Question

Mr. W., a 26-year-old man, entered the emergency department with complaints of fever, severe abdominal pain, and nausea. He denied any health problems but disclosed a daily intake of four to six beers per day. An abdominal computed tomography (CT) scan performed on admission revealed pancreatic inflammation and intraabdominal ascites. He was admitted to the step-down unit for the management of acute pancreatitis. His treatment plan included intravenous antibiotics, pain control, and management of alcohol withdrawal. Within 48 hours of admission to the hospital, Mr. W. developed tachycardia (heart rate 120 beats per minute), hypotension (blood pressure 88/46 mm Hg), and tachypnea (respiratory rate 30 breaths per minute) and a temperature of 38.5° C. Arterial blood gases results were pH 7.20; partial pressure of arterial oxygen (PaO2) 78 mm Hg; partial pressure of arterial carbon dioxide (PaCO2) 28 mm Hg; and bicarbonate 18 mEq/L. He was intubated for acute respiratory distress syndrome (ARDS) and transferred to the critical care unit. Prone positioning and pressure control ventilation were initiated for the management of hypoxemia. Mr. W. required repeated fluid boluses and the titration of vasoactive infusions to achieve hemodynamic stability. A second CT scan of the abdomen revealed extensive edema and necrosis of the pancreas. Intraabdominal pressure was measured at 17 mm Hg. During the first 48 hours of admission to the critical care unit, urine output ranged from 10 to 20 mL per hour or greater than 0.5 mL/kg/hr. His serum potassium level was 6.3 mEq/L, and his creatinine level had risen to 3.8 mg/dL (admission creatinine level was 0.9 mg/dL). The renal medical service was consulted for management of acute kidney injury. Continuous venovenous hemofiltration was initiated and continued for 5 days. The patient was extubated on day 14 and transferred to the step-down unit on day 20.

1. What are the factors that predispose Mr. W. to acute kidney injury?

2. Acute kidney injury can be classified as prerenal, intrarenal, or postrenal. Select the classification that best describes Mr. W.’s acute kidney injury, and provide rationale for your selection.

3. The physician requested intraabdominal pressure measurements. Why is this measurement important in the evaluation of acute kidney injury?

4. Discuss the benefits of continuous venovenous hemofiltration (CVVH) in the management of Mr. W.’s acute kidney injury.

5.On hospital day 20, a third CT scan of the abdomen was requested by the treatment team. What precautions need to be considered to prevent or minimize further kidney injury?

Answer 1

1 The factors that contribute to acute kidney injury of Mr W are pancreatitis,alcohol abuse ,CT scan and ARDS.

2 He is in stage 2 .Because patients in stage 2 has serum creatinine levels increase greater than two to three fold from baseline and urine output less than 0.5 ml per kg per hour for more than 12 hours.

Since Mr W creatinine level has risen to 3.8 within the last 48 hours and urine output greater than 0.5ml/kg/hr .He is in stage 2.

3 Increase in intraabdominal measurements(IAP) is known to affect the renal function adversely. Kidney dysfunction is among the earliest physiological consequences of increased IAP.IAP values of greater than 8mmof Hg to predict the development of AKI.The kidney seems to be extremely sensitive to the harmful consequences of increased IAP even at low levels.

4 CVVH is a type of continious renal replacement therapy used to treat AKI.It helps in more gradual solute removal,flexible fluid administration and minimal heparin .

5 Check with the doctor whether CT scan is performed without contrast so that the patient can eat ,drink and take prescribed medications on time. Taking a prescan drug called N-Acetylcysteine can prevent serious kidney damage which can be caused by iodine containing dyes which doctors use to enhance the quality of scans.