A Case Study On

Chronic Kidney Disease

In Partial Fulfillment of the Course Requirement in Clinical Chemistry 2

Medical Laboratory Science Department
Davao Doctors College,Inc.

SUBMITTED TO:

JOHN MARKE BERNARDO, RMT

Clinical Chemistry 2 Instructor

SUBMITTED BY:

OSAMA, ALHARVEY M.
PARDILLO, MELODY JANE B.
PAJARILLO,PHILIP JOHN JOEMAR

May 2021
 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 patient’s
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 patient’s kidney indicate that the patients is experiencing kidney problems.

1
 CHAPTER 2

PATIENT’S DATA
PERSONAL DATA:
Age: 64
Sex: Male

MEDICAL HISTORY:
Hypertension
Weakness
Anorexia
Bony pains
Impotence
Conjunctival pallor

LABORATORY RESULTS:
LABORATORY TEST RESULTS

HEMATOLOGY CHEMISTRY STUDIES

White Cell Count: 8 g/dL Sodium: 132 mmol/L

Platelet: 200 x 109/L Potassium: 5.6 mmol/L
Hemoglobin: 10.8 g/dL Urea: 22 mmol/L
MCV: 90 fL Alkaline Phosphatase: 230 IU/L
Calcium: 1.95 mmol/L
Phosphate: 1.9 mmol/L
Creatinine: 375 mmol/L
URINALYSIS Imaging Studies

Urine Dipstick
+++ Ultrasound (Kidney): 8.1 cm and 8.4 cm
(Protein):

2
 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.

3
 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
patient’s 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 patient’s 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 patient’s eyes. Lastly,
reduced blood levels, bony pains and disruption of the patient’s endocrine function, accompanied by the
patient’s old age are what caused the patient’s anorexia and general weakness.
 CHAPTER 4

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

ACTIONS
A. Laboratory Results and Interpretation

LABORATORY PATIENT’S NORMAL INTERPRETATION RATIONALE

TEST RESULTS VALUES
Hemoglobin 10.8 g/dL 11.4 – 15.0 Decreased A decreased Hb
(Hb) g/dL indicates low red
blood cell count
and/or low serum
iron

White Cell Count 8 g/dL 3.9 – 10.6 Normal A normal WBC count
g/dL indicates that the
patient is not
experiencing any
infection
Platelet count 200 x 109/L 150 – 440 x Normal A normal platelet count
109/L indicates that the
patient is not
experiencing any
clotting or bleeding
disorders
MCV 90 fL 77 - 95 fL Normal A normal MCV
indicates that the
patient’s red blood
cell are normal in
terms of size
Chemistry
Studies:
Sodium 132 mmol/L 135 -145 Decreased Low Sodium levels is
 mmol/L due to chronic kidney
disease the patient is
experiencing which
disrupts the ion
homeostasis
Potassium 5.6 mmol/L 3.5 – 5 Increased Increased Potassium
mmol/L levels is due to the
increased phosphate
levels in the body
which is caused by the
chronic renal
disease
Urea 22 mmol/L 2.5 – 7.8 Increased Increased Urea levels
mmol/L is due to the inability
of the kidney to filter
and excrete metabolic
waste products due to
chronic renal disease

Creatinine 375 µmol/L 60 – 110 Increased Increased Creatinine

µmol/L levels is due to the
inability of the kidney
to filter and excrete
metabolic waste
products due to
chronic renal disease
ALP 230 IU/L 20 – 140 Increased Increased ALP levels is
IU/L due to
hyperparathyroidism
caused by
hypocalcemia which is
the consequence
of chronic renal
 disease
Calcium 1.95 mmol/L 2.1 – 2.6 Decreased Decreased levels of
mmol/L Calcium is due to
increased levels of
phosphate, which
causes phosphate to
bind with ionized
calcium in the blood.
Phosphate 1.9 mmol/L 0.81 – 1.45 Increased Increased levels of
mmol/L phosphate is due
inability of the kidney
to maintain ion
homeostasis which is
caused by chronic
renal disease
Urinalysis
Urine dipstick +++ Negative Positive Presence of large
(Protein) amounts of protein in
the urine is due to the
failing filtration
system of the kidney
caused by chronic
renal disease
Imaging Studies
Ultrasound Size: 8.1 cm 9 – 12 cm Decreased Decreased kidney
(Kidney) and 8.4 cm sized is caused by
with no deteriorating effect of
obstruction the disease (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 patient’s 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 patient’s kidneys are decreased in size. Patient’s 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 patient’s 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 patient’s urea and creatinine levels and the patient’s abnormal electrolyte levels, the patient’s
distress is caused by chronic renal disease which is most likely caused by the patient’s 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

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 STUDENT CONTRIBUTION

OSAMA, A.-CHAPTER 5 & 6

PARDILLO, M.-CHAPTER 1, 3 & 4

PAJARILLO, P. -CHAPTER 2, 3 & 4