Aging Case Studies


CASE 6: Chronic Renal Failure


Clinical History:

A 63-year-old man has had increasing fatigue for the past year, ever since his wife died. He has stopped going out every Saturday with his friends. He is unhappy and bored and feels sad. He now sleeps late every morning. He has lost 7 kg in the past year.

Physical examination reveals 5/5 motor strength in all extremities, Deep tendon reflexes are normal. Sensation is intact. His mental status has not declined. A CBC shows WBC count 8400/microliter, Hgb 10.8 g/dL, Hct 31.9%, MCV 91 fL, and platelet count 188,000/microliter. A serum chemistry panel shows sodium 145 mmol/L, potassium 4.5 mmol/L, chloride 101 mmol/L, CO2 26 mmol/L, urea nitrogen 48 mg/dL, creatinine 5.0 mg/dL, and glucose 120 mg/dL.
  1. What does the history suggest?

    2. The history suggests depression. Lowered mood, difficulty in thinking, loss of interest, loss of energy, and excessive sleep can be features suggesting depression. His 'failure to thrive' was probably triggered by a key social event - the loss of his wife, and he went on to exhibit weight loss, weakness, and functional decline. An underlying disease process may be contributing to his problems.

  2. What do the laboratory findings suggest?

    3. The findings show evidence for renal failure, with the elevated creatinine and BUN. He also has anemia.

  3. Give possible etiologies.

    4. He most likely has chronic renal failure (there are no acute conditions, and the process has been gradual). There are a variety of causes for chronic renal failure:

    Hypertension: Hypertension leads to vascular damage. Hypertension contributes to the development of atherosclerosis, which can affect larger arteries, including the renal artery orifice and renal artery and branches. Arteriolar nephrosclerosis of small renal arterioles is another consequence. The result of years of renal vascular damage is loss of renal cortex with reduced renal function.

    Chronic GN: 30% of cases of glomerulonephritis have no identifiable cause, and are called "chronic glomerulonephritis". Regardless, the result is end stage kidney.

    Chronic pyelonephritis: Urinary tract infections are quite common, especially in women. A complication of a UTI is ascending infection to the kidney(s) with resultant pyelonephritis (interstitial nephritis). Multiple episodes of acute pyelonephritis can eventually lead to chronic pyelonephritis. Persons who develop urinary tract stones have an increased risk for infection. End stage kidney from UTI and/or stones is not common.

    Diabetes mellitus: Diabetes mellitus, whether type 1 or type 2, can affect the kidney in many ways. This is one of the most common underlying diseases that leads to chronic renal failure. Diabetes leads to: atherosclerosis, arteriolar nephrosclerosis, nodular glomerulosclerosis, and increased UTI's.

    DPKD: Dominant polycystic kidney disease (DPKD) is an uncommon disorder, but one that can have the onset of renal failure in middle to older aged adults. The kidneys become massively enlarged by replacment with multiple cysts.

    Note: the end result of any chronic renal disease is "end stage" kidney. They all look the same: small shrunken kidney with diminished cortex, sclerotic glomeruli, fibrotic intersititum, and thickened vessels.

  4. What other workup would you perform at this point?

    5. It is debatable what the value of further workup will be, given that the course is unlikely to be altered. Diagnosing and treating underlying conditions such as hypertension and diabetes mellitus can help to slow the advancement of the disease and to reduce the other complications. Diagnosing and treating UTI's can help prevent further damage. A simple abdominal ultrasound can determine if DPKD is present, something that would be important for the family to know.