NR 283 Week 3 Chronic Kidney Disease Case Study Example

System Case Study: Kidneys Failing Slowly in a 66-Year-Old Man With Diabetes, Traced Outward Organ by Organ to What a Nurse Records

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College of Nursing, Chamberlain University

NR 283: Pathophysiology

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Month Day, Year

System Case Study: Kidneys Failing Slowly in a 66-Year-Old Man With Diabetes, Traced Outward Organ by Organ to What a Nurse Records

One System, One Patient

Mr. R. is 66, a retired bus mechanic with type 2 diabetes for 20 years and high blood pressure for 15. At a nephrology clinic visit today, his estimated glomerular filtration rate (eGFR) is 22 mL/min/1.73 m², down from 31 a year ago, and his urine albumin-to-creatinine ratio is 480 mg/g. Under the KDIGO classification, which grades chronic kidney disease by filtration rate and by albuminuria, that places him in category G4, a severe decrease in filtration, with severely increased albuminuria, category A3 (Stevens et al., 2024). Details are composite.

The background that matters is short. Years of high glucose and high blood pressure damaged the small vessels of his glomeruli, first letting albumin leak into the urine and then reducing the number of working nephrons. Each surviving nephron works harder, which keeps the numbers acceptable for a time and then speeds its own decline. The case below is about the consequences of that failure, which is where a nurse meets it.

Outward, Organ by Organ

Water and salt. Kidneys that filter less excrete less sodium and water, so the body holds them. Mr. R. has pitting edema to mid-shin on both legs, his weight is 3 kilograms above his dry weight from three months ago, and his blood pressure today is 162/92 despite three medicines. Held fluid raises blood pressure, and high blood pressure damages the remaining nephrons further.

Potassium. Almost all potassium leaves the body through the urine. His potassium is 5.6 mmol/L, above the normal range. His lisinopril, which protects his kidneys, also raises potassium, which is one reason his medicines are reviewed at every visit.

Acid. Failing kidneys excrete less acid and regenerate less bicarbonate. His bicarbonate is 18 mmol/L, a mild metabolic acidosis, and his breathing is slightly faster at rest, 20 a minute, as his lungs blow off carbon dioxide to compensate.

Blood. The kidneys make erythropoietin, the hormone that drives red cell production. A year ago his hemoglobin was 11.2 g/dL; today it reads 9.8, and he says he is "tired all the time" and short of breath climbing the stairs to his bedroom.

Bone and minerals. Less phosphate is excreted and less vitamin D is activated. His phosphate is 5.4 mg/dL, his calcium 8.6 mg/dL, and his parathyroid hormone is raised. He reports itching, worse at night, which is common with high phosphate and waste products in the blood.

Gut and brain. Waste products that the kidneys would normally clear build up. He describes a metallic taste, a poor appetite and mild nausea in the mornings. His thinking is clear.

How the Organs Push on Each Other

The consequences above are listed one organ at a time, but they do not act one at a time. The anemia makes his heart work harder, and the extra fluid makes it work harder still; together they explain his breathlessness on the stairs better than either does alone. The acidosis pushes potassium out of cells into the blood, so part of his high potassium is a result of the acid, not only of reduced excretion. The nausea and metallic taste reduce what he eats, which lowers his protein and energy intake, which worsens his tiredness and weakens his muscles. And the high blood pressure, driven by held fluid, damages the remaining nephrons, which is why his eGFR fell by nine points in a year.

This is why the nurse's findings are read together. A rise in his weight is not only a fluid finding; it predicts higher blood pressure and more breathlessness. A fall in his appetite is not only a gut finding; it predicts weight loss that could hide fluid gain on the scale, and it helps explain the low blood sugars described below.

Findings a Nurse Records

Every consequence above appears in something a nurse measures or asks about: daily weight and edema grade for fluid; blood pressure at each visit, taken properly; potassium on the laboratory sheet and any palpitations or weakness; breathing rate at rest; hemoglobin and fatigue with stairs; itching, appetite, taste and nausea asked about directly, because patients rarely volunteer them; and the timing and volume of urine. Mr. R. reports passing urine normally, about the same amount as always, which is important because it means his kidneys are still excreting water, just not enough of everything else.

What Is Still Holding

Several things are still holding, and they matter as much as the failures. He is still making urine. His thinking is clear, with no confusion or drowsiness from waste buildup. He has no chest pain or rub that would suggest inflammation around the heart from high urea. His potassium is high but not at a level causing heart rhythm changes. These are the findings that, if they changed, would move him from careful monitoring toward urgent treatment or planning for dialysis, and they are the ones the clinic nurse checks first at each visit.

The Finding That Does Not Fit

One finding does not fit the picture at first glance. Mr. R. reports three episodes of low blood sugar in the past month, readings of 58 to 64 mg/dL in the late morning, although his diet and his insulin dose have not changed. Kidney failure is usually thought of as something that makes things build up, not fall.

The explanation is that the kidneys also clear insulin from the blood. As filtration falls, injected insulin stays active longer, so the same dose has a stronger and longer effect. His appetite has also fallen, so he is eating less. The two together explain low sugars on an unchanged dose. The finding is not a side issue: low blood sugar in an older man who lives with his wife and drives is dangerous, and it is the one consequence on the list that calls for a medicine change this week rather than monitoring. It was reported to the nephrologist during the visit, and his insulin dose was reduced.

What the Next Visit Will Watch

The plan agreed at the visit leaves most of his treatment with the nephrologist, but it gives the nurse four things to follow before the next appointment in six weeks. His weight each morning at home, with a call if it rises by 2 kilograms in a week. His blood sugar before breakfast and before lunch, with the new insulin dose, and any reading below 70. His potassium, rechecked in one week because of both the kidney failure and his lisinopril. And his readiness to talk about the next stage: at an eGFR of 22 and falling, the team has begun discussing options for kidney replacement, and he and his wife have been given written information to read before the next visit. The nurse's role there is to find out what they understood and what frightens them, which the numbers cannot show.

References

Stevens, P. E., Ahmed, S. B., Carrero, J. J., Foster, B., Francis, A., Hall, R. K., Herrington, W. G., Hill, G., Inker, L. A., Kazancıoğlu, R., Lamb, E., Lin, P., Madero, M., McIntyre, N., Morrow, K., Roberts, G., Sabanayagam, D., Schaeffner, E., Shlipak, M., . . . Levin, A. (2024). KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International, 105(4, Suppl.), S117-S314. https://doi.org/10.1016/j.kint.2023.10.018