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IM10.1-24 | Acute Kidney Injury and Chronic Renal Failure — Assignment

CLINICAL SCENARIO

You are the intern on the nephrology ward. A 58-year-old man, Mr Ramaiah, a school teacher from Tirunelveli with known hypertension and type 2 diabetes for 12 years, is admitted with 5 days of decreasing urine output, ankle swelling, and vomiting. His wife reports he has been feeling unwell and confused for 2 days. His serum creatinine is 7.2 mg/dL. He has no prior creatinine records available. Using this case as a clinical framework, you will produce a structured management report that demonstrates integration of the full AKI and CKD module — from clinical evaluation and diagnostic testing to management, patient communication, and ethical decision-making.

Instructions

Write a structured clinical report in the five sections below. Use clear, professional clinical language appropriate for a final-year MBBS intern. All calculations (anion gap, FENa) must be shown with the formula, substituted values, and interpreted result. All management thresholds must be stated with the specific numbers (e.g., 'hold metformin if eGFR falls below 30 mL/min/1.73 m2'). For patient communication sections, write in plain accessible English as if speaking directly to the patient. Word limit: 1,300-1,600 words across all sections.

Length: 1,300-1,600 words across all sections

What to Submit

Section 1: Clinical Evaluation — History and Examination

Guidance: Structure Mr Ramaiah's history across the five essential domains of renal evaluation: (1) precipitating and chronological story (onset, progression, triggers), (2) prior kidney disease or investigations, (3) systemic diseases and nephrotoxic drugs (including NSAIDs, contrast agents, herbal medicines), (4) obstructive symptoms, and (5) systemic review for possible causes (diabetes, hypertension, cardiac, autoimmune). Describe the physical examination findings you would prioritise and explain how each finding helps you classify the acuity (AKI vs CKD vs AKI-on-CKD) and category (pre-renal/intrinsic/post-renal). Approximately 250-300 words.

Section 2: Diagnostic Workup

Guidance: State the minimum investigation panel you would order and the rationale for each test. You must address: (a) serum creatinine, eGFR, electrolytes, urea — what each tells you; (b) calculate and interpret the anion gap from the following values: Na 136, Cl 102, HCO3 12 mEq/L; (c) urinalysis with microscopy — which casts suggest which diagnosis; (d) FENa calculation from these values: serum Cr 7.2 mg/dL, urine Cr 144 mg/dL, serum Na 136 mEq/L, urine Na 54 mEq/L — calculate and interpret; (e) renal ultrasound — what findings distinguish AKI from CKD; (f) ECG — describe the sequential ECG changes in hyperkalaemia from earliest to most dangerous. Approximately 300-350 words.

Section 3: Management Plan

Guidance: Write a structured management plan for Mr Ramaiah. Address all five priority domains for AKI management: (1) volume management (how to assess and correct); (2) dietary management (protein, potassium, phosphate, sodium, and fluid specifics); (3) drug dose adjustments (name three drug classes that require adjustment in AKI and the principle for each); (4) monitoring plan (what parameters, how frequently, and what triggers escalation); (5) dialysis — state whether Mr Ramaiah meets any AEIOU criteria and name all five AEIOU indications with their specific thresholds. If his underlying condition is CKD, extend your plan to include: ACE inhibitor/ARB use (rationale and safety thresholds), glycaemic management (metformin threshold), anaemia management (ESA indication), and CKD-MBD management (phosphate binders and vitamin D analogue). Approximately 350-400 words.

Section 4: Patient Communication and Renal Diet Counselling

Guidance: Draft the conversation you would have with Mr Ramaiah and his wife after the investigations are back. Using plain language (no medical jargon), explain: (1) what has happened to the kidneys and why; (2) what the treatment involves and what to expect; (3) the follow-up plan. Then write a brief renal diet counselling note for Mr Ramaiah: specify the restrictions on protein (and why protein is not zero), potassium, phosphate, sodium, and fluid intake, explaining the reason for each restriction in language he can understand. Approximately 200-250 words.

Section 5: Quality of Life and Ethical Considerations

Guidance: Describe the likely impact of Mr Ramaiah's renal diagnosis on his quality of life — physical (fatigue, fluid restrictions, dialysis schedule), occupational (work as a teacher), and family (dependence, emotional burden). Explain how you would incorporate his preferences into the care plan. If dialysis is being considered, apply all four principles of biomedical ethics (autonomy, beneficence, non-maleficence, justice) to the dialysis decision in his case. Approximately 150-200 words.

Grading Rubric — Renal Failure Management Plan Rubric

Criterion	Points	Full-marks descriptor
History and Examination (Section 1): Structures the clinical history across the five essential domains of renal evaluation; accurately identifies the likely AKI or CKD category (pre-renal/intrinsic/post-renal; AKI vs CKD vs AKI-on-CKD) from clinical features; physical examination findings interpreted correctly with emphasis on volume status and uraemic signs.	20 pts	All five history domains covered with specific, clinically relevant details; correct category classification from clinical data; examination findings precisely linked to category (e.g., JVP, skin turgor, asterixis, oedema, flank tenderness) with accurate interpretation.
Diagnostic Workup and Interpretation (Section 2): Selects appropriate investigations aligned to the presumed category and aetiology; correctly interprets FENa, urine electrolytes, urinalysis with microscopy, renal ultrasound, anion gap calculation, and ECG findings in hyperkalaemia; explains the rationale for each test.	25 pts	Full minimum panel selected with rationale; FENa correctly calculated and interpreted (including caveat for diuretics); anion gap calculated correctly; ECG hyperkalaemia findings described in sequence (peaked T → QRS widening → sine wave); urinalysis findings linked to diagnosis (e.g., red cell casts for GN, waxy casts for CKD, muddy brown casts for ATN).
Management Plan (Section 3): For AKI — addresses all five priority domains (volume management, diet, drug dose adjustment, monitoring, dialysis indications using AEIOU). For CKD — addresses multi-target supportive therapy (BP target and antihypertensives, glycaemic management including metformin thresholds, anaemia, CKD-MBD: phosphate binders and vitamin D analogue, hyperkalaemia management). Dialysis indications named precisely.	30 pts	All five AKI priorities addressed with specific detail (e.g., correct volume strategy, drug dose adjustments named, monitoring frequency stated); OR CKD multi-target plan complete (BP less than 130/80 stated, ACE inhibitor/ARB rationale, metformin hold at eGFR less than 30, ESA indication stated, phosphate binder choice justified, AEIOU dialysis indications all five named correctly).
Patient Communication and Diet Counselling (Section 4): Drafts a clear patient-facing explanation of the diagnosis, treatment plan, and follow-up; renal diet counselling is stage-specific (protein intake guidance, potassium, phosphate, sodium, and fluid restrictions appropriate to the AKI or CKD stage); avoids jargon; addresses patient concerns and preferences.	15 pts	Explanation is clear, jargon-free, empathetic, and complete (diagnosis explained in lay terms, treatment plan with rationale, follow-up plan with specific intervals); diet counselling is stage-specific with specific restrictions named and reasons explained to the patient.
Ethics and Quality of Life (Section 5): Addresses the impact of CKD or ESRD on the patient's quality of life, work, and family; discusses the patient's preferences and how they were incorporated into the care plan; for any dialysis decision, applies the four bioethical principles correctly.	10 pts	QoL impact described specifically (physical, psychosocial, occupational, family dimensions); patient's stated preferences documented and incorporated into the plan; bioethical analysis of dialysis decision references all four principles correctly.

PEER REVIEW

Review your peer's management report using the rubric provided. For each section, assign a score and write one specific comment explaining your assessment — do not simply copy the rubric descriptor. For Section 2, verify that the FENa calculation is shown with formula and substituted values, and that the anion gap of 22 mEq/L is correctly identified as high. For Section 3, check that all five AEIOU dialysis indications are named with their specific thresholds. For Section 4, assess whether the communication is genuinely jargon-free and whether the dietary restrictions are stage-specific with reasons. Return your review within 72 hours of submission.