CASE

DISCUSSION 1
DR. ANITA BHAJAN MANOCHA
HOSPITAL SEBERANG JAYA, PULAU PINANG
DR. KOW FEI PING
KLINIK KESIHATAN BANDAR BARU AIR ITAM, PULAU
PINANG

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Case 1 - History
• Mrs. M, a 62-year-old factory worker, was referred to
the Klinik Kesihatan for follow-up in April 2017.

• She was diagnosed to have hypertension by her panel

doctor 4 years ago & initiated on Tab. Amlodipine 2.5
mg daily.

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 20 April 2017

Examinatio FBS
Renal profile
6.2 mmol/L

n Urea 5.0 mmol/L

Sodium 139 mmol/L
• BMI: 29.2 kg/m 2
Potassium 4.09 mmol/L
• BP: 160/90 mmHg Creatinine 78 µmol/L
• Pulse: 74/min Fasting lipid profile
• Systemic: Total Cholesterol 6.5 mmol/L
◦ Grossly normal Triglycerides 10.03 mmol/L
HDL 0.63 mmol/L
LDL invalid
Liver Profile
ALT 26 U/L
ALP 63 U/L
Uric Acid 539 µmol/L
ECG RBBB, otherwise normal
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Question 1
• Would you screen this patient?
o If yes, why?

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 Answer 1

 Why is it important to screen patients for CKD who

have hypertension? 
 Hypertension may be a cause or consequence of CKD.
 Hypertension may accelerate the progression of renal
disease leading to ESRD.

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 Common pathway in
disease progression

RENAL INJURY

 Nephron mass
Glomerular capillary hypertension
SYSTEMIC  Glomerular permeability to macromolecules
HYPERTENSION  Filtration of plasma proteins  Proteinuria
Excessive tubular protein re-absorption
Tubulo-interstitial inflammation

RENAL SCARRING

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Question 2
• What are the risk factors identified?

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Answer 2

 Obesity increases the risk of developing low eGFR with

RR of 1.18 & albuminuria with RR of 1.5.10
 Metabolic syndrome is a risk factor for CKD as shown by
a large meta-analysis of 11 cohort studies.11
 The strength of the association increases as the number of
components of metabolic syndrome increases  

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9
Question 3
• How to stage this patient?

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Answer 3

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Answer 3 (cont.)
• Classification of CKD should be based upon cause,
GFR category & albumin category (CGA).
◦ Cause
 Presence or absence of systemic disease & location within the
kidney of observed or presumed HPE findings
◦ GFR category
◦ Albuminuria category

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Answer 3 (cont.)
• Cause of CKD
◦ Presence or absence of systemic disease & location
within the kidney of observed or presumed HPE findings

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Answer 3 (cont.)

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Answer 3 (cont.)
• Estimation of renal function

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Answer 3 (cont.)
• Use your Smart Phone
• Download the App
• Install QxMD
• Go to eGFR
• Go to eGFR using CKD-EPI
• Answer the 4 questions
◦ Gender? Male/Female
◦ Race? Not African-American
◦ Age? ………
◦ Creatinine ? ......... µmol/L
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Question 4
• What is the GFR category of the patient?

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 Answer 4
Renal profile
Urea 5.0 mmol/L eGFR
70.2 ml/min/1.73m2
Creatinin 78 µmol/L
e

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Question 5
• Does your patient have CKD?

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Answer 5

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Question 6
• What will you do now?

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Answer 6

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Answer 6 (cont.)

Urine dipstick 1+
  

 Proteinuria has both diagnostic & prognostic value in

CKD.
 Presence of proteinuria should be confirmed by a repeat
test within three months.
 Proteinuria shows considerable biological variation.

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Answer 6 (cont.)

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Answer 6 (cont.)

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Answer 6 (cont.)

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Question 7
• How would you manage this patient?

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Answer 7

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 Follow-up
20 April 2017 18 April 2018
FBS 5.8 mmol/L 5.9 mmol/L
Renal profile Urine FEME: protein 2+, blood negative
Urea 5.0 mmol/L 4.2 mmol/L Urine ACR =
400 mg/g
Sodium 139 mmol/L 140 mmol/L
Potassium 4.09 mmol/L 4.02 mmol/L
Creatinine 78 µmol/L 90 µmol/L eGFR =
Fasting lipid profile 59 ml/min/1.73 m2
Stage G3a
Total Cholesterol 6.5 mmol/L 4.1 mmol/L
Triglycerides 10.03 mmol/L 2.84 mmol/L
HDL 0.63 mmol/L 0.94 mmol/L
LDL invalid 1.8 mmol/L
Liver Profile
ALT 26 U/L 23 U/L
ALP 63 U/L 60 U/L
Uric Acid 539 µmol/L 450 µmol/L 29
Question 8
• How would you manage this patient?

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Answer 8 (cont.)

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Case 2 - History
• In May 2015, Mr. A, 35-year-old dental nurse, was
referred for persistent mildly elevated liver
enzymes (ALT ranged from 61 U/L to 159 U/L) on
routine blood test.

• He also complained of intermittent right lower

limb swelling especially on prolonged standing for
the past 1 year.

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History (cont.)
Past Medical & Treatment History
• Mr. A had a motor-vehicle accident in 2006 & sustained
right hip fracture. He was advised for surgery but refused.
This resulted in non-union of the right upper femur with
recurrent pain.
• Patient also has recurrent episodes of acute gouty arthritis
since 2010. He has been taking self-purchased analgesics
(voltaren tablets) ~ 20 tablets/week for pain of right lower
limb & for gouty arthritis.
• He also receives alternative herbal treatment for pain relief.
• Patient claims having epigastric discomfort on & off. He is
given pantoprazole by GP & has been taking it since 2016.

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Physical examination
On examination:
• Limping gait (minimal)
• BMI: 24 kg/m2
• BP: 103/84 mmHg
• Systemic: cardiovascular, respiratory & abdomen
– not remarkable

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Question 9
• Would you screen this patient for CKD? If yes,
why?

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Answer 9

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Answer 9 (cont.)
• Use of proton pump inhibitors (PPI) has been shown to
significantly increase the risk of developing CKD (RR/OR is 1.1
- 1.5)13 - 15 & progression of CKD (HR is 1.26 - 1.32).15 - 16
• The risk correlates with cumulative dose of exposure.14 - 16
• The most common risk factor for acute decline in GFR in CKD
patients is the use of NSAIDs including COX2 inhibitors.12
• Certain herbal products containing aristolochic acid are
associated with CKD.9

• Gout & asymptomatic hyperuricaemia are associated with

CKD.17 - 18

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Follow-up May 2015 September 2015
FBS 4.7 mmol/L 4.6 mmol/L
Renal profile
Urea 4.8 mmol/L 4.1 mmol/l
Sodium 139 mmol/L 141 mmol/l
Potassium 4.09 mmol/L 3.9 mmol/l
Creatinine 135 µmol/l 150 µmol/l
eGFR 58.2 ml/min/1.73 m2 eGFR 51.2 ml/min/1.73 m2
Stage G3 Stage G3
Liver profile
Total protein 89 g/L 84 g/L
Albumin 43 g/L 45 g/L
Globulin 46 g/L 39 g/L
Total Bilirubin 11.5 g/L 15.0 g/L
ALT 159 U/L 73 U/L
ALP 140 U/L 93 U/L
Urine FEME Protein - trace, blood 1+ Protein - trace, blood 2+
Uric Acid 644 µmol/L 483 µmol/L 38
Question 10
• This patient has haematuria. How will you
investigate a patient with hematuria?

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Answer 10

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Question 11
• Will you do an ultrasound for this patient?

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Answer 11
• Ultrasound is a useful first line test for imaging the
renal tract in patients with CKD.
• It provides information on:
◦ renal size & symmetry
◦ cortical thickness & echogenicity
◦ urinary tract obstruction
◦ solid or cystic lesions

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Ultrasound findings
• Length of right kidney is 11.2 cm & cortical thickness
of 2.0 cm
• Right mild hydronephrosis
• Length of left kidney is 12.4 cm & cortical thickness
of 1.5cm
• Left gross hydronephrosis with echogenic sediments
within with visualised proximal left hydroureter
• Multiple left renal calculi suspicious of staghorn
calculi

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Question 12
• What will you do now?

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Answer 12

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Thank you

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