A Case Study On

Chronic Kidney Disease

In Partial Fulfillment of the Course Requirement in Clinical Chemistry

SUBMITTED BY:
LAHORA, YANCY DANICA
LAPASTORA, ANMARIE GRACE
LOTILLA, RIZZLE JOY
MATUCO, JULIO NICOLAS
MEMBREVE, GRACE LYN
PERFAS, ERVIL

Group 5
Clinical Chemistry
Davao Medical School Foundation Hospital

SUBMITTED TO:
SETRINA GRACE CARBAJOSA
Clinical Chemistry Clinical Instructor

February 2015

OBJECTIVES OF THE STUDY

This 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 1

INTRODUCTION 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 2

PATIENTS DATA
PERSONAL DATA:
Age: 64
Sex: Male
MEDICAL HISTORY:
Hypertension
Weakness
Anorexia
Bony pains
Impotence
Conjunctival pallor
LABORATORY RESULTS:
LABORATORY TEST RESULTS
HEMATOLOGY
White Cell Count:
Platelet:
Hemoglobin:
MCV:

8 g/dL
200 x 109/L
10.8 g/dL
90 fL

URINALYSIS
Urine Dipstick
(Protein):

+++

CHEMISTRY STUDIES
Sodium:
Potassium:
Urea:
Alkaline Phosphatase:
Calcium:
Phosphate:
Creatinine:
Imaging

132 mmol/L
5.6 mmol/L
22 mmol/L
230 IU/L
1.95 mmol/L
1.9 mmol/L
375 mmol/L
Studies

Ultrasound (Kidney):

8.1 cm and 8.4 cm

CHAPTER 3

DEFINITON OF THE CASE, ANATOMY AND PHYSIOLOGY, AND PATHOPHYSIOLOGY

OF THE AFFECTED PARTS
A. DEFINITION OF THE CASE
Generalized weakness is 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 4

LABORATORY RESULTS, INTERPRETATION, AND MEDICATION/S USED AND ITS

ACTIONS
A. Laboratory Results and Interpretation
LABORATORY
TEST
Hemoglobin
(Hb)

PATIENTS
RESULTS
10.8 g/dL

NORMAL
VALUES
11.4 15.0
g/dL

INTERPRETATION

RATIONALE

Decreased

A decreased Hb
indicates low red
blood cell count
and/or low serum
iron

White Cell
Count

8 g/dL

3.9 10.6
g/dL

Normal

Platelet count

200 x 109/L

150 440 x
109/L

Normal

MCV

90 fL

77 - 95 fL

Normal

A normal WBC count

indicates that the
patient is not
experiencing any
infection
A normal platelet
count indicates that
the patient is not
experiencing any
clotting or bleeding
disorders
A normal MCV
indicates that the
patients red blood
cell are normal in
terms of size

Chemistry
Studies:
Sodium

132 mmol/L

135 -145
mmol/L

Decreased

Potassium

5.6 mmol/L

3.5 5
mmol/L

Increased

Urea

22 mmol/L

2.5 7.8

Increased

Low Sodium levels is

due to chronic
kidney disease the
patient is
experiencing which
disrupts the ion
homeostasis
Increased Potassium
levels is due to the
increased phosphate
levels in the body
which is caused by
the chronic renal
disease
Increased Urea

mmol/L

levels is due to the

inability of the
kidney to filter and
excrete metabolic
waste products due
to chronic renal
disease
Increased Creatinine
levels is due to the
inability of the
kidney to filter and
excrete metabolic
waste products due
to chronic renal
disease
Increased ALP levels
is due to
hyperparathyroidism
caused by
hypocalcemia which
is the consequence
of chronic renal
disease
Decreased levels of
Calcium is due to
increased levels of
phosphate, which
causes phosphate to
bind with ionized
calcium in the blood.
Increased levels of
phosphate is due
inability of the
kidney to maintain
ion homeostasis
which is caused by
chronic renal
disease

Creatinine

375 mol/L

60 110
mol/L

Increased

ALP

230 IU/L

20 140
IU/L

Increased

Calcium

1.95 mmol/L

2.1 2.6
mmol/L

Decreased

Phosphate

1.9 mmol/L

0.81 1.45
mmol/L

Increased

Urinalysis
Urine dipstick
(Protein)

+++

Negative

Positive

Presence of large
amounts of protein
in the urine is due to
the failing filtration
system of the
kidney caused by
chronic renal
disease

Size: 8.1 cm
and 8.4 cm
with no
obstruction

9 12 cm

Decreased

Decreased kidney
sized is caused by
deteriorating effect
of the disease

Imaging Studies
Ultrasound
(Kidney)

(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 5

SUMMARY, 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

BIBLIOGRAPHY, WEBLIOGRAPHY, AND BOOKS

A.D.A.M., Inc. (2015). Bone pain or tenderness. Retrieved January 27, 2015 from
http://www.nlm.nih.gov/medlineplus/ency/article/003180.htm
A.D.A.M., Inc. (2015). Erection problems. Retrieved January 30, 2015 from
http://www.nlm.nih.gov/medlineplus/ency/article/003164.htm
A.D.A.M., Inc. (2015). Weakness. Retrieved January 22, 2015 from
http://www.nlm.nih.gov/medlineplus/ency/article/003174.htm
Arora, Pradeep. (2014). Chronic Kidney Disease. Retrieved September 9, 2014 from
http://emedicine.medscape.com/article/238798-overview#aw2aab6b2b2
Arora, Pradeep. (2014). Chronic Kidney Disease Treatment & Management. Retrieved
September
9,
2014
from
http://emedicine.medscape.com/article/238798treatment#aw2aab6b6b5
Bishop, M., Fody, E., & Schoeff, L. (2013). Clinical Chemistry Principles, Techniques, and
Correlations, 7th Edition. Two Commerce Square. 2001 Market Street, Philadelphia.
Healthline Networks, Inc. (2015). Bone pain and tenderness. Retrieved from January 11,
2015 from http://www.healthline.com/symptom/bone-pain
Langhans, W. (2000). Anorexia of infection: current prospects. Volume 16, Issue 10, Pages
996-1005
Luger, N., Sevcik, & Mantyh, P. (2005). Bone cancer pain: From mechanism to model to
therapy. Journal of Pain and Symptom Management. 29(5): 32-46
Mayo Foundation for Medical Education and Research. (2015). Chronic Kidney Disease.
Retrieved January 15, 2015 from http://www.mayoclinic.org/diseasesconditions/kidney-disease/basics/definition/con-20026778
McPherson, R. & Pincus, M. (2012). Henrys Clinical Diagnosis and Management by
Laboratory Methods, 22nd Edition. Elsevier (Singapore) Pte Ltd. Winsland House I,
Singapore.
National Kidney Foundation Inc. (2015). About Chronic Kidney Disease. Retrieved January
5, 2015 from https://www.kidney.org/kidneydisease/aboutckd
Shamil, E., Ravi, P., & Chandra, A. (2014). 100 Cases in Clinical Pathology. CRC Press
Taylor & Francis Group. 6000 Broken Sound Parkway, Boca Raton.
Spinelli, M., Souza, J., Souza, S., & Sesoko, E. (2003). Reliability and validity of palmar and
conjunctival pallor for anemia detection purposes. Retrieved August 2003 from
http://www.scielosp.org/scielo.php?pid=S003489102003000400003&script=sci_arttext&tlng=en

WebMD, LLC. (2015). Diuretics for High Blood Pressure. Retrieved January 9, 2015 from
http://www.webmd.com/hypertension-high-blood-pressure/diuretics-for-high-bloodpressure
WebMD, LLC. (2015). Fatigue Home. Retrieved January 2, 2015 from
http://www.webmd.com/a-to-z-guides/weakness-and-fatigue-topic-overview
WebMD, LLC. (2015). High Blood Pressure and Diuretics (Water Pills). Retrieved January 11,
2015 from http://www.webmd.com/hypertension-high-bloodpressure/guide/diuretic-treatment