76-year-old female nursing home rehab patient was sent to the emergency department with complaints of nausea, abdominal pain and diarrhea for 2 days. She normally lives at home with ADL assistance and uses a walker. She is a non-smoker, uses no alcohol, and denies remarkable family history.

Past medical history is kidney failure, hypertension, fall with humeral fracture 4 weeks ago, acute respiratory failure, heart failure with reduced ejection fraction 3 months ago, obstructive sleep apnea, pneumonia 3 months ago, AFib, DMT2, and CPAP use nightly.

Medication:
allopurinol, amiodarone, aspirin, atorvastatin, cyclobenzaprine, enoxaparin, fluticasone, glipizide, loratadine, lorazepam, metformin, metolazone, metoprolol, sertraline, spironolactone, torsemide, warfarin, and zolpidem.

Vitals:
Temperature 36.7°C
BP 137/63 mm Hg
HR 83 bpm
Resp rate 18 bpm
O2 saturation 99% RA
Wt. 123 kg. Now; 127 kg. Dry Wt.

Abnormal Labs:
The blood level of creatinine was 7.66 mg per deciliter (677 μmol per liter; reference range, 0.60 to 1.50 mg per deciliter [53 to 133 μmol per liter]), and the level of lactic acid was 7.4 mmol per liter (67 mg per deciliter; reference range, 0.5 to 2.0 mmol per liter [4.5 to 18 mg per deciliter]). Urinalysis by dipstick showed a pH of 5.0 (reference range, 5.0 to 9.0) and a specific gravity of 1.012 (reference range, 1.001 to 1.035), and no protein, blood, nitrites, leukocyte esterase, glucose, or ketones were present.

Diagnostics Studies:

  • Chest radiography:  Mild pulmonary interstitial edema
  • Ultrasonography of the kidneys and urinary tract:  Simple cysts in the left kidney, with no evidence of hydronephrosis or nephrolithiasis.

Appendix A.

Acute kidney injury (AKI)

  • Serum creatinine => 0.3 mg/dL over 48 hrs
  • Serum creatinine increase =/> 1.5 from baseline with in the past 7 days
  • Urine volume  < 0.5 mL/kilograms/h for 6 hrs

Prerenal causes

  • Hypovolemia
  • Congestive heart failure or venous congestion
  • Sepsis
  • Use of certain medications (NSAIDs, angiotensin-converting–enzyme inhibitors, or angiotensin-receptor blockers)
  • Renal artery stenosis
  • Vascular conditions (vasculitis or dissection)

Intrinsic renal disease

  • Acute tubular necrosis (caused by ischemia, cisplatin use, amphotericin use, myoglobinuria, immunoglobulin light chains, or precipitation of crystals in the kidneys)
  • Acute interstitial nephritis (caused by antibiotic use, NSAID use, proton-pump inhibitor use, pyelonephritis, tuberculosis, sarcoid, lymphoma, or leukemia)
  • Glomerulonephritis
  • Cholesterol emboli
  • Scleroderma
  • Vascular conditions (thrombotic thrombocytopenic purpura, hemolytic–uremic syndrome, or disseminated intravascular coagulation)

Postrenal causes

  • Neurogenic bladder
  • Use of anticholinergic medications
  • Cancer
  • Bilateral nephrolithiasis

1. What is your differential diagnosis up to three?

2. What can cause acute renal failure?

3. What is the possible cause of this patient’s renal failure? (See Appendix A)

 
 
 

4. What lab should be wrong to diagnose a few renal failure?

 
 
 
 

5. Based on the labs in the case study, is this person in kidney failure?

 
 

6. Low-dose dopamine is a treatment option for AKI

 
 

7. Should patients with low kidney function, congestive heart failure, renal transplant, and greater than 75 years old receive volume expansion after iodine contrast?

 
 

8. Which medication can cause acute kidney injury?

 
 
 

9. It is important when evaluating a patient’s condition that past medical history including recent be closely considered. Which symptoms may have contributed to her current condition?

 
 
 
 

Question 1 of 9