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)