Case Presentation

Case2:  date 11-2-2012

65 year male admitted in nephrology ward through the OpD for the complaint of low grade fever for last 2 month, anorexia and weitht loss for same duration and leg edema for 6 weeks.

On investestigation : he had unilateral pleural effusion on xray. Urine d/r had 3+ protein with RBCs, low hemoglobin and renal failure requiring dialysis.U/S showd both kidnys between 9 to 10 cm.

Renal biopsy performed which was uneventful: showed Amyloidosis.

Labs at first: Urea  300, Creatinine 14.4, Na 134, K 6.3, Cl 102, Hco3 09.   Ca 8.1mg/dl:  PO4 10.6: Alb 1.5:

T. Prot 5.9:   Alp  111.  Serum LDH 223.

Hb 10.5: TLC 15000: Plat 655ooo.

Pleural Fluid analysis: Pro 3.4;  LDH 321;  Alb 1.1; Tlc 500( 90% Lymphocytes.)

Case disscussion

30 year Female admitted through emergency with history of septic abortion managed in some private hospital and reffered here for the oligouric renal failure.

According to the attendant, patients was alright till 5^th month pregnancy, then experience fever, high grade in nature. For which she consulted local doctor who prescribed some medication following which she had bledding per vagina. She went to hospital which septic abortion was diagnosed and subsequently evacuated. Following which she went into loigouria/anuria. Renal function got deteriorated and she started becoming restlessness and short of breath and finally she was reffered here.

Regarding her past history, she has 5 other children who all were born in home except last one who required C/section as the case was not handled by Dai ( Health care provider). In all those deliveries ware uneventful so as tenure of pregnancy.

There is no significant past history of note either medical or surgical.

There is no drug history.

Personally no addiction mentioned.

On examination: She was conscious but restless.

She had regular pulse 108 bpm

Apyrexial

BP was 79/42 mmhg

Respiratory rate 32 breath per minute.

She was pale but not icteric, not cyanosed. There was no clubbing and no koilynyckia. Peripheries were dry and JVP was positive.

Abdominal examination show distended symmetrical abdomen, soft with diffused mild tenderness. No viscera were palpable.

Chest was clear.

CVS: both S1 and S2 were audible in all four  areas with no significant difference of intensity. No murmur or rub notice.

CNS was grossly normal.

My conclusion was Acute renal failure following Obsteterical Problem( Septic Abortion). She can have ATN/CAN secondary of sepsis or some hemodynamic instability during the procedure of evacuation.

Management:

She was admitted in High dependency care.

Iv line maintained.

Follys catherized.

CP, MP , UCE, Blood culture, urine Dr and C/s If urine comes.

Chest xray and Arterial blood gases were ordered. LDH and Lft were also requested.

On basis of above DL cather was passed and she was dialysed.

Still admitted.

Labs: HB 9 mg/dl

Tlc 1100

platelets 32000

S.Creatinine 3.7

severe metabolic acidosis in ABGs.

Water deficit

A bedbound 70 kg 40 year old male had no access to water for many days. He is found by a neighbour and brought to the ER. His serum Na is 170 mmol/L.
A. What is the total water deficit?
B. How would you correct it? For fluid orders, specify the fluid type and rate of administration.
Answer

A. Water deficit is calculated by the formula:

                                                             plasma [Na+]
Water deficit = Current body water x (——————— - 1)
                                                                   140

Where current body water is about 60% and 50% of lean body weight in younger men and women, respectively, and is 50% and 45% in elderly men and women, respectively.

The water deficit in this case would be 0.6 X 70 X (170÷140 -1), or 9 L.
B. Water should ideally be replaced orally but often this is difficult due to altered sensorium. It is reasonable to provide water intravenously.
One should not allow serum Na to fall by more than 12 meq/L/day.
Since the Na is elevated by 30 mmol/L and that it should not be correct more than 12 meq/L/day, it should be correct over 30 meq ÷ 12 meq/L/day = 2.5 days or 60 hours.
Therefore, D5W could be administered at 9000 cc ÷ 60 hours = 150 cc/hour. Recall, this does not take into account ongoing losses.

Safe anti hypertensive in pregnancy

It is safe to use the following drugs to treat hypertension in pregnancy: 

PO:  methyldopa,hydralazine, labetalol, nefidipine

IV:  hydralazine, labetalol, diazoxide 

ACE inhibitors are contraindicated in all trimesters of pregnancy.  If used, fetal anomalies include oligohydramnios, lung hypoplasia, craniofacial deformity and renal failure. 

ACUTE INTERSTITIAL NEPHRITIS

Acute interstitial nephritis classically presents with fever, maculopapular rash, eosinophilia, eosinophiluria, and urinary WBC casts.  Eosinophiluria is neither sensitive (sensitivity 40%) nor entirely specific (specificity 72%, positive predictive value 38%).  The classic triad of rash, fever and eosinophilia is actually uncommon and only seen approximately 10% of the time.  One can also see mild proteinuria (usually < 1g/d) and other signs of tubular damage, such as renal tubular acidosis and Fanconi’s syndrome. Renal ultrasound generally reveals kidneys of normal to large size. Gallium scanning has been suggested as an aid to distinguishing this condition from acute tubular necrosis (ATN).  It is negative in ATN but generally positive in interstitial nephritis. 

Drug classes that can cause AIN:

Penicillin analogs (methicillin, ampicillin, etc.)– most common

Cephalosporins

Sulfonamides (sulfamethoxazole,cotrimoxazole)

Other antibiotics such as rifampin andciprofloxacin

NSAIDS (including Cox-2 specific agents)

Diuretics

Proton pump inhibitors

Miscellaneous – this includes a very largenumber of drugs such as allopurinol and cimetidine.