The mask of kidney disease

Most of us recognize kidney patients when they walk into the clinic. More often than not, the history includes hypertension and/or diabetes. The off color of the complexion, blood shot eyes, fatigue, swollen feet and ankles and the clincher, an odor particular to uremia.

But do we really know the look of kidney disease? A recent report estimated Americans have a two-in-three chance of developing kidney disease during their lifetimes. This is not to say we will become a nation of dialysis patients, but kidney disease, and the potential for kidney disease, is all around us, not just in our CKD and nephrology clinics.¹

What follows are a few examples of kidney disease appearing in unexpected places, in people who were not thought of as high risk. For many of the patients, it was a wake-up call. For others, unfortunately, it was the beginning of a downward spiral toward end-stage kidney disease.

Lawrence Herman, PA-C, MPA. The president of the American Association of Physician Assistants recently had an onset of severe abdominal pain. He went to his local emergency department and received a potent nonsteroidal anti-inflammatory drug (NSAID). In retrospect, he realizes he should have followed his instincts and not taken the drug, but pain is pain and he wanted relief. He subsequently developed acute kidney injury and although he recovered, he knows his risk of being a CKD patient again is very real.

A 60-year-old physician assistant. He worked in the operating room and recently had his dose of lisinopril increased by his cardiologist for the protective effect on the rennin-angiotensin-aldosterone (RAAS) system. Add in a slightly enlarged prostate and a relatively insignificant amount of urinary retention and some dehydration after standing long hours in the OR, and our surgical PA felt his heart beating irregularly, became short of breath and started having chest pain. His symptoms could not have happened in a better place or at better time. His colleagues immediately transported him to the emergency room and labs were drawn. The EKG showed characteristic tented T Waves supported by a serum potassium of 6.8. A short stay in the Intensive Care Unit (ICU), a Foley catheter, and modification of his antihypertensive regimen sent our surgical PA back to work.

Patient presents in the ER. This individual complained of a tightening in her abdomen preceded by a coughing spell. She had a history of COPD, hypertension and alcohol abuse. There was no odor of alcohol. Her vital signs showed an elevated temperature (100.4 F) and hypotension (92/54). Labs showed an elevated potassium of 5.6, creatinine of 4.8 and GFR of 10 down from a recent previous result of 59. She was diagnosed with a urinary tract infection (UTI), hospitalized, given IV fluids and antibiotics and her Angiotensin Converting Enzyme inhibitor ( ACEi) was held. Her kidney function soon returned close to normal but she also carries a diagnosis of CKD.

Kidney disease may be more common in older adults but it is no respecter of age. A young man, uninsured and with no medical follow up. A young man, uninsured and with no medical follow-up, had an acute cardiac arrest in the community. After a successful resuscitation he was transported to a local ER and found to have a non-ischemic cardiomyopathy and AKI. Dialysis was initiated in the ICU. Unfortunately, he did not recover function and he dialyzed per permcath until a permanent access could be placed.

A 40-year-old woman. She was noted by her family to have become lethargic with mental status changes. In the ED, she complained of a headache. Her history was significant for being born premature and having frequent UTIs as a child and was on antibiotics from age 2-6. As an adult she frequently used NSAIDS. She did not have regular medical follow-ups. Imagery revealed a large brain mass and while in the neuro ICU, her creatinine steadily climbed from 1.8 to 3.6. Surgery was planned but as an MRI with gadolinium was necessary; she was given supportive care until the creatinine trended down.

Close to home

Surprising cases of kidney disease often occur in our own homes. One nephrology practitioner tells the story of her mother, a 75-year-old with no previous health problems who developed acute pedal/lower leg edema. When the daughter saw her mom’s feet, she knew her mother would need a renal biopsy. Mom’s 24-hour urine showed nephrotic range proteinuria and her biopsy showed minimal change disease (the findings were quite a surprise). About four months later mom developed an axilla lump that the daughter knew had to be malignant. A biopsy showed Hodgkin's Lymphoma and although she received three months of chemotherapy, she became acutely ill and died of sepsis.

Another surprise diagnosis was a 50-year-old male who had always been the picture of health. He consulted his provider because of swelling and dark, foamy urine. His urinalysis showed protein and he was referred to a nephrologist. There was no reason for proteinuria and so he was referred for kidney biopsy. The pathology report diagnosed focal segmental glomerulosclerosis and the pathologist commented the damage was done before age 10.

The pathologist explained biopsies are akin to rings on a tree: he could date when the damage was done. The patient vehemently denied any childhood illnesses. However, he called his mother who told him when he was a toddler, his father, who was with the State Department, was stationed in Africa and the family joined him. While in Africa, the patient became seriously ill with malaria. Thus, the ring on the tree.

One last illustration of the illusiveness of CKD and its tendency to appear in unexpected places. Reamer Bushard, PA-C, swam with a 39-year-old CKD patient in the Bahamas. Turns out Kelly, a dolphin, has CKD Stage 3. The park closely monitors her fluids and diet and she is one of the prime attractions. She has had three healthy pregnancies and has no history of NSAID use. -by Jane Davis, DNP, CRNP; Kim Zuber, PA-C

References

1 Grams ME, Chow EKH, Segev DL, Coresh J. Lifetime incidence of CKD Stages 3-5 in the United States. Am J Kidney Dis. 2013; 62: 245-252.

Acknowledgements

Thank you to all the contributors to this column. We appreciate our fellow practitioners sharing both their personal and professional experiences.