A Case Study On

A Case Study OnChronic Kidney DiseaseIn Partial Fulfillment of the Course Requirement in Clinical ChemistrySUBMITTED BY:

LAHORA, YANCY DANICA

LAPASTORA, ANMARIE GRACE

LOTILLA, RIZZLE JOY

MATUCO, JULIO NICOLAS

MEMBREVE, GRACE LYNPERFAS, ERVILGroup 5

Clinical ChemistryDavao Medical School Foundation HospitalSUBMITTED TO:

SETRINA GRACE CARBAJOSAClinical Chemistry Clinical Instructor

February 2015

OBJECTIVES OF THE STUDYThis study aims to:

1. To know the patients condition and point out critical parts that will help in the making of

a diagnosis;2. Give the patients most likely diagnosis.

3. To correlate the laboratory findings with the presumed condition.

4. To explain the pathogenesis of the disease.

CHAPTER 1INTRODUCTION TO THE CASE

This case is all about a 64 year old man with poorly controlled hypertension who complains of generalized weakness, anorexia, bony pains and impotence occurring for the past few months. The patient has not seen anyone in primary care for the past five years and only takes a diuretic to control his hypertension if the patient remembers it. No other disease or disorders has been indicated in the patients medical history.Physical examination showed a weight of 60 kilograms and an evidence of conjunctival pallor. He has a high blood pressure which is 175/95. Laboratory examinations yielded a decreased hemoglobin level of 10.8; a normal White count of 8; a normal platelet count of 200; a normocytic red blood cells with MCV value of 90; a decreased sodium value of 132; a slightly elevated potassium of 5.6; an increased urea level of 22; an increased creatinine level of 375; an elevated alkaline phosphatase level of 230; an elevated calcium level of 1.95 and an elevated phosphate level of 1.9. The urine dipstick shows a 3+ protein. For the ultrasound of the kidney it revealed a measurement of 8.1 cm and 8.4 cm with no obstruction.

Diagnostic Findings

Abnormal electrolyte levels, increased urea and creatinine levels, presence of protein in the urine and the decreased size of the patients kidney indicate that the patients is experiencing kidney problems. CHAPTER 2PATIENTS DATA

PERSONAL DATA:

Age: 64

Sex: Male

MEDICAL HISTORY:

Hypertension

Weakness

Anorexia

Bony pains

Impotence

Conjunctival pallor

LABORATORY RESULTS:

LABORATORY TEST RESULTS

HEMATOLOGY

CHEMISTRY STUDIES

White Cell Count:8 g/dLSodium:132 mmol/L

Platelet:200 x 109/LPotassium:5.6 mmol/L

Hemoglobin:10.8 g/dLUrea:22 mmol/L

MCV:90 fLAlkaline Phosphatase:230 IU/L

Calcium:1.95 mmol/L

Phosphate:1.9 mmol/L

Creatinine:375 mmol/L

URINALYSIS

Imaging Studies

Urine Dipstick (Protein):+++Ultrasound (Kidney):8.1 cm and 8.4 cm

CHAPTER 3DEFINITON OF THE CASE, ANATOMY AND PHYSIOLOGY, AND PATHOPHYSIOLOGY OF THE AFFECTED PARTS

A. DEFINITION OF THE CASE

Generalized weaknessis a lack of physical or muscle strength. It is also defined as reduced strength in one or more muscles. It is a symptom that may be caused by illness, medicine, or medical treatment. General weakness often occurs after you have done too much activity at one time. The importance of weakness as a symptom can only be determined only when other symptoms are evaluated. Anorexia is a medical term used to describe people with loss of appetite. It is a symptom and has a distinct difference with the disorder, anorexia nervosa, as people suffering from anorexia nervosa do not lose their appetite. The symptom itself may be harmless harmless but may also indicate of a serious underlying condition such as infection, drug abuse or organ failure.Impotence or erectile dysfunction is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual activity or the inability to achieve ejaculation, or both. A penile erection is the hydraulic effect of blood entering and being retained in sponge-like bodies within the penis. The process is often initiated as a result of sexual arousal, when signals are transmitted from the brain to nerves in the penis. Erectile dysfunction can vary. It can involve a total inability to achieve an erection or ejaculation, an inconsistent ability to do so, or a tendency to sustain only very brief erection. The cause of such may be psychological in which erection may fail due to thoughts or feelings or due to an underlying condition or a metabolic consequence such as potassium deficiency, high blood pressure or drug abuse.Conjunctival pallor unusual or extreme paleness in the conjunctiva of the eye. It may be caused by shock, hypoglycemia, skin edema or respiratory distress, though the symptom is usually caused by anemia or decreased peripheral perfusion.Bony pain or bone pain is a common problem, particularly who are middle aged or older. It is often described as a dull pain that cannot be localized accurately by the patient. The pain originates from both the periosteum and the bone marrow which relay nociceptive signals to the brain creating the sensation of pain. It is usually caused by a decrease in bone density or injury to the bones. It can also be a sign of a serious underlying medical condition such as infection, a disorder in the blood supply or cancer.Chronic Kidney Disease (CKD) or Chronic Renal Disease is a common condition in which there is a loss of kidney function over a period of months or years. The symptoms of worsening kidney function are not specific and includes symptoms such as malaise or loss of appetite. The disease is often diagnosed as a result of screening tests of people who are known to be at risk of kidney problems, such as those with high blood pressure or diabetes or who has a family history of CKD. The disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis. Signs and symptoms of the disease include hypertension, edema, protein-malnutrition, muscle weakness, fatigue, gastrointestinal disorders and complications, skin manifestations, impotency, platelet dysfunction, encephalopathy, and pericarditis.B. ANATOMY AND PHYSIOLOGY

The kidneys:

The kidneys are a pair of organs located in the back of the abdomen. Each kidney is about 4 or 5 inches long -- about the size of a fist. The kidneys' function are to filter the blood. All the blood in our bodies passes through the kidneys several times a day.

The kidneys remove wastes, control the body's fluid balance, and regulate the balance of electrolytes. As the kidneys filter blood, they create urine, which collects in the kidneys' pelvis -- funnel-shaped structures that drain down tubes called ureters to the bladder.

Each kidney contains around a million units called nephrons, each of which is a microscopic filter for blood.

Bone:

Bone is the substance that forms the skeleton of the body. It is chiefly composed of calcium phosphate and calcium carbonate. It also serves as a storage area for calcium, playing a large in calcium balance in the blood. It is the supportive framework of the body, structural framework for tendons to attach and provides support for soft tissues. Lastly, it also protects internal organs from injury such as the heart and lungs.Blood vessels:

The blood vessels consist of arteries, arterioles, capillaries, venules, and veins. All blood is carried in these vessels. The arteries, which are strong, flexible, and resilient, carry blood away from the heart and bear the highest blood pressures. Because arteries are elastic, they narrow (recoil) passively when the heart is relaxing between beats and thus help maintain blood pressure. The arteries branch into smaller and smaller vessels, eventually becoming very small vessels called arterioles. Arteries and arterioles have muscular walls that can adjust their diameter to increase or decrease blood flow to a particular part of the body.Capillaries are tiny, extremely thin-walled vessels that act as a bridge between arteries (which carry blood away from the heart) and veins (which carry blood back to the heart). The thin walls of the capillaries allow oxygen and nutrients to pass from the blood into tissues and allow waste products to pass from tissues into the blood.

Blood flows from the capillaries into very small veins called venules, then into the veins that lead back to the heart. Veins have much thinner walls than do arteries, largely because the pressure in veins is so much lower. Veins can widen (dilate) as the amount of fluid in them increases.C. PATHOPHYSIOLOGY

Chronic Kidney Disease, to put simply, is characterized by a reduction in Glomerular Filtration Rate (GFR) over a period of 3 or more months, thus resulting in loss of kidney function over time due to the decrease in number of functioning nephrons. A number of disorders can cause chronic renal failure such as hypertension, diabetes mellitus, vascular disease, glomerular disease, etc. Due to the impaired function of the kidney, a number of metabolic consequences arise. As the kidney declines, there is decreased or loss of its endocrine function and/or loss of iron, thus causing impaired production of red blood cells, which gives low hemoglobin values upon testing. Impaired function of the kidney also causes a failure in ion homeostasis, which leads to altered levels of electrolytes such as sodium, potassium and phosphate. Increased phosphate levels leads to hypocalcemia as phosphate binds to ionized calcium, thus lowering serum calcium levels. Hypocalcemia, in turn causes hyperparathyroidism in order to compensate for the lost calcium. Hyperparathyroidism, then causes elevations in enzyme levels such as Alkaline Phosphatase (ALP) and Acid Phosphatase (ACP), and causes bone resorption and bone remodeling which are enhanced by the acidic state of the blood. Another consequence of kidney failure is the loss of water, since the kidney can no longer absorb water, which then leads to polyuria, which is aggravated by the loss of sodium ions. Lastly, waste metabolic products are retained, such as urea and creatinine due to the inability of the kidney to filter and excreate metabolic waste products, which may cause heart problems and disruption of the normal function of the endocrine system.

In this case, patient showed general weakness, conjunctival pallor, anorexia and bony pains. Laboratory results showed normocytic cells with low hemoglobin levels with normal platelet and white cell counts. Chemistry studies showed decreased sodium and calcium levels with increased urea, potassium, ALP, creatinine, and phosphate levels. Urine dipstick shows presence of large amounts of protein with reduced kidney size.

The long term hypertensive state of the patient is what caused the chronic kidney disease, thus leading to a number of metabolic consequences. Decreased levels of sodium is caused by the loss of water due to the inability of the kidney to retain water, but sodium is only slightly decreased due to the consequence of the kidney failing, which also results in retaining sodium, which also contribute to the patients hypertension. Increased phosphate levels is also caused by the kidneys inability to maintain ion homeostasis, which causes to decrease calcium levels as phosphate binds to ionized calcium. Decreased calcium levels in turn causes hyperparathyroidism, which causes to elevate ALP levels in the blood and bone resorption, thus reducing calcium in the bones. Reduced calcium in the bones, in turn causes bony pains the patient is experiencing. Increased levels of urea and creatinine in the blood and presence of protein in urine are caused by the failure of the kidney to filter metabolic waste products in the blood and to retain protein in the bloodstream, thus aggravates the patients hypertensive condition. The uremic state of the blood, then causes a disruption in the hypothalamo-pituitary-gonadal axis, which caused the patients impotence. Reduced hemoglobin levels is caused by the failure of the kidney in either producing EPO or maintaining iron levels in the blood, which contributes to the conjunctival pallor seen in the patients eyes. Lastly, reduced blood levels, bony pains and disruption of the patients endocrine function, accompanied by the patients old age are what caused the patients anorexia and general weakness.

CHAPTER 4LABORATORY RESULTS, INTERPRETATION, AND MEDICATION/S USED AND ITS ACTIONSA. Laboratory Results and Interpretation

LABORATORY TESTPATIENTS RESULTSNORMAL VALUESINTERPRETATIONRATIONALE

Hemoglobin (Hb)10.8 g/dL11.4 15.0 g/dLDecreasedA decreased Hb indicates low red blood cell count and/or low serum iron

White Cell Count8 g/dL3.9 10.6 g/dLNormalA normal WBC count indicates that the patient is not experiencing any infection

Platelet count200 x 109/L150 440 x 109/LNormalA normal platelet count indicates that the patient is not experiencing any clotting or bleeding disorders

MCV90 fL77 - 95 fLNormalA normal MCV indicates that the patients red blood cell are normal in terms of size

Chemistry Studies:

Sodium132 mmol/L135 -145 mmol/LDecreasedLow Sodium levels is due to chronic kidney disease the patient is experiencing which disrupts the ion homeostasis

Potassium5.6 mmol/L3.5 5 mmol/LIncreasedIncreased Potassium levels is due to the increased phosphate levels in the body which is caused by the chronic renal disease

Urea22 mmol/L2.5 7.8 mmol/LIncreasedIncreased Urea levels is due to the inability of the kidney to filter and excrete metabolic waste products due to chronic renal disease

Creatinine375 mol/L60 110 mol/LIncreasedIncreased Creatinine levels is due to the inability of the kidney to filter and excrete metabolic waste products due to chronic renal disease

ALP230 IU/L20 140 IU/LIncreasedIncreased ALP levels is due to hyperparathyroidism caused by hypocalcemia which is the consequence of chronic renal disease

Calcium1.95 mmol/L2.1 2.6 mmol/LDecreasedDecreased levels of Calcium is due to increased levels of phosphate, which causes phosphate to bind with ionized calcium in the blood.

Phosphate1.9 mmol/L0.81 1.45 mmol/LIncreasedIncreased levels of phosphate is due inability of the kidney to maintain ion homeostasis which is caused by chronic renal disease

Urinalysis

Urine dipstick (Protein)+++NegativePositivePresence of large amounts of protein in the urine is due to the failing filtration system of the kidney caused by chronic renal disease

Imaging Studies

Ultrasound (Kidney)Size: 8.1 cm and 8.4 cm with no obstruction9 12 cmDecreasedDecreased kidney sized is caused by deteriorating effect of the disease (chronic renal disease), which is caused by hypertension

B. Medication/s Used and its Actions

Diuretic causes the kidneys to remove more sodium, water, and salt from the body, which helps relax the blood vessel walls, thus lowering blood pressure

CHAPTER 5SUMMARY, CONCLUSION, RECOMMENDATION

A. SUMMARY

The case presented is about a 64 year old man, with poorly controlled hypertension accompanied with generalized weakness, anorexia, bony pains and impotence which have occurred for the past few months. The patients hypertension is maintained by a diuretic and is taken when the patient remembers the medication. No other disease or disorder is indicated in the patients medical history. Upon examination, it showed that the patient weighs only 60 kilograms, has a blood pressure of 175/95 and is found that to have a conjunctival pallor. Laboratory results showed decreased levels of hemoglobin, sodium, calcium, normal platelet and white cell count, normal mean cell volume, and increased levels of potassium, ALP, urea, creatinine, and phosphate, and presence of large amounts of protein in the urine. Lastly, imaging studies revealed that the patients kidneys are decreased in size. Patients clinical presentation, laboratory findings and patient history are consistent with chronic renal disease.

B. CONCLUSION

A 64-year old man is experiencing impotency, generalized weakness, conjunctival pallor, anorexia, bony pains and hypertension. Patient history and laboratory examination indicates that the patient may be suffering from a disease involving the heart and/or kidneys.

Imaging studies revealed that the patients kidney have decresed in size, thus points to the fact that the underlying cause of the disease is chronic or has been affecting the patient for quite some time. With the patients urea and creatinine levels and the patients abnormal electrolyte levels, the patients distress is caused by chronic renal disease which is most likely caused by the patients long term hypertension.

C. RECOMMENDATIONS

As the disease caused metabolic consequences for the body, treatment of such consequences is recommended such as: Use of erythropoiesis-stimulating agents to treat for anemia. Use of dietary phosphate binders and dietary phosphate restriction to control hyperphosphatemia. Use of calcium supplements with or without calcitriiol to treat for hypocalcemia. Use of calcitriol, vitamin D analogues or calcimimetrics to treat for hyperparathyroidism. Oral alkali supplementation to treat for metabolic acidosis. Long-term renal replacement therapy such as hemodialysis, peritoneal dialysis, or renal transplantation to treat for uremic manifestations. Appropriate treatment for cardiovascular complications. Salt restriction and protein restriction to delay progression of CKD.CHAPTER 6

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