Sample Paper on Case Studies

by Keith Mitten 

Acute renal failure: Ms. Jones, a 68-year-old female, underwent open-heart surgery to replace several blocked vessels in her heart. On her first day postoperatively, it was noted that she had very little urine output.

1. What is happening to Ms. Jones’s kidneys, and why is it causing the observed symptom?
Ms. Jones is having an impending Acute Renal Failure (ARF) or ischemic Acute Tubular Necrosis (ATN). After a major postoperative procedure that involves high volume blood loss, kidneys face insufficient blood supply. This results in rapid shutdown of kidneys and is manifested as impaired kidney functions like decreased urine formation and toxic substance excretion.

2. What other symptoms and signs might occur?
Usually such an acute renal failure is symptomless to begin with, making it harder for clinicians to detect. Some of the clinical features that are associated with acute onset renal failure include hypotension, increased thirst, tachycardia, dry mucous membranes (lips, palates), and decreased jugular venous pressure. In most cases, it is associated with moderate to high elevations in serum creatinine levels, deranged serum electrolytes. Urine examination may reveal the presence of casts and epithelial cells.

3. What is causing Ms. Jones’s kidney disease?
Research has revealed various independent factors because of which Ms. Jones must have developed ARF. Her old age definitely predisposes her to ARF post-cardiac bypass surgery. Other factors, alone or together, that could have played a role include diabetes, genetic predisposition to kidney disease, increased body weight, presence of heart failure characterized by reduced ejection fraction, carotid artery bruit, and increased pre-operative serum creatinine.

4. What are possible treatment options, and what is the prognosis?
If diagnosed in early stages, the prognosis is good (~1.8-2% mortality) with appropriate fluid restoration to combat blood loss. Fluid restoration is with whole blood in severe cases and with isotonic saline in mild to moderate blood loss cases. This restores the electrolyte imbalance too. Deteriorating cases may need dialysis to reduce serum creatinine and thus the burden on kidneys, but the prognosis in patients requiring dialysis is very poor with 28-30% mortality.

Chronic renal failure: Mr. Hodges, a 73-year-old man, has had congestive heart failure for the past 5 years. His doctor has told him that his heart is not functioning well, needing more and more medicine to maintain circulatory function. He has noticed that he is not urinating more than once a day.

5. Why is the condition of Mr. Hodges’s kidneys affecting the rest of his body?
Mr. Hodges’s congestive heart failure is the result of the chronic renal failure, which was asymptomatic until now. Chronic renal failure along with uremia (increased urea concentration in blood) leads to slowly increasing salt and water retention causing volume expansion, relative hyponatremia, hyperkalemia. This causes congestive heart failure, which requires continuous increase in medications as underlying chronic renal failure is masked.

6. As his chronic renal failure worsens, what other symptoms and signs might occur in his respiratory, digestive, nervous, and urinary systems?
Symptoms of respiratory distress such as dyspnoea, right heart failure (cor pulmonale) may become evident with signs of pulmonary edema. Nausea, vomitting, peptic ulcer disease, gastroenteritis, idiopathic enteritis and peritonitis may affect the GI tract. Neurological manifestations like lethargy, sleep disorders, asterixis, muscular irritability, and restless leg syndrome may ensue. Further reduction of urine output with albuminuria, abnormal urinary sediments may be seen.

7. What is causing Mr. Hodges’s kidney disease?
Mr. Hodges’s kidney dysfunction can be because of various etiologies, but primarily it is due to old age. Differential diagnosis to age-related chronic renal failure may include diabetic nephropathy, hypertensive nephropathy and progressive nephrosclerosis due to vascular diseases. Drug-induced renal failure is usually acute.

8. What are possible treatment options, and what is the prognosis?
Treatment action plan is two-fold, general and specific. General treatment aims to halt the falling GFR (urine production) by appropriate medications to increase renal flow. Protein restriction and anti-hypertensive medications to reduce the glomerular pressure impede the disease development. Specific treatment includes controlling glucose for diabetic patients, reducing cardiac load and blood pressure for chronic heart failure patients, etc. The prognosis of chronic renal failure is dependent on its stage. Earlier its detection better is the prognosis. End stage renal failure requires frequent dialysis and managing its complications.

References:

Kasper, D. L., Braunwald, E., Fauci, A. S., Hauser, S. L., Longo, D. L., & Jameson, J. L. (2005). Chronic Kidney Disease. Harrison’s Principles of Internal Medicine (16 ed., Vol. 2, pp. 1746-1762). New York: McGraw-Hill Companies.

Conlon, P. J., Stafford-Smith, M., White, W. D., Newman, M. F., King, S., Winn, M. P. (1999). Acute renal failure following cardiac surgery. Nephrol. Dial. Transplant., 14(5), 1158-1162.

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