Thursday, February 25, 2010

Kidney Failure, Update

An update on the little boy with kidney failure.

It turned out that the hospital did not have IV steroids available, and I knew the mother would not be able to buy any, so I got some steroid pills (prednosolone) from our clinic and gave it to her. I told her to give two pills in the morning and two pills at night. When we have the family member administer the medication, it is much more reliable than the overtaxed nurses who have too many patients to care for.

I went back to see the boy every day. He stopped crying when I arrived, and it worried me because I thought it indicated he was weaker. He was looking more and more swollen – his head was now hugely swollen with fluid, his eyes so puffy they were almost swollen shut. The urine continued to drain well, and the scrotum actually became much smaller, to about the size of an orange.

One of the ongoing problems was the mother’s poverty. She had no money for food. She had no change of clothing for herself or the boy. She didn’t even have clean sheets – the two she was using were dirty, and she had nothing to use while she cleaned them. She had no family with her, and no one had come to check on her from her village.

Then two days ago, I went to visit him, expecting a frown or a whimper on my arrival. The mother was sitting nearby with some other ward patients, who were generously sharing their food with her. I walked up to the boy’s bed, and to my surprise, he looked at me and smiled. It was possibly the best smile I had ever seen. I held out my hand, and he shook it. I couldn’t believe it – he was finally used to me. I pulled out my stethoscope, and he reached up and pulled his sheet off his chest, knowing I would be listening to his heart. I was so moved by that, it was nearly overwhelming.

His heartbeat was no longer fast, and apart from the swelling, he looked ok. But the swelling was so bad and made me very sad for this poor little boy. A man who was among the people sharing food with the mother came over to help translate. I explained the situation. The mother repeated her sorrows – no money, no food, she wants to go home to raise money. I explained again – the man translated – that her son could die if he goes home. I had bought her a large sheet that I cut in half to make two sheets. I gave them to her, and had the man tell her that they were donated from some nice people in our clinic. (I don’t want to create the image of mzungus throwing around money, but I couldn’t bear to see the little boy lying in dirty sheets). She was very grateful for the sheets. I reminded the nurses to give him the Lasix, and confirmed that he was getting the steroids.

His labs finally came back, and they were surprisingly uninteresting. He was moderately anemic, but everyone is here. His creatinine was just slightly elevated for his age. His blood urea nitrogen was also a little elevated, but not remarkably so. I took some urine from his urine bag, and had it analyzed. It had a lot of protein in it, and some triple phosphate crystals.

I started putting together a differential diagnosis. It seemed very likely that he had a nephrotic syndrome that is not uncommon in children. The kidneys themselves are functioning, but they allow protein to spill abundantly into the urine. That protein is sifted from the bloodstream into the urine. Because of the lack of protein in the blood, the water component in the blood filters through the capillaries, and causes anasarca (fluid in the skin) and ascites (fluid in the abdomen). It is treated with steroids, and with adequate care, children usually make a full recovery. The question is, what kind of “adequate” care does he need to survive this?

The next day, the boy was lying in bed, between the sheets I had bought. He shook my hand and exposed his chest and belly helpfully when I needed to examine him. His swelling was still severe. A woman on the ward translated for the mother, who again described her situation. She begged to be able to go home. I asked if she could go and come in one day – and possibly leave the boy behind in someone else’s care? No – she lived far away, and would need several days at home to raise money to be able to come back. I explained that I felt badly, but I couldn’t tell her to take him home, because he could die. The woman translating understood the gravity of the situation, and explained it to the mother.

Every day that I saw the boy, I held my breath, hoping that that day, the steroids had started working. Today, I went to the ward to see him, and his bed was empty. Other mothers told me that they had seen the mother take him home a few minutes earlier – she left on a motorcycle.

I don’t know what will happen to him. I don’t know if he will survive the time at home, and whether she will ever bring him back. I have had other patients in Antenatal clinic who were very sick, and they left for “a few days” and never came back.

No comments: