SHORT CASE : A 34-year-old gentleman with Chronic Kidney Disease undergoing Dialysis

 HALL TICKET NUMBER : 1601006161

A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis.

History of presenting illness :

  • The patient was apparently asymptomatic 3 years ago, when he was diagnosed with Hypertension, secondary to Chronic Kidney Disease. 
  • He was regularly taking his medication for Hypertension, until he abruptly stopped doing so 2 months ago.
  • The patient has been undergoing maintenance hemodialysis at our hospital since the past 10 months.
  • He complains of facial puffiness, abdominal distension and swelling in the legs. 
  • The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg.
General Physical Examination :

  • The patient is conscious, coherent and cooperative, lying supine on the bed
  • He is well oriented to time, place and person.
  • He is moderately built and moderately nourished.
  • On head-to-toe examination :
  • There is presence of Pallor in the lower palpebral conjunctiva.
  • There is evidence of :
  • Facial and periorbital puffiness
  • Bipedal edema which is of pitting type 
  • Moderate ascites - Shifting dullness is present. 
  • There are small, dark brown spots of hyperpigmentation visible on the palms
  • There is no Icterus, Clubbing, Cyanosis, Generalized lymphadenopathy.
Vitals :
  • Temperature = afebrile
  • Pulse = 80 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
  • Blood pressure = 140/90 mm of Hg in the left arm in supine position.
  • Respiratory rate = 16 cycles per minute.
  • JVP is elevated to 11.5 mm of H20 at 45 degrees.
Per Abdominal Examination :
  • On Inspection : The abdomen is mildly distended.
  • On palpation :  The abdomen is soft and non-tender.
  • Shifting dullness is present. 
  • Fluid thrill is absent.
  • Suggestive of Moderate ascites.
Examination of other systems :
  • Cardiovascular system : Hyperdynamic apex is seen. S1, S2 is heard. No murmurs are heard.
  • Respiratory system : Bilateral air entry is present, Normal vesicular breath sounds are heard. No adventitious sounds are heard.
  • Nervous system : Motor and Sensory systems are normal. Cranial nerves are intact.

PROVISIONAL DIAGNOSIS :

Chronic Kidney Disease on Maintenance Hemodialysis (MHD) with secondary Hypertension, with bipedal edema, moderate ascites and anemia.

Clinical Images :

Facial Puffiness 


Elevated JVP 


Pedal edema, pitting type 



Abdominal distention due to ascites 


AV fistula / Cimino Fistula 


Investigations :
  • Hemogram 

  • Complete Urine Examination 

  • Renal Function Tests 

  • Liver Function Tests 

  • Ultrasonography of the abdomen 

  • ECG showing Left Ventricular Hypertrophy (LVH) in leads V1 and V6 

Treatment : 
  • Salt restricted diet (<2 gm/day) 
  • Fluid restriction (< 1 L/day)
  • TAB. FUROSEMIDE 40 mg BD
  • TAB. SODIUM BICARBONATE 500 mg BD
  • TAB. NIFEDIPINE 10 mg TID
  • TAB. CLONIDINE 0.1 mg BD
  • TAB. CALCIUM AND VITAMIN D3 SUPPLEMENTS 500 mg OD
  • Maintenance Hemodialysis (MHD) 

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