 1 eldest son) in a flat house at Jalan Ipoh,
KL
● Ex smoker and ex alcoholic drinker
● Works as a Brazil ambassy driver
● Financially stable with the aid of social welfare

SUMMARY
● Ravindran, 53 years old Indian gentleman, a company driver.
● With a long history of T2DM, HPT and newly diagnosed ESRF currently on HD.
● Came to ResQ HPUPM with a complaint of worsening pruritus for the past 1 week
following 2 weeks of defaulted HD session
PE (day 3 of admission)

General ● Appear sallow (evidence of CKD)

● Not in pain, respiratory distress, not cachexic
● On continuous drainage bag (CBD)

Peripheral ● CRT <2s

● No tar staining, clubbing
● No evidence of scratch marks at the cubital fossa
● No evidence of anemia: no conjunctival pallor/ no pale palmar
crease
● DXT: 7.9 mmol/L

Vital signs ● 36.4 oC (afebrile)

● 64 bpm (normal HR)
● 164/72 mmHg (hypertensive)
● 20 breath per minute
● Pain score: 0

CVS / RS ● No scars was noted

● No parasternal heaves/ palpable thrills
● Apex beat was not displaced (5th ICS, midclavicular line)
● S1 and S2 was heard with no added murmur
● Lungs was clear with vesicular breath sound

Rash ● Multiple palpable, blanchable rash measuring less than 1 mm

(papule) seen over his chest and his back
● Scratch marks was seen

Foot ● Trophic changes noted: lipodermatosclerosis, dry, scaly skin with

trophic nail changes.
● Loss of sensation in ‘glove and stocking’ distribution

Right leg Left leg

● On bandage ● Trophic nail changes

● Warm to touch up to mid ● Hypopigmentation seen at
shin the dorsal area of 1st
webspace
● Charcot foot evidenced by
loss of foot arch
SUMMARY
● Ravindran, 53 years old Indian gentleman, a company driver.
● With a long history of T2DM, HPT and newly diagnosed ESRF currently on HD.
● Came to ResQ HPUPM with a complaint of worsening pruritus for the past 1 week
following 2 weeks of defaulted HD session
● PE revealed papular rash noted at his chest and back with trophic changes and loss of
sensation in ‘gloves and stocking’ distribution of both of his lower limbs.

DIAGNOSIS
Symptomatic uremia due to defaulted treatment for end stage renal failure

Points for Points against

● Generalised body itchiness ● Recent well controlled diabetes

● Newly diagnosed ESRF mellitus
● Defaulted HD
● Evidence of papular rash

DIFFERENTIAL DIAGNOSIS
1. Superficial skin infection due to T2DM

Points for Points against

● Itchiness ● Generalised body itchiness

● Long history of T2DM
● Frequent hospital admission due to
skin infection of the lower limbs
● Poorly controlled diabetes mellitus as
evidenced by the microvascular
complications of T2DM

2. Allergy reaction

Points for Points against

● Generalised body itchiness ● No history suggesting personal atopy

● Recently prescribed with new ● No family history of atopy
antibiotics (T. unasyn)
INVESTIGATIONS

Bedside ● Urine FEME

● 24-Hours holter monitoring

Blood ● Full blood count: evidence of anemia, infection

● Renal profile: kidney function (creatinine/ urea/ eGFR), screen for any
electrolyte imbalances
● Random blood glucose & HbA1c
● Evidence of renal osteodystrophy:
○ Elevated PTH and serum phosphate
○ Low serum Ca

Imaging ● Ultrasound KUB:

○ Assess the size, symmetry, anatomy, corticomedullary
differentiation and to exclude obstruction

MANAGEMENTS

Acute management ● Emergency haemodialysis

Control comorbids ● T2DM

○ SC insulin
● HPT
○ ACE inhibitors e.g. perindopril/ captopril
○ ARBs e.g. telmisartan/ losartan

Definitive managements ● Refer nephrologists

● Preparation for renal replacement therapy:
○ Hemodialysis
○ Peritoneal dialysis
○ Renal transplant
● Treatment of other complications of CKD:
○ Anemia:
■ Rule out other causes and treat accordingly,
consider giving erythropoietic stimulating
agents
○ Edema:
■ Restrict fluid and sodium intake
○ Bone-mineral disorders:
■ High potassium (> 1.5 mmol/L), treat with
deity restriction and phosphate binders
■ Prescribe vit. D supplements (colecalciferol,
ergocalciferol), if PTH is high, give activated
vit. D analogue (calcitriol)
○ Cardiovascular disease:
■ Low dose aspirin (antiplatelets)
■ Atorvastatin 20 mg