Case #1

1.  "presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis." what does the symptoms suggest to you?

Uremia

Symptoms of uremia are are non-specific. You have to keep this possibility in mind whenever there is consideration for renal disease.

• Lethargy

• Nausea and vomiting

• Fatigue

• Lethargy

• Pruritus

2. What are the fundus changes in a hypertensive?

• AV nicking

• Hemorrhage

• Papilloedema

3. What are the fundus changes of a diabetic?

• Exudates

• Hemoorhage

• Neo-vascularization

• Aneurysms

4. What does S4 signify? What cardiac findings will you expect to find in a hypertensive?

Pressure work

• Apical impulse low and out

• Sustained apical impulse

• Loud A2 component over aortic area

• S4

5. What are the possibilities for his  symmetrical 2+ lower extremity edema?

• Congestive heart failure

• Hypoalbuminemia

• Water retension from renal failure

6. What is the significance of the finding " superficial excoriations of his skin from scratching." ?

Uremia leads to pruritus and explains the excoraitions from scratching.

7. Why was a renal ultrasound ordered?  What information can you gather from renal untrasound studies?

To determine kidney 

• size

• echogenicity 

• rule out obstruction

8 .How does the results of the renal ultrasound influence your thinking on the diagnosis? What is the normal size of the kidney?  Is his kidney size normal? What does small or large kidney signify?

Size: 

• Normal

• Large: Consider

• Small: Consider

9.  What is the significance of the report "Both kidneys illustrate hyperechogenicity"  How does evaluation of echogenicity help in the diagnosis?

Echogenicity

10. What evidence in renal ultrasound will suggest obstruction?

Obstruction

• Large kidney

• Dilated calyses

• Dilated ureter

11. Is the cause of this patient’s renal failure acute or chronic? How did you arrive at that conclusion?

Chronic

Acute: Short duration and rapid rise of BUN and creatinine.

Chronic: Long duration of BUN and creatinine elevation, Hemoglobin is low, Calcium and Parathormone disturbances

12. What is the calculated GFR?

  140-41 (76.5 kg) = 6.6 ml/min
  72 x 16.0

13. What would be the calculated GFR in this case if the patient was female?

  (140-41) (76.5)=6.6 x .85=5.6

females have less muscle mass per kilogram than males. 

72 x 16

14. What is the 24 hour urine protein excretion in this patient? 

600 mg/dl x 8.5 dl) = 5,100 mg

15. Is this 24 hour urine collection adequate? How did you arrive at that conclusion?

Yes; (180 mg/dl x 8.5 dl) = 1530 mg creatinine; 1530 mg/76.5 kg = 20 mg/kg. This is adequate for a male patient.

16. How is a 24 hour urine to be collected and when is it appropriate to order this test? 

• Method of collection

  • The first morning void should be discarded. 

  • All following voids should be saved in the container provided including the following morning sample. 

• When appropriate

  • It is only appropriate to get a 24 hour urine sample for protein and creatinine clearance when renal function is in a steady state. 

  • If the function is acutely deteriorating at the time of collection the GFR will be overestimated and if the function is improving during the collection, the measured GFR will be underestimated.

17. What is the measured GFR in this patient?

  (180 mg/dl x 850 ml/1440 min) = 6.6 ml/min
             (16.0 mg/dl)

18. Why is the parathyroid hormone elevated? 

• Due to the decrease in GFR there is decreased excretion of phosphate. 

• This results in a decrease in serum ionized calcium and stimulation of parathyroid hormone release.

19. What is the most likely cause of this patient’s anemia? 

• Decreased erythropoietin. 

• This is typically a normochromic and normocytic type of anemia.

20. Should this patient be started on dialysis? What are the indications for dialysis?

Yes, indications to be considered for dialytic therapy include 

• abnormalities in acid-base 

• balanceelectrolyte disturbances

• volume overload

• dialyzable toxins 

• uremia.

This patient demonstrates symptoms of uremia.

21. What is the most likely diagnosis for his renal disease? How did you arrive at that conclusion?

• The leading cause of end stage renal disease in this country is diabetes. 

• The most likely cause in this case is diabetes because of the 

  • bland urinary sediment

  •  nephrotic range proteinuria 

  • long history of diabetes.

22. What are the most likely histological findings on renal biopsy in this patient? 

The renal biopsy may demonstrate 

• capsular drop lesions

• mesangial expansion

• KW lesions 

• basement membrane thickening 

• glomerulosclerosis 

• tubular atrophy.

23. Could his renal failure be due to hypertension? What evidence you will need to implicate hypertension as the cause for his renal failure?

24. If you were to place this patient on a 2 gram sodium diet how many milliequivalents of sodium would this diet contain?

 2,000/23 m.w.=87 meq. 

25. How many grams of sodium chloride would this be?

 (87 meq) x (58 m.w.) = 5 grams.