Renal failure with skeletal abnormalities.

Accepted 15 September 1995 A 40-year-old man presented with complaints of persistent vomiting for six months, periorbital puffiness for four months, ankle swelling for one month and chest pain for three days. He was apparently asymptomatic prior to the onset of these symptoms. He had experienced persistent vomiting two to three times a day, which was non-projectile and non-bilious with no constant relation to meals. He had noticed increasing puffiness of face, maximally in the morning for the past four months. One month prior to admission he had noticed swelling around his ankles. Along with these complaints he also noticed a decrease in his urine output. The patient had been diagnosed as suffering from chronic renal failure due to chronic glomerulonephritis at another hospital and had received peritoneal dialysis. He had then been referred to this hospital for further management. Examination revealed a pale man of average build with anasarca. He had a pulse rate of 112 beats/min, blood pressure of 180/115 mmHg, respiratory rate of 20 breaths/min and a temperature of 99'F. His jugular venous pressure was 11 cm above the sternal angle with normal wave patterns. The thumb and index nails were hypoplastic as were all the toe nails. Other findings included fixed flexion deformity of bilateral elbows, excessive lumbar lardosis with high iliac crests, genu varum and bilateral absent patellae. Abdominal examination revealed a firm non-tender spleen 6 cm in size. The rest of the systemic examination was unremarkable. Investigations showed him to be in renal failure. The patient was subjected to peritoneal dialysis following which there was improvement in biochemical parameters. X-rays of the left knee, right knee and pelvis are shown in figures 1, 2 and 3, respectively. Ultrasound examination of the abdomen revealed bilateral contracted kidneys with loss of corticomedullary differentiation and small cortical cysts in both kidneys.