Прошу Вас посоветовать как можно понизить креатин у больного . с уважением Армен Dear Sir/Madam, Patient Sargsyan...

Прошу Вас посоветовать как можно понизить креатин у больного . с уважением Армен Dear Sir/Madam, Patient Sargsyan Henrik 69 years old 23.12.11 admitted to the Z HVMC with peripheral oedema, breathlessness , dyspnea more intensive during exertion and in the horizontal position. History of Disease 30.08.2001 admitted to the NMMC with pressing retrosternal pains in the chest. Patient underwent on coronary angiography and CABG 5 shunts, 2 of them were venous in the a. diagonalis and RCA, and 3 arterial shunts in the Ramus and OM, and a. mamaria interna LIMA in the LAD, peri operation and postoperation periods without complications. 2007 patient admitted with discomfort in the chest, dyspnea, breathlessness, underwent on recoronarography and shuntography and all shunts were working normal. Patient has goat and arterial hypertension. Objective examination Cardiac sounds are rhythmic, clean, BP 130/80mmhg, rales in the lower areas of the right lung, moderate peripheral oedemas, swelling in the ankles. ECG -sinus rhythm 81 bm, horizontal position of the heart, left ventricular hypertrophy signs. Echo CG- LV chamber diameter is normal, LV moderate hypertro phy, LV EF is moderate 50%,there are hypokynesis in the LV lateral and inferior walls, cardiac valves are intact. Doppler CG - diastolic dysfunction 1 type, MR0, TR0 grade.Vena cava inferior were not congestive, collapsed. LA 3.9 cm, Ao 3.8 cm, LVEDD 5.0 cm, PW d/s 1.2, IVS 1.4cm , RV 2.6cm , PAAT 0.120, EF 50% Clinical diagnosis; CAD, postinfarction cardiosclerosis , CABG 2001, arterial hypertension II stage, chronic pyelonephritis , chronic renal disease (stage V, GFR Cockroft 10.5 ml/m, MDRD 7.7ml/m). During treatment renal failure became more severe and patient had nephrologist consultation in the Arabkir MC. Nephrologist consultation 09.01.2012. Firstly observed hyperazotaemia 2007 not so high. Medications curantil, carvedilol, valsartan, norvasc (NORMODIPIN), Recormon, colchicin during goat attacks. Laboratory analysis dynamic changes Denomination Result of 11.2011 Result of 09.01.2012 Result of 14.01.2012 Result of 30.01.2012 Reference Total protein 62 62 68 60-80g/l Urea 22 21.7 28 <8.3mmol/l Creatinine 556 663 403 866 59-104mkmolm/l Na 153 145 146 136 135-150mmol/l K 4.8 4.5 5.2 4.4 3.8-5.1mmol/l Ca++ 0.77 0.58 0.53 1.13-1.32mmol/l Glucose 5.0 3.9-6.4mmol/l Bilirubin total 10.6 4-21mkmol/l Bilirubin direct 1.6 0-5 mkmol/l Bilirubin indirect 9.0 2-18mkmol/l Albumin 33.5g/l 45.5 69% 34-48g/l, 52-65 % Globulin 2.8 8.7 8.2 11.3 2.5-5% 7-12% 8-14% 12-22% Cholesterol 3.0 <5.2 mmol/l LDL 1.7 2.59-3.34 mmol /l HDL 1.0 >1.45 TG 1.24 <2.3 Uric acid 681 202-416mkmol/l HGB 100 96 102 130-160g/l RBC 3.31 4.0-5.0 x10 12 /l Fi 0.87 0.85-1.05 HTC 29 43-49 % PLT 200 150-400x109 /l WBC 6.5 4.0-10.0x109/l STUB 2 1-6% 0.04-0.3 109/l SEG 65 47-72% 2.0-5.5109/l EO 4.5 0.5-5% 0.02-0.3 109/l BASO 0.5 0-1% LYMPH 23 19-37% MONO 5 3-11% ESR 27 2-10mm/h Ferritin 422ng/ml FIBRINOGEN 7.5 2-4g/l PT INDEX 93% 77% 70-100% INR 1.19 0.91-1.25 Hepatit B NEG Hepatit C NEG HIV NEG HCO3 18.8 20mmol/l pH 7.37 7.3 SAT 86.9% PO2 56.6 PCO2 33.4 SBE 5.5mmol/l 5.5mmol/l Urine density 1008 1013 Proteinuria 1.41g/l 1.32 g/l WBC 4-5 v/a 2-3 v/a RBC - 0-1 v/a US examination 08.09.2011 Kidneys; left kidney diameter 9.5 cm, right kidney diameter 10.5 cm, diffuse sclerotic changes in the kidney parenchyma. In the upper part of the right kidney there were cystic cavity with diameter 2.5 cm, contains fluid, in the middle part there were 2 analogic cystic cavities with diameter 1.0 cm, in the upper part of the left kidney cystic cavity with diameter 2.5 cm, protected embryonic lobular structure. Prostatic gland diameter increased 5.3 cm, with noduliar hypertrophy in the periuretral part, with periuretral subbladder volumic mass with diameter 2.3 cm, gland conturs are normal, lateral lobes are symmetric after urination, in the urine bladder there was 30ml residual urine. Liver, pancreas, gall-bladder, spleen, mesenteric and postabdominal lymphatic nodes, thyroid gland without obvious changes. There was no effusion in the abdominal and pleural cavities. Conclusion; US picture of fibrotic changes in the kidney parenchima, tendense to kidney atrophy, adenoma of the prostatic gland, kidney cystic disease. Conclusion • BP control is normal • There are severe oedemas in the lower extremities, cholesterol corrected, • There are need to correct hypocalcaemia, and add high doses of diuretics, and prepare to replacement therapy, haemodialysis. Recommendations • Nephrologist΄s follow up • Mirsera 1 s/c for month • Furosemide 100mg/d i/v • Calcium Nicomed • Valsartan discontinue I am from Armenia, Yerevan and would like to kindly ask for your support to examine my nephrological case suggesting necessary analysis, studies and further medical treatment in your clinic. In your offer please include details and cost estimate regarding my transportation/ transfer, entry visa, accommodation for me together with my wife, treatment details, period of required stay, payment conditions. Please find below summary of my disease in addition to the attached document. About a year ago my kreatinine was 250-300 mkmolm/l and I feel normal. After that kreatinine started to grow and reached 663 mkmolm/l as of January 9, 2012 and protein in the urine was 1-1,30-1,5. In the result my legs and my face became swollen and I experienced shortness of breath. After doctor’s consultation I was treated with Furosemide (Lasix) 2-4 tablets a day after which kreatinine was fallen down until 403 mkmolm/l as of January 14, 2012. Afet that I continued Furosemide (Lasix) until January 30 and kreatinine became 866 mkmolm/l. Now my breath is normal and I have no edema. Anyway doctor now cannot suggest any other medical treatment but dialysis in a short period of time. I would like to ask you to recommend whether it is possible in my situation to escape dialysis and continue/undergo treatment with medicines. Please do not hesitate to contact me if you need more information. Thank you very much in advance, Sincerely, Henry Sargsyan, Armenia, Yerevan