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