A 65-year-old diabetic woman presents to the emergency room with right upper quadrant pain that radiates around to the back, together with nausea, vomiting, anorexia, lightheadedness, and a diminished urine output during the last 24 hours. She has no previous history of renal dysfunction. Her temperature is 37.5°C (99.5°F); supine, her blood pressure is 110/70 mm Hg and pulse is 80 beats per minute; upright, her blood pressure is 85/60 mm Hg and pulse is 110 beats per minute. The physical examination findings are otherwise remarkable for the presence of decreased skin turgor, dry mucosal membranes, flat neck veins, and absence of axillary sweat. Her lungs are clear and the cardiac findings are normal. There is exquisite right upper quadrant abdominal tenderness that worsens with inspiration, her stool is guaiac negative, and no edema is noted. Neurologic examination reveals nonfocal findings.
The following laboratory data are obtained: hematocrit, 50.2%; white blood cell count, 19,500/mm3 with 82% polymorphonuclear leukocytes, 16% band forms, and 2% lymphocytes; platelets, 312,000/mm3; sodium, 146 mEq/L; potassium, 4.1 mEq/L; chloride, 111 mEq/L; carbon dioxide, 22 mEq/L; glucose, 195 mg/dL; BUN, 35 mg/dL; creatinine, 1.6 mg/dL; total bilirubin, 1.8 mg/dL; alkaline phosphatase, 289 IU; and aspartate aminotransferase (AST), 35 U/L.
Urinalysis reveals a pH of 5, a specific gravity of 1.028; 1+ glucose, trace ketones, occasional nonpigmented granular casts, and no cellular casts or bacteria. The urine sodium level is 10 mEq/L and the urine creatinine level is 80 mg/dL.
Abdominal ultrasonography reveals the existence of gallstones and dilatation of the biliary tree. The kidneys measure 11 cm but exhibit no hydronephrosis or increased echogenicity.
While in the emergency room, the patient's fever spikes to 39°C (102.2°F), which is accompanied by 3 minutes of rigors and a decrease in blood pressure to 80/50 mm Hg. She is admitted to the hospital with a diagnosis of acute cholecystitis for the purpose of observation and eventual cholecystectomy. She is given gentamicin [2 mg/kg intravenously (IV)] and ampicillin (2 g IV every 6 hours). Her urine output over 12 hours is 100 mL. The next morning, the following laboratory values are reported: sodium, 140 mEq/L; potassium, 5 mEq/L; chloride, 100 mEq/L; carbon dioxide, 15 mEq/L; glucose, 130 mg/dL; BUN, 40 mg/dL; and creatinine, 2.5 mg/dL. Urinalysis now reveals a pH of 5 and a specific gravity of 1.010 with occasional renal tubular epithelial cells and a rare, muddy-brown granular cast. The urine sodium level is 80 mEq/L and the urine creatinine level is 40 mg/dL. Blood cultures are positive for a gram-negative bacillus.
During the next 3 days, the patient remains oliguric and mild congestive heart failure develops. The BUN and creatinine levels rise steadily to 100 and 5.5 mg/dL, respectively.
tentare di rispondere alle seguenti domande:
At the time of arrival in the emergency room, what is the most likely explanation for this patient's acute renal dysfunction, and why?
At the time of the patient's arrival in the emergency room, what treatment would you prescribe, and why?
What is the cause of the continuing rise in the serum creatinine level after the patient is admitted to the hospital, and why?
What is the role for diuretics in this patient, and what is the proper dosage?
What is the appropriate approach to fluid management when the patient becomes oliguric?
What are the indications for acute dialysis in acute renal failure, and what alternative extracorporeal procedures could be considered?
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