A 30-year old female patient was admitted with symptoms of shortness of breath, pedal edema, facial puffiness, and periorbital swelling. She has a history of acute kidney infection. Laboratory tests revealed decreased calcium and albumin levels, increased phosphorus, and a glomerular filtration rate of 18 ml/min, consistent with chronic kidney disease. Her treatment plan includes medications to reduce swelling, acidosis, and blood pressure, as well as mineral and vitamin supplements. She was counseled on lifestyle changes like a salt-restricted diet and exercise to help manage her condition.

1. Case presentation on chronic kidney
disease
Presented by :
METI.BHARATH KUMAR
16DK1T0014
Pharm-D(Intern)

2. Demographics
• Name :xyz
• Age :30 yrs
• Sex: female
• Admission No:3439
• Department : general medicine
unit : fm-7
• Date of admission :19-1-2022
• Consultant physician: Dr Maheswara Reddy

3. SUBJECTIVE EVIDENCE
A 30yrs old female patient admitted to general
medice unit with
--c/o shortness of breath since 2 days
--c/o pedal edema since 5 days
--c/o facial pufiness since 5 days
--c/o of periorbital swelling since 5 days
--c/o vomitings

4. Past history:
--known case of acute kidney infection
There is a previous admission to the hospital for
acute kidney injury and discharged.

5. Objective evidence
Sr.calcium : 7.3mgdl (decreased )
Sr.magnesium :2.5mg/dl
Sr.phosphorus:5.9mg/dl (increased)
CBP:
Hb :8g/dl
RBC :2.7 millions/cumm
PLT:231000cells/cumm
Sr Electrolytes:
sodium :140mmol/l
potassium:6.5mmol/l
chlorine:101mmol/l

6. LFT:
total bilirubin:0.6mg/dl
conj bilirubin:0.3mg/dl
unconj bilirubin:0.3mg/dl
Total protien -6.8mg/dl
Albumin:3.7mg/dl
Globulin:3.1mg/dl

7. Serum creatinine :6.3mg/dl
URINE ANALYSIS:
albumin:2+
sugar :nil
deposit cells:3-4 pus cells /HPF
1-2epithelial cells/HPF
RBC :NIL
CRYSTALS: NIL
CASTS:NIL
estimated GFR:18ml/min

8. Assesment
Based on subjective and objective evidences
patient is assesed as CKD.

9. Treatment plan
s.No Drug generic
name
Brand
name
Indication Dose ROA Frequency
1 Salbutamol Bronchodilation 5mg/2.5ml Nasal OD
2 Piperacillin+tazoba
ctum
piptaz To reduce
bacterial
infection
4.5g in
100ml NS
Iv BID
3 Ranitidine Rantac To reduce GI
irritation
2cc Iv BID
4 Ondansetron Vomiset To reduce
vomiting
1cc Iv SOS
5 Amlodipine To reduce high
bp
5mg Oral OD
6 Furosemide Lasix To reduce
swelling
40mg Oral BD
7 Sodium
bicarbonate
Nodosis To reduce
acidosis
500mg Oral TID
8 Iron folic acid Mineral
supplement
Oral BD
9 B complex Vitamin
supplement
oral OD

10. Discussion
• Irreversible loss of kidney function this condition is due to
hypertension, diabetes,acute kidney injury. Long term
dialysis is required in this patient to recover from
symptoms.
• Chronic kidney disease is a slow and progressive loss of
kidney function over a period of several years. Eventually, a
person will develop permanent kidney failure.
• As kidney failure advances and the organ’s function is
severely impaired, dangerous levels of waste and fluid can
rapidly build up in the body. Treatment is aimed at stopping
or slowing down the progression of the disease – this is
usually done by controlling its underlying cause.

11. Stages
Changes in the GFR rate can assess how advanced the kidney
disease is. In the UK, and many other countries, kidney disease
stages are classified as follows:
Stage 1 – GFR rate is normal. However, evidence of kidney
disease has been detected.
Stage 2 – GFR rate is lower than 90 milliliters, and evidence of
kidney disease has been detected.
Stage 3 – GFR rate is lower than 60 milliliters, regardless of
whether evidence of kidney disease has been detected.
Stage 4 – GRF rate is lower than 30 milliliters, regardless of
whether evidence of kidney disease has been detected.
Stage 5 – GFR rate is lower than 15 milliliters. Renal failure has
occurred.
The majority of patients with chronic kidney disease rarely progress beyond
Stage 2. It is important for kidney disease to be diagnosed and treated early
for serious damage to be prevented.

13. signs and symptoms
The most common signs and symptoms of chronic kidney disease
include:
Anemia , blood in urine,dark urine ,decreased mental alertness
,decreased urine output
edema – swollen feet, hands, and ankles (face if edema is severe)
,fatigue (tiredness) ,hypertension (high blood pressure) ,insomnia
,itchy skin, can become persistent, loss of appetite
male inability to get or maintain an erection (erectile
dysfunction),more frequent urination, especially at night, muscle
cramps, muscle twitches
Nausea,pain on the side or mid to lower back, panting (shortness of
breath) protein in urine ,sudden change in bodyweight ,unexplained
headaches

14. Causes
• Diabetes – chronic kidney disease is linked to diabetes types 1 and
2. If the patient’s diabetes is not well controlled, excess sugar
(glucose) can accumulate in the blood. Kidney disease is not
common during the first 10 years of diabetes; it more commonly
occurs 15-25 years after diagnosis of diabetes.
• Hypertension (high blood pressure) – high blood pressure can
damage the glomeruli – parts of the kidney involved in filtering
waste products.
• Obstructed urine flow – if urine flow is blocked it can back up into
the kidney from the bladder (vesicoureteral reflux). Blocked urine
flow increases pressure on the kidneys and undermines their
function. Possible causes include an enlarged prostate, kidney
stones, or a tumor.
• Kidney diseases – including polycystic kidney disease,
pyelonephritis, or glomerulonephritis.

15. • Kidney artery stenosis – the renal artery narrows or is blocked before it
enters the kidney.
• Certain toxins – including fuels, solvents (such as carbon tetrachloride),
and lead (and lead-based paint, pipes, and soldering materials). Even
some types of jewelry have toxins, which can lead to chronic kidney
failure.
• Fetal developmental problem – if the kidneys do not develop properly in
the unborn baby while it is developing in the womb.
• Systemic lupus erythematosus – an autoimmune disease. The body’s own
immune system attacks the kidneys as though they were foreign tissue.
• Malaria and yellow fever – known to cause impaired kidney function.
• Some medications – overuse of, for example, NSAIDs (non-steroidal anti-
inflammatory drugs), such as aspirin or ibuprofen.
• Illegal substance abuse – such as heroin or cocaine.
• Injury – a sharp blow or physical injury to the kidney(s).

16. Diagnosis
A doctor will check for signs and ask the patient about symptoms. The
following tests may also be ordered:
Blood test – a blood test may be ordered to determine whether waste
substances are being adequately filtered out. If levels of urea and
creatinine are persistently high, the doctor will most likely diagnose
end-stage kidney disease.
Urine test – a urine test helps find out whether there is either blood or
protein in the urine.
Kidney scans – kidney scans may include a magnetic resonance
imaging (MRI) scan, computed tomography (CT) scan, or an ultrasound
scan. The aim is to determine whether there are any blockages in the
urine flow. These scans can also reveal the size and shape of the
kidneys – in advanced stages of kidney disease the kidneys are smaller
and have an uneven shape.

17. • Kidney biopsy – a small sample of kidney tissue is
extracted and examined for cell damage. An analysis of
kidney tissue makes it easier to make a precise
diagnosis of kidney disease.
• Chest X-ray – the aim here is to check for pulmonary
edema (fluid retained in the lungs).
• Glomerular filtration rate (GFR) – GFR is a test that
measures the glomerular filtration rate – it compares
the levels of waste products in the patient’s blood and
urine. GFR measures how many milliliters of waste the
kidneys can filter per minute. The kidneys of healthy
individuals can typically filter over 90 ml per minute.

18. pathophysiology

20. Choice of treatment
• Treat hypertension with ACE inhibirors
• Avoid nephrotoxins
• Treat fluid overload with diuretics
• Treat anemia with erythropoeitin and iron
supplements
• Hyperphosphatemia with CaCO3 with meals
• Hypocalcemia with CaCO3 and vitD3 .
• Renal replacement therapy:
dialysis and transplant.

21. • Use steroids in glomerulonephritis induced
CKD.
• Treatment for acidosis: oral bicarbonate @2-
3meq/kg
• Maintaining mineral bone disease: calcium
carbonate and vitamin D analouges

22. Patient counselling
• Patient education:
1. Minimize risk of ADRs
2. Minimize pills usage in CKD and renal
transplanted individuals.
3. Review medication carefully.
• Management:
1. Diet : control Na+, K+ ,fluid and protien.

23. • Life style changes:
1. Stop smoking
2. Eat balanced diet
3. Restrict salt diet less than 6g/day
4. Do regualr exercise -150min/wk
5. Moderate intake of alcohol