a case of acute kidney injury (arf)
Post on 12-May-2015
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PHYSICIANS’ MEET
An interesting case ofAcute Kidney Injury
Prof. MAHESH KUMAR’s unit,Dr.R. Israel, PG
35 yr old male, auto driver by occupationAdmitted with c/o decreased urine output for 3 daysc/o fever &c/o abdominal pain for 10 days
HOPI
• Pt was apparently normal till 10 days back• c/o fever- 10 days; low grade; intermittent;
not associated with chills & rigor, sweating• c/o abdominal pain- 10 days; lower abdominal
pain; pricking; aggravated on passing urine; associated with vomiting later; not associated with constipation
• c/o decreased urine output- 3 days; 300ml/day;
• h/o b/l leg swelling +• h/o facial puffiness +• h/o breathlessness +• h/o generalized body ache• no h/o hematuria• No h/o arthralgia• No h/o skin rash• No h/o chest pain• No h/o headache• No h/o burning micturition• No h/o urgency/hesitancy• No h/o loose stools
• Not a k/c of HTN/DM/BA/IHD/CVA/PT• No h/o blood transfusion
Examination
• Conscious, oriented, cooperative• Afebrile, pallor, BPPE, • No icterus/lympadenopathy• Vitals: BP-120/80; PR-80/min; Temp- 36.2
Examination of other system
• CVS- S1, S2 +, no murmur• RS- NVBS +, no added sounds• CNS- NFND• Abdomen- soft; mild hepatomegaly; bowel
sounds +, no FF, external genetalia normal
Provisional diagnosis
Acute Kidney Injury/? Cause/
? Leptospirosis
Initial treatment • DIL• SRD• Nasal O2 & back rest• I/O chart• Fluid restriction• Inj. CP 20 lac U QID• Inj. Artesunate 120 mg iv stat & 60 mg iv od• Tab. Pmol 500 tid• Fluid challenging with lasix
HD started in nephrology department
Investigations CBC
Hb 9.7 gm%
TC 14,800
DC P89% L6% E5%
RBC 3.56 million
MCV 85.4 fl
MCH 27.2 pg
MCHC 31.98
Platelet 2,28,000
RFT
Urea 170 mg%Creatinine 8 mg%
Na 137 Meq/LK 4.3 Meq/L
Blood sugar 109 mg%
Urine routinePus cells – 8-12/hpf
RBC nilAlbumin +
Sugar +
24 hour urine protein – 360 mg
• Periph smear for MP neg• Mf neg• Widal neg• MSAT neg• Dengue for IgM neg• CXR –NAD• ECG- WNL• Viral markers neg• Urine C/S – 75,000 CFU/ml; gram neg straight bacilli
sensitive to imipenam, amikacin, netilmycin, nitrofurantoin
USG abdomen
• Rt kidney 13 cm ×6.4 cm• Lt kidney 13cm ×7 cm• Increased cortical echotexture• CMD normal• Otherwise normal
investigations
4/3/10
5/3/10 6/3/10 8/3/10 12/3/10 15/3/10 17/3/10
Na 138 138 137 138 136 137 138
K 4.0 4.7 3.9 4.4 3.2 4.8 4.4
Glucose 109 78 80 131 100 120 92
Urea 148 166 156 158 142 152 130
Creatinine 8.2 6.9 9.9 10.2 7.7 7.8 5.2
Etiology
• Inflammation of the structures of the kidney:– the renal pelvis– renal tubules– interstitial tissue
• Almost always caused by E.coli Presented By: Jillymae
Etiology
• Usually seen in association with:– Pregnancy– diabetes mellitus– Polycystic– hypertensive kidney disease– insult to the urinary tract from catheterization,
infection, obstruction or trauma
What happens to the kidney?
• The kidney becomes edematous and inflamed and the blood vessel are congested
• The urine may be cloudy and contain pus, mucus and blood
• Small abscesses may form in the kidney
Clinical Manifestations
• Acute pyelonephritis may be unilater or bilateral, causing chills, fever, prostration and flank pain.
• Studies has shown that chronic pyelonephritis may develop in association with other renal disease unrelated to infection processes
• Azotemia (the retention in the blood of excessive amounts of nitrogenous compounds) develops if enough nephrons are nonfunctional
Signs and Symptoms
• Subjective Data in acute pyelonephritis:– pt will become acutely ill, w/ malaise and pain
in the costovertebral angle (CVA)– CVA tenderness to percussion is a common
finding• In the chronic phase the pt may show
unremarkable symptoms such as nausea and general malaise
Costovertebral Angle (CVA)
Chronic Pyelonephritis
The autopsy specimenconsists of a bisectedkidney which ismarkedly shrunkenbecause of chronicinflammation andScarring.(B) multiple calculi inthe proximal ureter(A) Calyceal system
Signs and Symptoms
• Objective data includes assessing the pt for:– Elevated Temperature– Chills– Pus in the urine
• Systemic signs occur as a result of the chronic disease:– elevated BP– Vomiting– Diarrhea
Diagnostic Tests
• Diagnosis is confirmed by bacteria and pus in the urine and leukocytosis
• A clean-catch or catheterized urinalysis with culture and sensitivity identifies the pathogen and determines appropriate antimicrobial therapy
Medical Management
• Pt w/ mild signs and symptoms may be treated on an outpatient basis with antibiotics for 14 to 21 days
• Antibiotics are selected according to results of urinalysis culture and sensitivity and may include broad-spectrum medications
Medicines
• Ampicillin or vancomycin combined with an aminoglycoside (Nebcin, Garamycin)
• Cipro
• Septra
• Bactrim
• Floxin
Medical Management
• Adequate fluids at least eight 8-oz. glasses per day
• Urinary analgesics such as Phenazopyridine (Pyridium)
is helpful• Follow up urine culture is indicated
Nursing Intervetion & Patient Teaching
• Pt is taught to identify the S&S of infection:
• Elevated temp.• Flank pain• Chills• Fever• Nausea• Vomiting• Urgency
• Fatigue• General malaise• Pt should also be taught:• Indications• Dose• Length of course• Side effects• Importance of follow up care
with the physician on a routine basis
Prognosis
• Prognosis is dependent upon early detection and successful treatment
• Baseline assessment for every pt must include urinary assessment because pyelonephritis may occur as a primary or secondary disoder
Acute Renal Failure
• 1. Prerenal Azotemia – Decreased RBF → ↓ GFR. Kidney retains sodium and water.
2. Intrinsic Renal – Usually due to acute tubular necrosis or ischemia.
3. Postrenal – Outflow obstruction (stones, BPH, etc.) Only seen if obstruction is bilateral.
Acute Renal Failure
Variable Prerenal Renal Postrenal
Urine Osmolality > 500 < 350 < 350
Urine Na < 10 > 20 > 40
Fe Na < 1% > 2% > 4%
BUN/ Cr ratio > 20 < 15 > 15
Uremia – Syndrome marked by ↑ BUN and ↑ Creatinine.
Consequences1. Anemia (failed erythropoietin production)2. Renal osteodystrophy (Vit. D not activated in
kidneys)3. Hyperkalemia (possible arrhythmias)4. Metabolic acidosis (↓ acid secretion and ↓
generation of HCO3-.
Uremia – Syndrome marked by ↑ BUN and ↑ Creatinine.
• 5. Uremic encephalopathy
• 6. Sodium and H2O excess → CHF and
pulmonary edema
• 7. Chronic Pyelonephritis
• 8. Hypertension
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