AI Scribe for Nephrologists

SUBJECTIVE:
64-year-old female with CKD stage 4 secondary to diabetic nephropathy and hypertensive nephrosclerosis presents for routine nephrology follow-up. Last seen 3 months ago with Cr 2.8, eGFR 18 mL/min. Patient reports stable energy level, no new edema. Following low potassium, low phosphorus diet. Taking all medications as prescribed. No missed doses. Denies nausea, vomiting, or decreased appetite. Urine output stable, no dysuria or hematuria. Following up on recent labs.

PAST MEDICAL HISTORY:
- CKD stage 4 (diabetic and hypertensive nephrosclerosis)
- Type 2 diabetes mellitus (A1C 7.2% last month)
- Hypertension
- Secondary hyperparathyroidism
- CKD-related anemia on ESA

MEDICATIONS:
- Lisinopril 40mg daily
- Amlodipine 10mg daily
- Furosemide 40mg BID
- Sevelamer 800mg TID with meals
- Calcitriol 0.25mcg daily
- Darbepoetin alfa 40mcg SC monthly (last dose 2 weeks ago)
- Insulin glargine 28 units at bedtime
- Metformin discontinued (GFR <30)

OBJECTIVE:
Vitals: BP 138/82, HR 74, Weight 168 lbs (stable), BMI 29.4
General: Well-appearing, no acute distress
Cardiovascular: Regular rate and rhythm, no murmurs
Lungs: Clear bilaterally
Extremities: Trace bilateral pedal edema, no cyanosis
Access: No AV fistula yet (planning placement soon)

LABORATORY DATA (today):
Renal Function:
- Creatinine: 3.1 mg/dL (up from 2.8 three months ago)
- BUN: 64 mg/dL
- eGFR: 16 mL/min/1.73m² (down from 18)
- Albumin: 3.6 g/dL

Electrolytes:
- Sodium: 138 mEq/L
- Potassium: 5.2 mEq/L (mildly elevated)
- Chloride: 106 mEq/L
- Bicarbonate: 20 mEq/L (mild metabolic acidosis)
- Calcium: 8.8 mg/dL
- Phosphorus: 5.4 mg/dL (elevated)

Anemia Labs:
- Hemoglobin: 10.8 g/dL (stable on ESA)
- TSAT: 28%
- Ferritin: 245 ng/mL

Bone/Mineral:
- Intact PTH: 286 pg/mL (goal 150-300 for stage 4 CKD)
- Vitamin D 25-OH: 32 ng/mL (adequate)

Urine Studies (from last week):
- Urine protein/creatinine ratio: 1,850 mg/g (nephrotic range)
- No active sediment

ASSESSMENT:
1. Chronic kidney disease stage 4, progressive
   - eGFR 16 mL/min (declining from 18)
   - Etiology: Diabetic nephropathy and hypertensive nephrosclerosis
   - Nephrotic-range proteinuria (1,850 mg/g)
   - Approaching need for renal replacement therapy

2. Secondary hyperparathyroidism
   - PTH 286 pg/mL (within goal range for CKD stage 4)
   - Hyperphosphatemia (5.4 mg/dL)

3. CKD-related anemia
   - Hemoglobin 10.8 on darbepoetin
   - Iron stores adequate

4. Mild hyperkalemia (5.2 mEq/L)

5. Metabolic acidosis (HCO3 20 mEq/L)

6. Hypertension - adequately controlled on current regimen

7. Type 2 diabetes - stable glycemic control

PLAN:
1. Renal Replacement Therapy Planning:
   - eGFR now 16 mL/min - approaching dialysis threshold
   - Schedule AV fistula placement within 1 month (contacted vascular surgery)
   - Discussed dialysis modalities: hemodialysis vs peritoneal dialysis
   - Patient prefers hemodialysis
   - Referred to dialysis education class
   - Will plan for dialysis initiation when eGFR <10-12 or symptomatic uremia

2. Hyperphosphatemia:
   - Increase sevelamer to 1600mg TID with meals
   - Reinforce low phosphorus diet
   - Goal phosphorus 3.5-5.5 mg/dL

3. Hyperkalemia management:
   - Continue low potassium diet
   - May need to reduce lisinopril if K+ rises further (currently tolerating well)
   - Recheck in 2 weeks

4. Metabolic acidosis:
   - Start sodium bicarbonate 650mg TID to target HCO3 >22 mEq/L
   - Helps slow CKD progression

5. Anemia:
   - Continue darbepoetin 40mcg monthly
   - Target Hgb 10-11.5 g/dL per KDIGO
   - Iron stores adequate, no supplementation needed

6. Blood pressure:
   - Continue current regimen (lisinopril, amlodipine, furosemide)
   - Goal <130/80 per KDIGO

7. Proteinuria:
   - Maximized RAAS blockade with lisinopril
   - Consider SGLT2 inhibitor but GFR too low (need eGFR >20)

8. Labs in 6 weeks:
   - CMP, CBC, phosphorus, PTH, TSAT, ferritin
   - Monitor eGFR trend

9. Follow-up in 6 weeks or sooner if symptoms develop

10. Educated on uremic symptoms: nausea, vomiting, confusion, shortness of breath
    - Call if any of these develop

11. Discussed importance of AV fistula maturation before dialysis need
    - Will coordinate with vascular surgery

Extensive discussion with patient regarding approaching need for dialysis. Patient understands and is preparing mentally and logistically. Questions answered.