Age: 56.0
Sex: M
Vaccine: COVID19
Symptoms: Anion gap, Anticoagulation drug level below therapeutic, Atrial fibrillation, Blood bilirubin increased, Blood creatinine increased
Clinical narrative: Moderna Dose 1 4/26/21 (002C21A) Moderna Dose 2 5/24/21 (035C21A) COVID Positive 2/18/22  2/18/22: Pt. is a 57-year-old male with PMH history of renal transplant x 2 due to APOL-1 related FSGS, current CKD 4, immunocompromised status, atrial fibrillation on chronic anticoagulation, CHF, and HTN who presented to ED today for swelling of bilateral legs and increased dyspnea on exertion.  He states his feet are killing him and have made it difficult to stand.  His wife notes his legs are the most swollen may have ever been.  He also notes significant shortness of breath with activity as minimal as sitting or drinking water.  Associated symptoms include a dry cough, lightheadedness, chills, and decreased appetite. He believes symptoms have been coming on for 3-4 days, however his wife believes symptoms have been present for 1-2 months.  He notes that he has not been urinating much recently.  His torsemide dose is 200 mg however he is able to titrate himself down as he feels necessary, and he has been taking 200 mg for the past couple days.  He does note missing 2 days of all medications in a row prior to this. He takes albuterol which very slightly improved his symptoms.   Per chart review, patient had end-stage renal disease presumed secondary to APOL-1 related FSGS s/p deceased donor kidney transplant in 1999, which lasted to 2004, then subsequently on chronic hemodialysis followed by 2nd kidney transplant on 11/1/15.  Noted baseline at most recent nephrology visit on 2/3/22 indicated baseline creatinine 2.5-3.0, with Cr 3.91 1/31/22.  At that time there were no clear signs of rejection of kidney.  Last seen in clinic 2/10/22 with Cr 5.94.  He is taking torsemide 100 mg for diuresis, to titrate up to 200 mg as patient deems fit. Current medications for history of transplant include mycophenolate, prednisone, and tacrolimus.   In the ED patient presented with pulse 115, BP 99/67, saturating 98% on room air.  Labs notable for Na 131, anion gap 23, glucose 58, creatinine 8.14, total bili 8.0, lactate 3.9, proBNP >70000, troponin 0.18, platelets 43, INR 2.4.  EKG indicated atrial fibrillation with RVR, RAD, incomplete right bundle branch block.  CXR indicated cardiomegaly and pulmonary vascular congestion, patchy airspace disease in bilateral lungs could represent pulmonary infiltrate versus pulmonary edema.  Due to clinical status, central line was placed in right IJ, CXR indicated termination within the SVC.  In the ED he was given 2 mg of Bumex and 250 mL NS.   Surgical Hx: Kidney transplant 1999, 2015.  Family Hx: Noncontributory  SH: Denies current tobacco, alcohol, or recreational drug use  2/27/22: patient is a 57-year-old male with PMH history of renal transplant x 2 due to APOL-1 related FSGS, current CKD 4, immunocompromised status, atrial fibrillation on chronic anticoagulation, CHF, and HTN who initially presented to ED 2/18/22 for swelling of bilateral legs and increased dyspnea on exertion.  In the ED labs were notable for creatinine over 8 with baseline 2.5-3, in addition to pro BNP greater than 70,000, lactate 3.9, platelet 43, and troponin 0.18 which trended to 0.17 with repeat.  He was found to be in AFib with RVR in the ED and started on diltiazem drip which was transitioned to PO on day 3 of hospitalization.  Nephrology was consulted and patient was initially on bicarb and Bumex drip however ultimately required dialysis starting 2/21/22.  He had a supratherapeutic INR at admission and this continued to rise despite holding warfarin. Patient was also noted to have thrombocytopenia for which he did receive platelet transfusions. Hematology was consulted. Patient was treated for possible concurrent CAP. Patient was difficult to manage from a dialysis standpoint as he had both fluid overload and hypotension. Due to this, on 2/27 patient was transferred to the ICU with plan to initiate CRRT. Pulmonology was also consulted as patient had had several episodes of respiratory distress requiring placement of BiPAP. Patient arrived to the ICU initially in stable condition, on 5L NC. Had rapid decompensation with PEA. Patient was coded 5 times and ROSC was achieved with each attempt. Patient was intubated after first code Patient was noted to have large amount bloody fluid in output from OG tube, GI bleed was believed to be the reason for his decompensation. Patient received 2 units pRBCs, 2 units platelets, 2 doses Kcentra. Discussion was had with family (see Dr.'s note) and decision was made not to code patient again. Family came to the bedside and patient passed away.