A = AR = REAL

F = FIX

Dr.S. KRISHNAN / DR.RAVI ANDREWS

APOLLO HOSPITALS

SUNDAY,17TH DEC. 2006(Day 1)

16/F Anuric ARF preceded by

hematuria for a day (Ser. Cr. – 10.8 mg/dl)

Anemia (Hb – 3.0 gm/dl) [ 4 units of blood 2 weeks ago]

Unexplained fever since 2 monthsBackache Headache,Irritability – Off/OnSkin Rash / Alopecia – 1½ years

ago (Homeopathy)

O/E:-

Obtunded, Febrile, Pale Pedal edema(+),JVP - Elevated

Bilateral cracklesTender HepatomegalyNo icterus / Lymphadenopathy

No focal neuro. signs

Clinical possibilities:-

SEPSISMALARIATMA (HUS)RPGNHematologic MalignancyDrugs

FEVER + ANEMIA + CHF + ARF

Primary Action:- ICU JUGULAR HD + Blood + ANTIBIOTICS

PRELIM. LABS……… Hb – 2.8 gm/dlRBC Count < 1 million/mm3

PBS –Macrocytic Hypochromia &Spherocytes

LDH – 3012, Bilirubin – 3.0 (Indirect–2.1)

Plasma Supernatent – Pink

Hemolytic Anemia

Retic count – 3% TLC – 7400, Platelets – 1.6 lakh ESR – 150 MP X 3 - Negative

LABS………

Amylase 2387, Lipase 97 (N<60)LFT - WNLHIV,HCV,HBsAg – NegativeUSG – Normal Kidneys,

HepatosplenomegalyDCT – Positive, ICT – NegativeCollagen Profile, ANCA - Awaited

CLINICAL SITUATION

Auto – immune Hemolytic

Anemia

Pancreatitis

ARF

Hepato- splenomegaly

MONDAY,18TH DEC. 2006(Day 2)

Some possibilities ruled out………Malaria - Neg X 3HUS – Normal platelets,no schistocytesDrugs – No rashes, patient too sickSepsis – CRP – 16

Lactate - WNL Procalcitonin – WNL

Prelim. Cultures – SterileRPGN – POSSIBLEHemat. Malignancy - POSSIBLE

MONDAY,18TH DEC. 2006(Day 2)

Morning- Dialysis, BloodEvening –

Refractory Pulmonary Edema Ventilation

Hypotension Volume, Inotropes, CRRT

2D Echo-WNL

Empiric I.V Methylprednisolone pulses started

TUESDAY,19TH DEC. 2006(Day 3)

Patient betterLess inotrope requirementLess FiO2 requirementHowever still anuric, CRRT – dependentLabs…ANA (1:100) +++, Granular (1F)

Anti – ds DNA – Neg, C3, C4 – WNL CRP – 16 mg/L, cANCA, pANCA – Neg. Bone Marrow Aspiration – WNL Cultures -Sterile,G6PD,B12,Folate-WNLI.V METHYLPREDNISOLONE CONTINUED

TUESDAY,19TH DEC. 2006(Day 3)

DIAGNOSIS……….SLE + Autoimmune Hemolytic Anemia? Lupus Nephritis (Presenting as ARF)But… No e/o Renal Lupus Activity Presence of Renoprotective Auto–antibodies No HTN

? ARF sec. To Hemolysis Pigment Nephropathy

KIDNEY BIOPSY NEEDED !!

WEDNESDAY,20TH DEC. 2006(Day 4)

Better – CRRT stopped

Off VentilatorOff InotropesConscious, Tolerating oral feedsBut ANURIC ( Ser.Cr > 5mg/dl)

THURSDAY,21st DEC. 2006(Day 5)

FRIDAY,22ND DEC. 2006 -WEDNESDAY,3RD JAN. 2007

(Day 6- DAY 18)Shifted to wards, oral steroidsHypercatabolic, Anuric, Daily Dialysis

DependentTransfusion dependent – 10 unitsPerpetual postponement of Renal

Biopsy(Too sick Generalised Rash Line

Sepsis Prolonged PTT)

THURSDAY,4TH JAN. 2007(DAY 19)

RENAL BIOPSYDONE

(FINALLY) ! !

FRIDAY,5TH JAN. 2007 - TUESDAY,9TH JAN. 2007

(DAY 20- DAY 24)

Small amount of chocolate urine Clear urine

Daily dialysisBlood – 2 unitsSteroids reduced to 40

mg/day

DISCHARGED ! !

WEDNESDAY,10TH JAN. 2007 - THURSDAY,25TH JAN. 2007

(DAY 25- DAY 40)

Alternate Day Dialysis Urine output 500ml /

day Oral Antibiotics Blood – 2 Units

0

5 0 0

1 0 0 0

1 5 0 0

2 0 0 0

2 5 0 0

3 0 0 0

3 5 0 0

1 4 6 8 16 19 41

S e r . L D H( m g / d l )

FRIDAY,26TH JAN. 2007 (DAY 41 - YESTERDAY)

Urine output - 700mlHb - 7.6 gm/dl, TLC – 8900Platelets – 2.6 lakhs mm3

Urea - 77, Creat. – 6.0 mg/dlElectrolytes – WNLLDH – 355, Bilirubin – 0.4 mg/dlUSG–Normal Kidneys,CRP–65 mg/L