A Case Study about A Case Study about Chronic Renal Disease Chronic Renal Disease

by Michelle LeBlancby Michelle LeBlanc

Patient HistoryPatient History27 year old female who presented to the 27 year old female who presented to the Emergency Room with the following Emergency Room with the following symptoms:symptoms:– Vomiting for 2 daysVomiting for 2 days– DehydrationDehydration– Sever migraine headacheSever migraine headache– Blood pressure 158 / 100Blood pressure 158 / 100

Patient has a history of Chronic Renal Patient has a history of Chronic Renal Disease with nephrectomy and transplant Disease with nephrectomy and transplant one year priorone year prior

Questions to ConsiderQuestions to ConsiderWhat complications are associated What complications are associated with Chronic Kidney Disease (CKD)?with Chronic Kidney Disease (CKD)?How does CKD affect kidney How does CKD affect kidney function?function?What are the symptoms of CKD?What are the symptoms of CKD?What laboratory results correlate What laboratory results correlate with kidney disease?with kidney disease?What is dialysis?What is dialysis?

Laboratory ResultsLaboratory ResultsTESTTEST PATIENT RESULTSPATIENT RESULTS REFERENCE REFERENCE

RANGESRANGESNa (mmol/L) Na (mmol/L) 136136 135 – 145135 – 145K (mmol/L)K (mmol/L) 6.86.8 3.5 – 5.23.5 – 5.2Cl (mmol/L)Cl (mmol/L) 9393 95 – 10795 – 107CO2 (mmol/L)CO2 (mmol/L) 1717 21 – 3121 – 31Anion GapAnion Gap 2626 5 – 175 – 17Glucose (mg/dL)Glucose (mg/dL) 9494 65 – 11065 – 110BUN (mg/dL)BUN (mg/dL) 8383 8 – 228 – 22Creatinine (mg/dL)Creatinine (mg/dL) 14.514.5 0.7 – 1.50.7 – 1.5Calcium (mg/dL)Calcium (mg/dL) 9.39.3 8.5 – 10.58.5 – 10.5Phosphorous (mg/dL)Phosphorous (mg/dL) 10.410.4 2.3 – 4.32.3 – 4.3AlbuminAlbumin 3.93.9 3.5 – 5.13.5 – 5.1

Laboratory Results – Laboratory Results – continuedcontinuedTESTTEST PATIENT RESULTSPATIENT RESULTS REFERENCE REFERENCE

RANGESRANGESWBC (bill/L)WBC (bill/L) 9.39.3 4.3 – 10.94.3 – 10.9

RBC (tril/L)RBC (tril/L) 2.512.51 3.87 – 5. 083.87 – 5. 08

Hemoglobin (g/dL)Hemoglobin (g/dL) 7.07.0 12.1 – 15.012.1 – 15.0

Hematocrit (%)Hematocrit (%) 21.021.0 35.4 – 44.235.4 – 44.2

Iron (mcg/dL)Iron (mcg/dL) 269269 30 – 16030 – 160

TIBC (mcg/dL)TIBC (mcg/dL) 388388 228 – 417228 – 417

% Saturation (%)% Saturation (%) 6969 15 – 5515 – 55

Ferritin (ng/mL)Ferritin (ng/mL) 26,946 (by dilution)26,946 (by dilution) 12 – 20712 – 207

TSH (ulU/mL)TSH (ulU/mL) 6.696.69 0.5 – 5.20.5 – 5.2

Prolactin (ng/mL)Prolactin (ng/mL) 47.547.5 Less than 24Less than 24

DiagnosisDiagnosisPrimary:Primary: Hypertensive (unspecified) renal Hypertensive (unspecified) renal disease with renal failuredisease with renal failureSecondary:Secondary:– Post-surgical dialysisPost-surgical dialysis– Anemia Anemia (based on Hgb and Hct result)(based on Hgb and Hct result)– Migraine and feverMigraine and fever– Iron metabolism disorder Iron metabolism disorder (based on Iron & Saturation (based on Iron & Saturation

results)results)– Anterior pituitary hyperfunction Anterior pituitary hyperfunction (based on Prolactin (based on Prolactin

result)result)– Unspecified hypothyroid Unspecified hypothyroid (based on TSH result)(based on TSH result)– Acquired absence of kidney Acquired absence of kidney (based on History)(based on History)

Renal FunctionRenal FunctionThe main function of a healthy kidney is The main function of a healthy kidney is to:to:• Help remove waste and excess fluid Help remove waste and excess fluid • Filter the blood, keeping some compounds Filter the blood, keeping some compounds

while removing others while removing others • Control the production of red blood cells Control the production of red blood cells • Make vitamins that control growth Make vitamins that control growth • Release hormones that help regulate blood Release hormones that help regulate blood

pressure pressure • Help regulate blood pressure, red blood cells, Help regulate blood pressure, red blood cells,

and the amount of certain nutrients in the and the amount of certain nutrients in the body, such as calcium and potassium. body, such as calcium and potassium.

Chronic Kidney DiseaseChronic Kidney DiseaseChronic kidney (or Chronic kidney (or renal) disease renal) disease occurs when the occurs when the kidneys are no kidneys are no longer able to clean longer able to clean toxins and waste toxins and waste products from the products from the blood and perform blood and perform their functions to their functions to full capacityfull capacity

Chronic Kidney DiseaseChronic Kidney DiseasePresently there are about 240,000 end Presently there are about 240,000 end stage renal disease patients in the United stage renal disease patients in the United States with 200 cases per 1 million States with 200 cases per 1 million personspersonsThe number one cause of renal disease is The number one cause of renal disease is Diabetes Mellitus which is responsible for Diabetes Mellitus which is responsible for 40% of all kidney failure40% of all kidney failureHigh blood pressure (or hypertension) High blood pressure (or hypertension) accounts for about 24%accounts for about 24%CKD may be hereditary or likely acquiredCKD may be hereditary or likely acquired

What are the warning signs of What are the warning signs of kidney disease?kidney disease?

Although many forms of kidney disease do not Although many forms of kidney disease do not produce symptoms until late into the course of produce symptoms until late into the course of the disease, there are six warning signs of kidney the disease, there are six warning signs of kidney diseases: diseases: – High Blood Pressure High Blood Pressure – Blood and/or protein in the urine. Blood and/or protein in the urine. – A creatinine blood test greater than 1.2 for women and A creatinine blood test greater than 1.2 for women and

1.4 for men. 1.4 for men. – A filtration rate (GFR) less than 60 A filtration rate (GFR) less than 60 – More frequent urination, particularly at night; difficult or More frequent urination, particularly at night; difficult or

painful urination. Puffiness around eyes, swelling of painful urination. Puffiness around eyes, swelling of hands and feet, especially in children.hands and feet, especially in children.

What are the symptoms of chronic What are the symptoms of chronic renal disease?renal disease?

Changes in urinationChanges in urinationSwelling of hands and feetSwelling of hands and feetFatique or weaknessFatique or weaknessShortness of breathShortness of breathMetallic taste in mouthMetallic taste in mouthBack or flank painBack or flank painLoss of appetiteLoss of appetiteNausea / vomitingNausea / vomiting

Evaluation of Renal Function Evaluation of Renal Function Examine circulating levels of:Examine circulating levels of:– Non-protein nitrogenous compounds (e.g, BUN Non-protein nitrogenous compounds (e.g, BUN

and creatinine)and creatinine)– Glomerular filtration rateGlomerular filtration rate– Secretory capacitySecretory capacity– Kidney’s reabsorptive capacity for water and Kidney’s reabsorptive capacity for water and

electrolyteselectrolytesAbnormal laboratory results:Abnormal laboratory results:– Increased serum creatinine / BUNIncreased serum creatinine / BUN– Increased potassium and phosphorousIncreased potassium and phosphorous– Abnormal thyroid and hormone levels Abnormal thyroid and hormone levels

secondary to renal insufficiencysecondary to renal insufficiency– AnemiaAnemia

TreatmentTreatmentHemodialysisHemodialysis– Blood is pumped from the body to a special Blood is pumped from the body to a special

filter (or dialyzer) with two parts, one for blood filter (or dialyzer) with two parts, one for blood and one for a washing fluid called dialysate. A and one for a washing fluid called dialysate. A thin membrane separates these two parts. thin membrane separates these two parts.

– Blood cells, protein and other important things Blood cells, protein and other important things remain in the blood because they are too big remain in the blood because they are too big to pass through the membrane. Smaller waste to pass through the membrane. Smaller waste products in the blood, such as urea, creatinine, products in the blood, such as urea, creatinine, potassium and extra fluid pass through the potassium and extra fluid pass through the membrane and are washed away.membrane and are washed away.

– The purified blood is returned to the body. The purified blood is returned to the body.

Dialysis ProcessDialysis Process

Dialysis Process - Dialysis Process - continuedcontinued

Dietary RecommendationsDietary RecommendationsLow proteinLow proteinLow potassium / phosphorousLow potassium / phosphorous

Kidney TransplantKidney TransplantRenal transplantation is considered an Renal transplantation is considered an effective form of replacement therapy with effective form of replacement therapy with a success rate of 80% survival after one a success rate of 80% survival after one year and 60% survival after 4 years.year and 60% survival after 4 years.Evaluation for transplant includes:Evaluation for transplant includes:– Measurement of general operative healthMeasurement of general operative health– Full human leukocyte antigen tissue typingFull human leukocyte antigen tissue typing– Full screen for infectious diseasesFull screen for infectious diseases

Patient OutcomePatient OutcomeTests for Hereditary Hemochromatosis Tests for Hereditary Hemochromatosis gene were negative and no pituitary gene were negative and no pituitary tumor was detected tumor was detected Patient was released after one week in Patient was released after one week in the hospitalthe hospitalDischarged with a battery of 16 Discharged with a battery of 16 different medications!different medications!

SummarySummaryPatient with a history of renal disease was Patient with a history of renal disease was admitted with vomiting, headache and admitted with vomiting, headache and high blood pressurehigh blood pressureMany secondary complications due to Many secondary complications due to renal disease and nephrectomyrenal disease and nephrectomyTreatment upon discharge was to continue Treatment upon discharge was to continue dialysis, follow a restricted diet, and dialysis, follow a restricted diet, and continue on prescribed medicationscontinue on prescribed medicationsFollow up visit scheduled for renal check Follow up visit scheduled for renal check and evaluation of hyperprolactinemia and and evaluation of hyperprolactinemia and hypothyroidism hypothyroidism

ReferencesReferencesKidney Disease, Living with One Kidney, Kidney Disease, Living with One Kidney, Dialysis -Dialysis - National Kidney Foundation, National Kidney Foundation, www.kidney.orgwww.kidney.org, Last accessed 11/08/04., Last accessed 11/08/04.

Kidney and Urologic DiseasesKidney and Urologic Diseases, National , National Kidney and Urologic Diseases Information Kidney and Urologic Diseases Information Clearinghouse (NKUDIC), Clearinghouse (NKUDIC), http://kidney.niddk.nih.gov/kudiseases/a-z.http://kidney.niddk.nih.gov/kudiseases/a-z.aspasp Last accessed 11/08/04.Last accessed 11/08/04.

CreditsCreditsThis case study was This case study was

prepared by prepared by Michelle Leblanc, MT(ASCP) Michelle Leblanc, MT(ASCP)

while she was a while she was a Medical Technology student Medical Technology student

in the in the 2004 MT Class at 2004 MT Class at William BeaumontWilliam Beaumont

Hospital, Hospital, Royal OakRoyal Oak, MI., MI.