f.

Weight loss
MED OSCE CHRONIC KIDNEY DISEASE (CKD) • Weight loss is common in cancer, and it is often the first
visible sign of the disease.

*N.B.: Although CKD is in line with our lectures this second semester, DIAGNOSTICS
the patient in this case has a co-morbidity which may be beyond the 1. Creatinine
scope of our second semester lectures but is still noteworthy. • Creatinine has been found to be a reliable indicator of
kidney function. Elevated creatinine level signifies
CASE impaired kidney function or kidney disease.
History
• 53 years old, Male 2. Complete Blood Count
• Chief complaint: body weakness and pallor • It is for the evaluation of anemia since the patient is
• Other clinical manifestations: weight loss and anorexia complaining of body weakness and pallor, and on
• KUB UTS was done revealing multiple nephrolithiasis; physical examination, he is weak looking with pale
bilateral renal parenchymal disease palpebral conjunctivae and pale nailbeds and palms.
• Family history of colon cancer • It is also used to detect infection.
• Heavy smoker and an alcoholic
• Taking Diclofenac and Ibuprofen for arthritis 3. Urinalysis
• Gross or microscopic hematuria is present in
Physical Examination approximately 85% of patients with urinary calculi.
• Pallor: palpebral conjunctivae, nail beds and palms
• Weak looking 4. Fecal Occult Blood Test
• Although there are several possible causes of blood in
DIFFERENTIAL DIAGNOSES
the stool, one important cause is the presence of polyps
1. Chronic Kidney Disease, anemia secondary
or cancers in the digestive tract. Physical examination
Bases: was not indicative of Colorectal cancer but having a
a. 53-year-old, Male family history suggests a hereditary predisposition.
• Elderly men are 2-3x more likely than women to develop Increasing age and nicotine dependence also increase
nephrolithiasis; this gender gap may be because of the risk.
protective effects of estrogen
b. Heavy smoker for 20 years Patient’s Results and Interpretation
• Cigarette smoking may induce kidney stone formation by Laboratory Results Normal Interpretation
decreasing urinary flow and increasing serum cadmium Test Value
in healthy subjects.
Creatinine 4.20 0.52 to 1.00 ELEVATED
c. Drinks alcoholic beverage daily ng/dL ng/mL
• Beer and grain alcohol have an especially high purine
CBC
count. Uric acid stones are composed of purine.
Hemoglobin 90 g/L 120-160g/L DECREASED
Excessive accumulation versus excretion precipitates the
Hematocrit 0.26 0.38-0.47 DECREASED
formation of renal stones.
d. Arthritis WBC count 15x103/L 4.5- ELEVATED
• The overall inflammatory burden of arthritis contributes 11x103/L
to kidney dysfunction. The use of NSAIDs secondary to Neutrophils 0.75 0.50-0.70 ELEVATED
arthritis also damages the kidneys which would decrease Lymphocytes 0.18 0.20-0.50 DECREASED
its functionality and increase the risk for development of Platelets 600x103/L 150- ELEVATED
renal stones. 450x103/L
e. KUB-UTS Urinalysis
• It revealed multiple nephrolithiasis and bilateral renal Specific gravity 1.015 1.015-1.022 NORMAL
parenchymal disease. Glucose (-) (-) NORMAL
Protein (+++) (-) ELEVATED
2. Colorectal cancer, anemia of chronic blood loss WBC 15-25/hpf 0-5/hpf ELEVATED
Bases: RBC 0-1/hpf 0-5/hpf NORMAL
a. 53-year-old, Male Bacteria Few (-) NORMAL
• The risk of acquiring colorectal cancer increases as Casts/ crystals None None NORMAL
people age due to accumulation of gene mutations. FOBT
b. Brother died of colon cancer FOBT Positive Negative
• Up to 25% of patients with colorectal cancer have a
family history of the disease, suggesting a hereditary • Using CKD-EPI, the eGFR of our patient is 15.1 mL/min
predisposition. and basing on the table below, the patient has CKD
c. Heavy smoker for 20 years Stage 4, very high risk (proteinuria result of +++ on
• Associated with an increased risk for Colorectal CA the patient’s urinalysis).
d. Drinks alcoholic beverage daily • Patient’s hemoglobin and hematocrit are decreased,
• There is an increased risk of bowel cancer for those who suggesting the presence of anemia. In addition, to
are drinking one drink (or 10 g of alcohol a day), which bacterial infections, neutrophil counts are increased in
• includes light alcohol drinkers. Moreover, the risk is many inflammatory processes. Patient has
higher for men than for women probably because alcohol thrombocytosis which may be reactive to bleeding within
metabolism is different between men and women the colon.
e. 5-month history of weakness and pallor • The presence of proteinuria identifies patients at
• Patients with tumors of the ascending colon often increased risk of adverse clinical outcomes, including
present with symptoms such as fatigue and are found to progression to ESRD.
have a hypochromic, microcytic anemia secondary to • If the result is positive for fecal occult blood test, it
bleeding from cancer ulceration. means the patient is likely to have bleeding somewhere

TEAM MEDICINE 😊 Page 1 of 2

 in the digestive tract. It does not necessarily mean it • Renal tubular acidosis
is cancer as there are other conditions which may o Sodium bicarbonate
produce a positive result on a fecal occult blood test. • Hypophosphatemia and hypocalcemia
o Phosphate-restricted diet and use of
phosphate binders such as calcium
carbonate and Sevelamer
• Hypertension
o First line of therapy: salt restriction
o ACEIs and ARBs BUT CONTRAINDICATED IN
hyperkalemia; they cause efferent
arteriolar dilation leading to a decreased
pressure in the glomerulus causing decreased
hyperfiltration thereby decreasing proteinuria
o Renal dose reduction of nephrotoxic agents
and dialysis
• Diet
o Protein requirement (HIGH BIOLOGIC VALUE)
▪ Hemodialysis: 1 g/kg/day
▪ Peritoneal dialysis: 1.2-1.5
g/kg/day
o Caloric requirement: 30-35 kcal/kg/day
o Sodium requirement: 3 to 6 g of salt/day
o Fluid requirement: 1L per day
o Potassium requirement: 50 to 100 mEq/day
Final Diagnosis o Phosphate requirement: 1 to 1.8 g/day
Chronic Kidney Disease Stage 4 with Multiple Nephrolithiasis,
Anemia Secondary
Cannot totally rule out Colorectal Cancer 2. Arthritis
Comorbidity: Arthritis • If NSAIDs must be used, aspirin, the agent with the lowest
adverse effect on glomerular filtration, may be considered.
Additional Diagnostics Long-acting NSAIDs or those having a half-life >12h should
1. Anemia secondary to Chronic Kidney Disease Stage 4 be avoided to prevent persistent and clinically significant
with multiple nephrolithiasis depression in GFR induced by NSAIDs.
• Serum electrolytes should also be determined to
uncover probable hypokalemia and renal tubular Patient Education
acidosis. • Compliance to dialysis, reduction of NSAID intake and
medications in managing the complications of CKD
2. Colorectal cancer screening • Low protein diet (0.6 to 0.75 kg BW) can reduce occurrence
• Colonoscopy of uremia and slows down rate of GFR decline by reducing
intraglomerular pressure/hyperfiltration.
THERAPEUTICS
1. Anemia secondary to Chronic Kidney Disease Stage 4
with multiple nephrolithiasis
a. General
• Treat as in-patient to manage the overt proteinuria,
weight loss, and anemia
• Urgent urologic consultation or to a nephrologist referral
for the management of the multiple nephrolithiasis
• For stages 1 to 4, treating the underlying cause of the
CKD and its complication to delay the progression of the
disease is the primary goal.
• Medical management of the anemia should be
dependent on the cause or underlying pathology.
b. Specific
• Anemia
o Erythropoietin
o Iron supplementation

• Hyperkalemia
o Dietary restriction of potassium, the use of
kaliuretic diuretics and avoidance of potassium
supplements
o Avoid ACEIs and ARBs which retain
potassium

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