What to do now so no further decrease in the working of kidney - #9788

**Patient Name**: [Abhay ] **Age**: 20 years **Date**: 12-04-2025 **Consultation Type**: Nephrology Referral **History**: Bilateral Vesicoureteral Reflux (VUR) – surgically corrected at age 2.5 years and again at age 18 (left side). **Presenting Complaints**: Elevated blood pressure (145/100 mmHg), serum creatinine 2.5 mg/dL, generalised weakness, and fatigue throughout the day. **Clinical Impression**: The patient is presenting with elevated creatinine and persistent hypertension, suggestive of **chronic kidney disease (CKD)**, likely secondary to previously treated VUR. Current signs and symptoms point towards **Stage 3–4 CKD** with reduced glomerular filtration rate and early uremic features including fatigue. The presence of elevated BP further contributes to renal damage and needs urgent intervention. Nephrology input is required to assess renal function, control blood pressure, and prevent disease progression. --- **Plan of Management**: 1. **Nephrology Referral**: Immediate referral to nephrology for staging of CKD and long-term renal management. 2. **Investigations Advised**: - Renal Function Panel (Urea, Creatinine, eGFR, Electrolytes) - Urine Routine and Microscopy + Urine Protein/Creatinine Ratio - Complete Blood Count (CBC) – to rule out anemia of chronic disease - Serum Calcium, Phosphorus, Vitamin D, and PTH levels - Renal Ultrasound – to assess kidney size, cortical thickness, and any evidence of scarring or asymmetry - 24-hour ambulatory BP monitoring or daily home BP charting 3. **Medication (To Start After Nephrology Confirmation)**: - **Tab. Telmisartan 20 mg OD** – for blood pressure control and renal protection (ARB class) - Avoid NSAIDs and nephrotoxic medications - Continue any urology-prescribed medications unless advised to discontinue 4. **Diet and Lifestyle**: - Renal-safe diet: Moderate protein intake, reduced salt, phosphorus, and potassium (as per nephrologist’s guidance) - Adequate hydration unless fluid-restricted - Avoid processed and high-sodium foods - Avoid over-the-counter medications without medical advice - Daily physical activity (gentle walking) as tolerated - Regular BP monitoring at home 5. **Patient Education and Monitoring**: - Educated about signs of worsening renal function (swelling, breathlessness, decreased urine output, nausea) - Counseled on the importance of nephrology follow-up, BP control, and dietary compliance - Advised not to miss scheduled appointments and to repeat renal function tests every 4–6 weeks or as advised by nephrologist **Provisional Diagnosis**: **Chronic Kidney Disease (Stage 3–4), secondary to Bilateral VUR – Post Surgical Correction** **Hypertension – CKD Related** **Fatigue – Likely CKD-Associated** **Next Follow-Up**: After nephrology assessment and lab reports Dr Shayeque Reza MD 9800280276