AN INTERESTING CASE
OF ACUTE KIDNEY
INJURY
Presented by-
Dr. Moni Sankar Bhattacharjee
Postgraduate trainee
[Link] Medical College and Hospital
PART-1
CASE SCENEARIO
PRESENTATION AT EMERGENCY…
A 58-year old female presented with altered sensorium and
breathlessness at emergency
- for last 18-24 hour
- without any history of Trauma
- without any history of vomiting or diarrhea
she had history of fever for last 5 days along with
decreased urine output for last 2 days as per her family
members.
CHECKING VITALS…
On rapid assessment patient had-
Altered sensorium
Glasgow coma scale score – E2 V3
M4(9/15)
Pulse- 96/min, low-volume
BP- 90/64 mm Hg
Capillary blood Glucose- 226 mg/dl
Temperature- 100.5oF
Respiratory Rate- 22/min
Saturation- 98% with nasal prongs
EMERGENCY INVESTIGATIONS…
ECG- No significant changes noted.
NCCT Brain- No significant changes noted.
Arterial Blood Gas Analysis-
pH- 7.00 (7.35-7.45)
pO2- 92 mmHg (75-100 mmHg)
pCO2- 29 mmHg ( 35-45 mmHg)
Bicarbonate- 7 mmol/L (22-26 mmol/L)
Lactate- 12 mmol/L (0.5-2.5 mmol/L)
Sodium- 132 mmol/L (135-145 mmol/L)
Potassium- 5.4 mmol/L (3.5-5 mmol/L)
CONTD.
Foleys catherization done at emergency and around 30 ml
urine collected in bag.
There is absence of ketone bodies in urinary dipstick
She had cold, clammy extremities with signs of poor
hydration without any features of volume overload.
CONTD.
EMERGENCY LABORATORY EVALUTION-
Hemoglobin- 10.7 gm%
Total leucocyte count- 18,200 cells/microliter
Differential count- N88% L07% E3%
Platelet- 175,000/microliter
Urea- 230 mg/dl
Creatinine- 6.2 mg/dl
IMPRESSION
SEPTIC SHOCK WITH ACUTE KIDNEY
INJURY(AKI)
What is the Definition of AKI (Manisankar) and What are the Stages of AKI -Manishankar
how does AKI differ from AKD or acute on CKD (sakuja)
What the risk factors of AkI or what are the causes of AKI (Purbasha with One Slide )
How kidney Maintains homeostasis ( Himadri with one Slide)
How AKI affects Homeostasis ( Manali)
PART-2
DETAILED HISTORY AND
EXAMINATIONS
SALIENT POINTS FROM HISTORY-
COMPLAINTS:(Before Admission in Hospital)
Fever for last 5 days
Lower abdominal pain for last 3 days
Decreased urine output for last 2 days
CONTD.
HISTORY OF PRESENT ILLNESS:
Patient complained of fever for last 5 days before
admission
High-grade, intermittent fever
Associated with chills, anorexia and generalized malaise
Temperature subsided with sweating
Not associated with vomiting or diarrhoea
Not associated with headache, chest pain, arthralgia or
skin rash
CONTD.
HISTORY OF PRESENT ILLNESS:
Also complained with lower abdominal pain aggravated on
passing urine
Pricking in nature, also radiating to flank
Associated with urgency and dysuria
But not associated with haematuria
And for last 2 days patient also noticed decreased urine
output but not associated with facial puffiness or pedal
oedema.
CONTD.
PAST HISTORY:
Patient is known Diabetic , non-hypertensive
On regular oral hypoglycemic medications
No other co-morbidities
Had no history of underlying kidney disease.
DETAILED EXAMINATION:
GENERAL EXAMINATION:
Higher function status- Altered level of
consciousness( Glasgow coma scale-E2V3M4)
Built- Average
Nutrition- Not adequate
Weight- 62kgs
Clinically no pallor or cyanosis or icterus
Clinically no Pedal edema or facial puffiness
Costovertebral tenderness present
No Lymphadenopathy
CONTD.
SYSTEMIC EXAMINATION:
Respiratory System- Bi-lateral vesicular breath sound
present
Cardio-Vascular System- Both S1 and S2 present.
Gastro-intestinal System- No organomegaly found
Neurological System- normal
PART-3
INVESTIGATIONS AND
MANAGEMENT
INITIAL MANAGEMENT
Patient was shifted to medicine ward and fluid challenge with
crystalloid solutions( 0.9% Normal saline) done over 1 hour.
Simultaneously-
Oxygen support was given
Initial empirical Anti-biotics support was given
Correction of electrolytes.
Urine output was monitored
Marinating intake-output chart
Monitoring vitals
Monitoring volume status
Particularly look for any features of volume overload
RENAL FUNCTION TESTS REPEATED…
AFTER 12 HOUR AFTER 24 HOUR
UREA (mg/dl) 236 270
CREATININE (mg/dl) 6.4 6.8
SODIUM (mmol/l) 130 128
POTASSIUM (mmol/l) 5.8 6.2
Serum creatinine and GFR are related?(Mahesh)
How you will differentiate between functional impairment vs Structural injury.
(sakuja)
How to differentiate between Prerenal azotemia vs Intrinsic AKI .(Mahesh)
What are the fallacies of Functional Biomarkers and What are the implications
of structural Biomarkers (Sakuja)
Among the novel biomarkers, which signifies progression of AKI to CKD (Sakuja)
Role of biopsy in AKI (Mahesh)
OTHER INVESTIGATIONS…
URINE ANALYSIS:
Routine microscopical examination:
o Protein- 2(+)
o RBCs- 1-2/HPF
o Pus cells- 10-12/HPF
o Granular casts were found
Urine ACR: 250 mg/g
Urine Culture and sensitivity:
o Culture shows colony count 75,000 CFU/ml of urine sample
o Shows growth of gram negative rods
o Sensitive to meropenem, imipenem, amikacin
OTHER INVESTIGATIONS…
RADIOLOGICAL INVESTIGATIONS:
ULTRASOUND-
o Right Kidney- 10 cm
o Left Kidney- 9.7 cm
o Cortical echogenicity increased
o Though corticomedullary differentiation maintained
o Swollen kidney (left>right) with focal change in echotexture
Plain CT-Scan-
o Shows diffusely swollen kidney ( left>right)
OTHER INVESTIGATIONS…
BLOOD CULTURE:
Did not reveal any growth
Fever Profile:
MPDA- Negative
Peripheral smear for MP- Not found
Dengue IgM- Negative
Leptospira IgM- Negative
Scrub Typhus IgM- Negative
CRP- 6.4 mg/dl (Normal range:0.8-1.0 mg/dl)
DCXR- does not reveal any abnormality.
AFTER INITIAL MANAGEMENT…
Even After adequate fluid resuscitation-
Patient had still poor vitals ( SBP NOT IMPROVING)
Considered for vasopressor support
And monitoring vitals parameter closely
Meropenem with dose modification was started
On close Monitoring-
No improvement in her sensorium
Increasing trend of serum creatinine along with serum potassium
Urine output is only 350 ml over 24 hours
And patient showed features of volume overload
CONSIDERATION OF DIALYSIS…
Due to development of metabolic and uremic complication-
Patient was planned for intermittent haemodialysis
Though it can not started initially due to poor vitals
After correction of haemodynamic status, haemodialysis
started and given slowly over prolonged period of time with
close monitoring of blood pressure.
.What is the principle of Stage based Management in AKI ? Sakuja
What is the problem of overzealous fluid resuscitation? Rafikul
.What vasopressor is to be used and why in vasodilatory shock? Sakuja
How to prevent contrast induced nephropathy in AKI? Sakuja
.What are the common nephrotoxic drugs ? Manishankar
what is the principle of dose modification? Mahesh
Indications of RRT in AKI. manishankar
What are the RRT Modalities preferred in AKI? Sakuja
how to maintain nutrition in AKI ? Rafikul
LABORATORY PARAMETERS…
AFTER 48 AFTER 72 AFTER 5 AFTER 7 AFTER 10
HOURS HOURS DAYS DAYS DAYS
TOTAL 18000 16000 12500 11500 8500
LEUKOCYTE
COUNT(cell
s/mcl)
SERUM 332 300 220 176 112
UREA(mg/dl
SERUM 7.5 7.0 6.5 5.4 5.0
CREATININE
(mg/dl)
SERUM 128 130 132 134 140
SODIUM(m
mol/l)
SERUM 6.0 5.8 5.0 4.5 4.6
POTASSIUM
(mmol/l)
FINAL IMPRESSION
SEPTIC ACUTE TUBULAR
NECROSIS(ATN) DUE TO UROSEPSIS
PART-4
FOLLOW-UP
(Patient on Dialysis Support)
CLINICAL FOLLOW-UP…
Along with improvement of laboratory parameters
Patient also regained her consciousness gradually after 5 days
Urine output also increased gradually
Intermittent Haemodialysis is continued along with monitoring of all
laboratory parameters
Along with monitor urine output, maintain intake/output chart and
maintain glycaemic control.
3 weeks after intermittent Haemodialysis patient became clinically
stable and advised to attend Nephrology Department
Thank you
What are the complications of AKI (Sakuja)
. In which phase of AKI, arrthymia and uremic complications can arise?
(Sakuja)
What is the prognosis of AKI ? Rafikul
newer advances Regarding AKI.
