A Case of Acute Kidney Injury (ARF)

1. PHYSICIANS’ MEET
An interesting case of
Acute Kidney Injury
Prof. MAHESH KUMAR’s unit,
Dr.R. Israel, PG

2. 35 yr old male, auto driver by occupation
Admitted with
c/o decreased urine output for 3 days
c/o fever &
c/o abdominal pain for 10 days

3. 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;

4. •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

5. •Not a k/c of HTN/DM/BA/IHD/CVA/PT
•No h/o blood transfusion

7. Examination
•Conscious, oriented, cooperative
•Afebrile, pallor, BPPE,
•No icterus/lympadenopathy
•Vitals: BP-120/80; PR-80/min; Temp- 36.2

8. 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

9. Provisional diagnosis
Acute Kidney Injury/
? Cause/
? Leptospirosis

10. 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

11. HD started in nephrology department

12. 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

13. RFT
Urea 170 mg%
Creatinine 8 mg%
Na 137 Meq/L
K 4.3 Meq/L
Blood sugar 109 mg%
Urine routine
Pus cells – 8-12/hpf
RBC nil
Albumin +
Sugar +
24 hour urine protein – 360 mg

14. •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

15. USG abdomen
•Rt kidney 13 cm ×6.4 cm
•Lt kidney 13cm ×7 cm
•Increased cortical echotexture
•CMD normal
•Otherwise normal

16. investigati
ons
4/3/1
0
5/3/106/3/108/3/1012/3/1015/3/1017/3/10
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
Creatinine8.2 6.9 9.9 10.2 7.7 7.8 5.2

17. Etiology
•Inflammation of the
structures of the kidney:
–the renal pelvis
–renal tubules
–interstitial tissue
•Almost always caused by
E.coli Presented By:
Jillymae

18. Etiology
•Usually seen in association with:
–Pregnancy
–diabetes mellitus
–Polycystic
–hypertensive kidney disease
–insult to the urinary tract from catheterization,
infection, obstruction or trauma

19. 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

20. 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

21. 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

22. Costovertebral Angle (CVA)

23. Chronic Pyelonephritis
The autopsy specimen
consists of a bisected
kidney which is
markedly shrunken
because of chronic
inflammation and
Scarring.
(B) multiple calculi in
the proximal ureter
(A) Calyceal system

24. 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

25. 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

26. 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

27. Medicines
•Ampicillin or vancomycin
combined with an
aminoglycoside (Nebcin,
Garamycin)
•Cipro
•Septra
•Bactrim
•Floxin

28. 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

29. 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

30. 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

31. 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.

32. 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

33. Uremia – Syndrome marked by ↑ BUN and
↑ Creatinine.
Consequences
•Anemia (failed erythropoietin production)
•Renal osteodystrophy (Vit. D not activated in
kidneys)
•Hyperkalemia (possible arrhythmias)
•Metabolic acidosis (↓ acid secretion and ↓
generation of HCO
3-.

34. Uremia – Syndrome marked by ↑ BUN and
↑ Creatinine.
•5. Uremic
encephalopathy
•6. Sodium and H
2
O
excess → CHF and
pulmonary edema
•7. Chronic
Pyelonephritis
•8. Hypertension