Mr. Saeed M. M. is a 73-year-old Saudi male who has a history of diabetes for 30 years and hypertension for 3 years. He presents with itching, bruising, swelling of the face and limbs, and vomiting for the past few weeks. He is known to have chronic kidney disease for the past 3 years. On examination, he has edema, ascites, and elevated creatinine. Laboratory tests show anemia, thrombocytopenia, and metabolic acidosis. He is diagnosed with end-stage renal disease and started on management including fluid restriction, medications, and education for future hemodialysis treatment.

1. Hamza J. AlGhamdi
Supervised by:
Prof. Mohammed Alhomrani

2. contents
Introduction Examination Investigation
epidemiology History Management Conclusion

3. INTRODUCTION

4. What is CKD ?
• Also known as Chronic Renal Failure.
• It is defined by either a pathologic abnormality of the kidney, such as
hematuria and/or proteinuria, or reduction of GFR of <60
mL/minute/1.37 m^2 for >3 months duration.
Proteinuria
and/or GFR < 60
Hematuria
For 3
Months

5. Stages
Stage 1 disease is defined by a normal GFR (greater than 90 mL/min per
1.73 m2) and persistent albuminuria
Stage 2 disease is a GFR between 60 to 89 mL/min per 1.73 m2 and
persistent albuminuria
Stage 3 disease is a GFR between 30 and 59 mL/min per 1.73 m2
Stage 4 disease is a GFR between 15 and 29 mL/min per 1.73 m2 Stage 5
disease is a GFR of less than 15 mL/min per 1.73 m2 or end-stage renal
disease

6. EPIDEMIOLOGY

7. Epidemiology
• Common condition
• Often unrecognized until advanced stages.
• It is estimated that 10% of the adult population world wide will have
CKD
• Incidence is raising
• Due to different factors (aging population, increased incidence of DM
& HTN, Increased incidence of glomerular diseases …….)

8. Epidemiology
• conclude that prevalence of CKD in
the young Saudi population is
around 5.7%
• Only 7.1% of the CKD patients were
aware of their CKD status
• 32.1% were told that they had
protein or blood in their urine and
10.7% had known kidney stones in
the past.

9. By the end of
2008, there
were 10,203
patients on
hemodialysis

10. The question:
HOW TO
APPROACH ??

11. Meet Our Patient:
• Mr. Saeed M. M.
• 73 Years old Aging process causes decline in
• Saudi GFR. Typically 1 per year after the
• Male age of 50
• From Abha
• Admitted Feb 26th 2012. Men are at higher risk than women.
• Through OPD The mechanism Is unknown but it is
though to be related to sex hormones
• Hx was taken from his son and is
reliable.
• C/C
• Itching and bruising for 1 month
• Swelling of face and limbs for 2 weeks

12. HPI
• Mr. Saeed is known Diabetic for 30 years Diabetes is the most common cause.
on insulin and Hypertensive for 3 years
It is estimated that 30% of diabetics
• He is known to have kidney disease since will have CKD within 5 to 10 years
3 years and following up
of Diagnosis
• Came to Nephrology clinic for regular
follow up complaining of itching all over
his body for 1 month. Second Most common cause of
• This itching started gradually and is CKD. Accounts for 1 third of
continuous and moderate with no rashes or patients undergoing renal
fever. replacement therapy
• It was associated with easy bruising on
minimal trauma over his limbs. Thought to be due to accumulation
• he has Hx of recurrent melena for the past of toxic waste products in the
3 months circulation such as urea
• Pt has also edema around his eye
developed 1 month gradually with Nitrogen retention that causes
puffiness of the face and abdominal impaired prothrombin consumption,
distention defect in platelet factor and
abnormal platelet aggregation

13. Cont
• Mr. Saeed also has chronic
intermittent productive cough for 3
years and it progressed in severity in
the last year, clear to greenish yellow
sputum of moderate amount not
associated with fever or hemoptysis. Associated with pulmonary edema due to
• He also has dyspnea grade 2, no reduced urine output
orthopnea no PND.
• He also has vomiting for the past 3
weeks, of food content after taking
breakfast. No hematemesis.
• He also has anorexia and weight loss
of 7 Kg over the last year Thought to be due to accumulation of
• he also has dysuria, frequency (10 toxic waste products in the circulation
times/day), nocturia such as urea
• No hematuria, flank pain or
obstructive Lower urinary tract Important to exclude obstructive
symptoms.
nephropathy

14. • Patient is known to have kidney
To confirm the chronicity. Sometimes you
disease since 3 years ago
have to look for previous investigations
• Admitted 3 years ago with LL and follow up notes.
edema, ascites and treated for
proteinuria
• Discharged after 45 days
• On follow up with nephrologist
• Was found to have very high
creatinine in the last follow up Incidental discovery is common
• Was admitted for management of his
problem

15. Systemic enquiry
General GI
• Fatigue • Anorexia
• Dizziness • Wt loss
• No loss of consciousness • Melena
• Abdominal distention
CVS • Morning vomiting
• No jaundice
• Dyspnea
• No pain
• No chest pain • No dysphagia
• Cough
• No PND Nervous
• No orthopnea • Headache
• No palpitations • No confusion or LOC
• No cyanosis • No weakness
• No claudication • Other unremarkable

16. Respiratory
• Productive cough
Skin
• Dyspnea
• No chest pain • Easy bruising
• No hemoptysis
• No other symptoms • Itching
MSK • no rash
• Knee pain
• Lower back pain • No eruptions
• No joint swelling of redness
• No limitation of movement • No ulcers

17. Past Medical History

18. Drug Hx
Insulin Mixed 20
a.m. 30 p.m.
Captopril 25 mg
BID
Aspirin 81 mg OD
Simvastatin 40 mg
OD
Phenytoin
(Discontinued)

19. Past Surgical Hx
Little toe
Hernia Cataract
amputation
repair – 20 surgery – 2
– 15 years
years ago years ago
ago

20. Allergy Hx
• -ve People with close family member with the
disease are at higher risk themselves of
developing CKD. The mechanism is
Transfusion Hx thought to be due in part to genetic
• -ve susceptibility to certain diseases such as
DM, HTN, PKD, Alport syndrome.
Family Hx
• His brother had renal transplantation
• History of chronic diseases, DM, HTN, IHD in first degree relatives
• No Hx of malignancy
Social
• Married
Smoking has been associated as a risk factor for
• 40 pack-years Ex-smoker the development and progression of the disease.
• Lives in Abha Likely because of accelerated atherosclerosis and
• Illiterate vascular disease as well as exacerbating
underlying HTN

21. On Examination
General
• Patient looks not well, not
comfortable, lying on his side and
tachypnic
• He is drowsy, not alert, not
dehydrated, connected to IV line.
Vitals
• Pulse: 94 BPM regular, average
volume, no special character, no
radio-radial or radio-femoral delay.
• BP: 130/85 mmHg
• RR: 35 per minute – Shallow and Indicating metabolic acidosis
fast pattern
• O2 Saturation: 96% in room air

22. Hands Brown line of at least 1mm wide at distal
• Clubbing in the nails end of nail may be present in some
patients
• Pallor in the palmar creases
• Scratch marks over both arms As result of pruritus Due to deposition of
• 3 echymotic patches around calcium or phosphate in the skin or
the elbow and the site of IV stimulation of nerve endings due to some
cannula- 1-3 cm in diameter retained toxins
• Fine white scales over both
arms Due to precipitation of high concentration
of urea in the sweat
• No astrexis
• No liver disease stigmata
• No A/V fistula For dialysis

23. H&N
• Periorbital edema
• Pallor
• No Jaundice Anemia
• No parotid swelling
• No uremic fetor
Smell from mouth due to breakdown of
• No oral ulcer
urea to ammonia
• Bad dental hygiene
• JVP is raised (4+5 cm)
• No lymph node enlargement May be present due to dryness
• No bruit over the carotids
• no spider angiomata
• Trachea is central
Fundoscopy To look for retinal changes of DM and
• Not done HTN

24. Chest
• Inspection
• No chest deformity or scars
• Equal bilateral chest movement
• No visible veins
• Apex beat is not visible
• Palpation
• Normal bilateral chest expansion
• Normal tactile fremitus
• No heaves
• No thrills
• Apex beat is palpable in the 5th IC space 3 cm
lateral to the mid- clavicular line.
• Auscultation
• Normal bilateral air entry
• Coarse bilateral basal crepitation
• Normal S1 + S2 + 0 Due to pulmonary edema
• No added sounds, No murmurs
• No pericardial Rub

25. Abdomen
• Inspection
• Distended flanks
• Hernial repair scar
• No visible veins
• Normal umbilicus
• Palpation
• Soft, lax
• No masses or tenderness
• Kidneys are not palpable
• No hepatomegaly (liver span= 12 cm) You may find enlarged kidneys or mass or
• No splenomegaly polycystic kidney
• Percussion
• Ascites elicited by shifting dullness
• No fluid thrill
• No organomegaly
• Auscultation
• Normal bowel sounds
• No renal artery bruits

26. Back
• No renal angle tenderness
• Sacral edema
LL
• Amputated Rt little toe
• Wasting of muscles in both limbs Indicator for poor control of DM
• Bilateral pitting edema
• Loss of hair distally
• Scaling of the skin
• No temperature difference
• Dorsalis pedis pulsation is not palpable Peripheral vasculopathy due to DM
• Posterior tibial pulsation is not palpable
• Popliteal artery pulsation is palpable in
both legs

27. Motor and sensory examination
Right Left
UL LL UL LL
Power 3 5 4 5
Tone + N + N
Light touch N N N N
Position N N N N
Coordination N N N N
Reflexes are ++ in right knee and Biceps. Others Normal

28. SUMMARY

29. Urea & Creatinine
High >1.1 mg/dl in men
>1.2 mg/dl in women
• Estimating Creatinine Clearance (ml/min)
• Cockcroft and Gault equation:
• CrCl = (140 - age) x IBW / (Scr x 72) (x 0.85 for females)
• In our patient = 7.24 mL/min
• Which Stage ??

30. Electrolytes
• Hyponatremia is common
• Potassium is normal until end stage
• Calcium is low
• Phosphate is high

31. Other RFT

32. LFT

33. Glucose
HbA1C = 9 %

34. Investigations
test Value findings
WBC 5000
RBC 1.71*10^6
HGB 6 g/dl Macro
HCT 17.2% Hypochrom
MCV 100.6 fl Anaemia
MCH 35.1 pg
MCHC 35 g/dl
RDW++SD 57 fl
PLT 90000 thrombocytopenia

35. ABG
PH: 7.31
pCO2: 34 mmHg
pO2: 85 mmHg
HCO3: 18 mEq/liter
Metabolic acidosis because kidney is unable to regulate acid base balance

36. Urinalysis
• Screening test to determine for
pathologic markers of kidney
damage excreted in the urine
• Microalbuminurea is a risk factor for
development of progressive CKD
and CAD associated with DM and
HTN . Indicated in patient with DM
.

37. Other Investigations
• Chest X-ray
• pulmonary edema
• ECG May show abnormalities associated with electrolyte
• Normal disturbance in CKD
• Renal Ultrasound
• Small kidneys, No obstruction, No stones
• Others
• ?????????

38. Management
• Admission to MFS unit
• Investigations
• Fluid restriction
• Sliding scale (Glucose monitoring)
• Foley’s catheter
• Dietary modification:
• Protein restriction
• Potassium restriction
• Phosphorus restriction
• Diabetic diet

39. Management
• Drugs:
• Replacement therapy
• Iron 200 mg PO BID
• Folic acid 5 mg PO OD
• CaCO3
• 1-alpha
What if the patient has
• Hypertensive drug
Hyperkalemia ??
• Captopril 50 mg PO BID
• Pantazole 40 mg PO OD

40. Management
• Education about hemodialysis
• Referal for Radiology for Permacath insertion
• Preparation for hemodialysis

41. Hemodialysis
• method for extracorporeal removing
waste products such as creatinine
and urea, as well as free water from
the blood when the kidneys are in
renal failure. Hemodialysis is one of
three renal replacement therapies
(the other two being renal transplant;
peritoneal dialysis).

43. Any Question ??