Respected Sir, My father, from India, aged 59 years is suffering from CKD stage G5/A3 (?PKD). Presently he is fully ambulatory and has no symptoms, except pedal edema in the later part of the day. Sometimes he has bouts of cough with sneeze, and then vomiting. But such episodes are not daily. BP is now well controlled (120/70 mm Hg). Urine volume normal. Nocturia once. Past History: Resistant hypertension for last 20 yrs, had been on CCB, ACEI, Beta blocker, Diuretics, even Prazosin and Cloninidine, but still BP was around 150/90 mm of Hg. H/O hyperuricemia and gout, treated with allopurinol. No history of Diabetes. Family history of CKD (Diabetes) among relatives from paternal side. Investigations: A. USG and NCCT KUB – enlarged both kidneys with multiple small cortical cysts with small calculi, prostatomegaly. B. Blood biochemistry: 1. Serum Creatinine – 9.4 mg/dl 2. Urea – 168 mg/dl 3. Na+ – 135 meq/L 4. K+ – 3.8 meq/L 5. Serum phosphorus – 5.4 md/dl 6. Serum Calcium – 8.8 mg/dl 7. Parathyroid (intact) – 452.6 pg/ml 8. FBS – 83 mg/dl 9. Uric acid – 5.6 mg/dl (on febuxostat) 10. Lipid Profile – Normal 11. Plasma Proteins – Normal C. Urine Albumin Creatinine ratio (ACR) – 935 mg/gm D. Hematological Parameters: 1. Hb – 9.6 g/dl 2. RBC – 3.15 x 106/µL 3. WBC – 5.9 x 103/ µL 4. Platelet – 135×103/ µL 5. HCT – 29.1% 6. MCV – 92.4 fL 7. MCH – 30.5 pg 8. MCHC – 33.0 g/dl 9. RDW – 12.8% 10. DLC – normal E. Echocardiography: 1. LV ejection fraction: 72% 2. Mild pericardial effusion all around the heart, grade I diastolic dysfunction 3. Concentric LVH with good LV systolic function F. CXR – normal, no pleural effusion Present Medications (oral): 1. Amlodipine (5 mg) OD 2. Metoprolol (50 mg) OD 3. Torsemide (10 md) OD 4. Sevelamer (400 mg) BD 5. Iron (33 mg) BD 6. Calcitriol (0.25 mg) OD on alertnate days 7. Enteric coated Aspirin (75mg) OD 8. Febuxostat (40 mg) OD 9. Atorvastatin 10 mg (now stopped) *Arterio-venous fistula created. Renal transplantation is not feasible. *Nephrologist advised to wait for symptoms to start dialysis, till then to measure blood parameters monthly Please advise: 1. When to start hemodialysis? 2. What other investigations need to be done for further confirmation of diagnosis and follow-up? 3. What other medication or management is needed?

Your father appears to be very well managed at this point.  I suggest a low salt diet and to limit sodium intake to less than 2000 milligrams per day.  I suggest your father continue to follow the advice of his nephrologist.  I do not have any other recommendations.  The decision to start dialysis must be a decision between him and his nephrologist.  I cannot forecast when he might need dialysis.  This must be an individual decision based on examining and talking with your father.



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