Chronic Kidney Disease Case Report

General Data
RAT, 58 y/o Female, married, Filipino, from Laoag City, admitted for the second time last July 09, 2018
Admitting Diagnosis: Chronic Kidney Disease Stage V secondary to Polycystic Kidney Disease, Ascites secondary to
Polycystic Kidney Disease, Hypertension Stage II
Informant: Patient and her husband (98% Reliability)

Chief Complaint: Distended abdomen

History of Present Illness

The patient is a known case of CKD V secondary to PKD on hemodialysis 2x/week since February 2018 via her
arteriovenous fistula with maintenance medications: CaCO3 500 mg tab TID, NaHCO3 650 mg tab TID, FeSO4 + FA
tab OD, Amlodipine + Telmisartan tab OD, Vitamin B complex tab OD, compliant.

2 months PTA, patient noted progressive increase of her abdominal girth associated with easy fatigability, 3 to 4
pillow orthopnea, paroxysmal nocturnal dyspnea and decreased appetite. There was no chest pain. Patient stated
she is not compliant to the prescribed oral fluid intake limit of <1 liter per day and still eats any food she prefers.

1 week PTA, patient was transfused with 2 units of PRBC for her last 2 hemodialysis due to decreased hemoglobin.

2 days PTA, due to progression of abdominal distention with accompanied abdominal pain and difficulty of breathing,
was advised for admission for drainage of ascites.

Past Medical History

(+) hypertension in 1986 with a highest BP of 250/200 mmHg, usual BP ____, on Amlodipine + Telmisartan tab OD.
No DM, No Heart disease.

OB GYN history
Menstrual history: Patient had her menarche at 15 years old, regular interval, with a duration of 4 to 5 days,
moderate to heavy flow, no dysmenorrhea. The patient had her menopause at 49 years old.
OB Score: G3P2 (2022)
G1 – Twins, miscarriage
G2 (1988) and G3 (1993) – Normal delivery but was high risk due to her hypertension

Family History
(+) Kidney stones
(+) Hypertension
(+) Stroke
(+) Diabetes mellitus
(+) Heart disease (myocarditis? In heart failure, myocardial infarction)
(+) Arthritis (gouty arthritis, osteoarthritis)
(+) Caner (throat, father side; lung, mother side)

The patient has no family history of liver disease and asthma.

Personal and Social History

The patient is a Commerce Major in Accounting graduate and worked as a saleslady for a few years. She is a
housewife and lives with her husband and two children in a bungalow type house with adequate space.
She does not do formal physical exercise. For her diet, she eats 1 to 1 ½ rice, high fat diet (adobo, bagnet, longganisa,
fried food). She is not fond of eating fish and vegetables. She stated that she loves to drink coke and can consume 1
liter per day since 2004 since her husband works in the coca-cola plant. But at present, she only drinks coke
occasionally. She claims to have no allergies to food or drugs. The patient is a non-smoker and occasional light
alcoholic drinker and has no history of illicit drug use.

Review of Systems
General: (+) weight loss (78kg to 53kg in a span of 5 years, 5kg/year) (+) weakness/fatigue (-) fever
Skin: (-) pruritus (-) rashes, (-) changes in hair (-) changes in nail (-) color change
Head: (-) headache (-) dizziness (-) lightheadedness
Eyes: (-) visual impairment (-) pruritus (-) discharge (-) inflammation (-) glasses
Ears: (-) hearing loss (-) tinnitus (-) discharge (-) earaches
Nose, Throat, Mouth: (-) abnormal olfaction, (-) dental carries (-) gingivitis (-) dysphagia/odynophagia (-) tonsillitis (-
) hoarseness (-) gum bleeding (-) colds (-) nasal stuffiness (-) itching (-) nosebleed
Neck: (-) goiter (-) cervical lymph node enlargement (-) mass (-) lumps (-) sore throat
Respiratory: (-) cough (-) sputum (+) difficulty of breathing (-) night sweats (-) pleuritic pain (-) hemoptysis
Breast: (-) pain (-) mass (-) tenderness, (-) discharge
Cardiovascular: (+) orthopnea (-) palpitations (-) chest pains (+) paroxysmal nocturnal dyspnea (+) edema
Gastrointestinal: (+) decreased appetite (-) constipation (-) nausea (-) vomiting (-) dysphagia (-) hematemesis (-)
hemorrhoids (-) diarrhea (-) heartburn (-) dysphagia (-) black /tarry stool (-) bloody stool (+) abdominal pain
Urinary: (+) frequency of urination (-) polyuria (-) hesitancy (-) dribbling (-) pain (-) urgency (-) hematuria (-) nocturia
(-) hernia
Genitourinary: (-) loss of libido (-) sexual dysfunction (-) lesions (-) discharge
Peripheral Vascular: (-) edema (-) pruritus (-) intermittent claudication (-) leg cramps (-) varicose veins (-) ulcers
Musculoskeletal: (+) leg cramps (-) muscle weakness (-) wasting/atrophy (-) pain (-) fractures (-) stiffness (-) joint pain
Hematopoietic system: (+) anemia (-) abnormal bleeding (+) easy bruising
Endocrine: (-) polyphagia (-) polydipsia (-) polyuria (-) weight loss (-) goiter (-) heat/cold intolerance
Nervous: (-) slowed movement (-) vertigo (-) falls (-) headache (-) loss of consciousness (-) syncope

Physical Examination:

General Survey:
Patient is conscious, alert, coherent, cooperative and able to speak in full sentences. Patient is an
ectomorph and in no apparent cardiorespiratory distress.
Vital Signs:
PR: 88 beats per minute, regular rate and rhythm
RR: 20 cycles per minute
BP: 120/80 mmHg right arm, lying
Temp: 37.1oC axillary
O2 sat: 96%
Anthropometrics:
Weight: 53 kg
Height: 152 cm
BMI: 22.94 kg/m2
Skin:
Dry skin. Bruising noted at the location of AVF. No pallor, no cyanosis, no jaundice. Skin warm to touch.
HEENT:
Anicteric sclera, pale palpebral conjunctiva, no redness, pinguecula noted medially at the left eye. No sinus
tenderness. No tonsillopharyngeal congestion. Neck supple, no cervical lymphadenopathy, no neck vein
engorgement.
Thorax and Lungs:
Decreased but symmetric chest expansion, clear breath sounds, no retractions.
Cardiovascular:
Adynamic precordium. PMI displaced at 4th ICS left midclavicular line. Distinct heart sounds, S1 and S2,
normal sinus rate and rhythm. No murmurs noted.
Breasts:
Symmetric breasts. No discharge or masses.
Abdomen:
Globular, distended and bulging bilateral flanks. Visible masses, no pulsations. Normoactive bowel sounds.
Abdominal girth at 106 cm. No bruits heard. Dullness generally noted with tympanic above the umbilical
area. Multiple nodular masses below right subcostal area about 1 inch in diameter, a 13 cm x 13 cm palpable
mass noted below left subcostal area. No tenderness on light and deep palpation. Hepatomegaly noted. No
costovertebral angle tenderness. (+) fluid wave test.
Extremities:
(+) thrill and bruit noted at AVF located anteriorly at the proximal third of left upper arm. Full equal pulses.
No clubbing or cyanosis. Pale nail beds. Calves are supple and non-tender. Grade I bipedal edema. Capillary
refill time <2s.
Genitourinary and Rectal:
Not assessed.
Mental Status:
Normal.
Neurological
GCS:
15/15 (E4V5M6)
Cerebral:
She is oriented to person, place, time and situation.
Cerebellar:
No dysmetria, no dysdiadochokinesia, no nystagmus, no overshooting.
Cranial Nerves
I – No anosmia.
II – Pupils equally round and reactive to light and accommodation constricting from 4 mm to 2 mm. Pupillary
reflex intact, no RAPD.
III, IV, VI – Extraocular movements intact and equal without ptosis. Visual fields full.
V – Intact and equal sensation over the face. Corneal reflexes present. Masticator muscles 5/5.
VII—No facial asymmetry. Facial muscles 5/5.
VIII – Gross hearing intact.
IX and X— With intact gag reflex. No dysarthria or dysphagia.
XI – Trapezius muscle and sternocleidomastoid muscle 5/5.
XII – Tongue midline, no tongue deviation or fasciculations.
Motor: Sensory:
5/5 5/5 100% 100%

5/5 5/5
100% 100%
Reflexes and Miscellaneous:
2+ elbow, knee and ankle reflex. No Babinski or clonus noted.

Date of February 5, 2016 January 27, 2018 July 9, 2018

WA UTZ
Findings  Follow up scan of the entire  Liver and renal sizes 
abdomen correlated with a appear enlarged
 previous scan report dated with multiple
July 30, 2015 shows virtually trabeculated cystic
the same findings to wit: masses of varying
 The liver and kidneys are sizes occupying
enlarged with their boundaries their respective
rendered indistinct because of entire breadth,
multiple varisized thin walled obscuring their
cystic masses occupying them, respective
some with low level echoes peripheral hepatic
within theses cystic masses. and renal
Biliary ducts and pelvocalyces boundaries,
cannot be assessed because of precluding
aforementioned cystic masses. evaluation of the
 Gallbladder is devoid of any biliary tree,
stones or masses. gallbladder, hepatic
 Pancreas, spleen and urinary vascular passages,
bladder are unremarkable. aorta and pancreas.
 Aorta shows no undue  Spleen and urinary
dilatation. bladder are
 Uterus is enlarged with central unremarkable.
echogenic mass obliterating  Uterus is enlarged
the endometrial cavity. No with a uterine
abnormal adnexae. fibroid within.
 Note of generalized
ascites.
Conclusion  Severe polycystic disease  Generalized ascites 
involving the entire liver and  Severe polycystic
both kidneys. disease involving
 Enlarged uterus with probable the liver and
intramuscular and submucosal kidneys
myomatous changes.  Enlarged uterus
with uterine fibroid
within.

Labs:
CBC
Na, K
BUN, Crea
ECG
CXR
ABG
AST, ALT
UA
Abdominal CT scan with contrast or plain (Nephro clearance)
FBS, Lipid profile
BUA
Peritoneal fluid analysis

Meds:
Calcium carbonate 500 mg TID
Sodium bicarbonate 650 mg TID
Ferrous sulfate + folic acid OD
Amlodipine + Telmisartan tab OD
Vitamin B complex tab OD
Paracetamol 300 mg IV

July 9, 2018 labs

Chest Xray: No significant pulmonary findings
FBS 5.93
Cholesterol 3.87
HDL 0.30
LDL 3.19
Triglycerides 0.83
BUN 15.4 (9) 18.8 (10)
Creatinine 738
Sodium 126
Potassium 4.39
Hgb 79
Hct 0.25
RBC 3.13
WBC 11.11
Seg 0.88
Lym 0.06
Mon 0.06
Eosi 0.0
Baso 0.0
Plt 419
ALT 18.22
AST 33.48
AFB stain no mcg
UA
Y
ST
1.015
9
Protein +3
Glucose +1
Hgb +5
Leukoesterase +3
WBC 5-7
RBC 12-15
Epith cells Moderate

Case discussion:

POLYCYSTIC KIDNEY DISEASE


 group of genetically heterogenous disorder
 one of the leading cause of kidney failure
o ADPKD=most common life threatening monogenic disease

o ciliopathies= defect in the structure and function of the primary cilia

Autosomal Dominant Polycystic Kidney Disease

  caused by the mutation of PKD1 and PKD2 genes ( code for polycystic)
o PC1= large 11 transmembrane protein function like a G protein coupled receptor

o PC2=calcium permeable six transmembrane protein belongs to transient receptor potential cation
channel family
o PC1 and PC2= found in primary cilia

 = loss of the ciliary function of PC1 and PC2 leads to reduced calcium signalling → increase in adenyl cyclase
activity and decrease in phosphodiesterase activity → increased cellular cyclic AMP

 = progressive bilateral formation of renal cyst
 focal cyst

Clinical Manifestation

 highly variable

 asymptomatic

 hypertension, abdominal mass and flank pain (60%)
 40%= gross hematuria

 (+) CARDIOVASCULAR COMPLICATIONS= most common cause of mortality 

 (+) HPN =risk factor

 (+) INFECTION= second most common cause of death

 ESRD= typically present in late middle age
o Risk factors: early diagnosis of ADPKD, HPN, gross hematuria, multiple pregnancies and large
kidney size
Diagnosis
 + FHx of ADPKD
 Renal UTZ= often used for pre symptomatic screening
 The presence of at least two renal cyst (unilateral or bilateral) is sufficient for diagnosis of at risk subject
b/w 15-29 y/o
 the presence of at least two cyst in each kidney and the presence of atlas four cyst in each kidney are
required for the diagnosis of at risk subject age 30-59yo

Treatment
 no specific treatment to prevent cyst growth or the decline of renal function
 BP control to a target of 140/90
 Cyst infection= ( cotrimoxazole/quinolones/ chloramphenicol) 4-6 weeks
 more than half of patient eventually require hemodialysis and kidney transplant
 patients with very large polycystic kidneys and recurrent cyst infection may require pre transplant
nephrectomy or bilateral nephrectomy
Cystic Diseases of the Kidney
 Characterized by epithelium-lined cavities filled with fluid or semisolid debris within the kidneys
 Includes: simple cysts (50% of population >50), medullary cystic kidney, medullary sponge kidney, polycystic
kidney disease (autosomal dominant and recessive), and acquired cystic kidney disease (in chronic
hemodialysis patients

Adult Polycystic Kidney Disease

 Autosomal dominant: at least 2 genes: