Case study: acute renal failure

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Case study acute renal failure

• Bruce R. Wall, MD, FACP
• 4/3/06
• Renal resident conference

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Patient P B

• 80 yo white female with history of HBP for 20
  years, and previous Left hemispheric CVA
• CC Doc, I was playing bridge 2 weeks ago
• Known lumbosacral spine stenosis/listhesis with
  increasing back pain and loss of strength in
  lower legs
• 1 week of nausea and vomiting with minimal abd
  pain
• Two year history of ibuprofen use recent
  conversion of naprosyn for 1 month
• No abd distension no hematemesis occasional
  pink tinged sputum, while on Plavix
• Conversion to Ultram, then narcotics, which
  caused constipation

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H P continued

• No previous documentation of creat in caregate
  current creat 2.5 to 3.5mg
• Iron deficiency anemia documented negative
  colonscopy 1 year ago
• GI consulted for nausea, vomiting, anemia after
  naprosyn exposure EGD WNL
• Renal consulted for ARF? CRF?
• Lower leg weakness, poor gait, and GI symptoms
  were her main concerns

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PAST HISTORY

• Hypertension 20 yrs
• Coronary artery stent 2002
• CVA with mild expressive aphasia
• Anemia
• CKD
• Diverticulae and internal hemorrhoids
• Lumbar stenosis, moderate, at L3-4
• Cholecystectomy, appy, TAH

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History continued

• FH HBP, CVA ASCVD at young age
• SH remote smoker, very active, no ETOH
• ROS ataxia with abnormal gait, requiring walker
  GI symptoms no history of CHF no
  nephrolithiais, no endocrinopathy, no diabetes
  able to drive

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Medications

• Amitriptyline
• Aspirin 81 mg
• Atorvastatin
• Clonidine TTS
• Plavix
• Iron
• Lisinopril
• Metoprolol

• Protonix
• Morphine
• SL nitroglycerin
• Vitamin K
• Centrum
• ALLERGYVoltaren (nausea)

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Physical exam

• 140/88 90 14 afebrile
• Awake, alert, preserved muscle mass
• HEENT minimal facial asymmetry
• NECK no nodes, chronic stiffness
• LUNGS no hemoptysis no rales
• COR RRR, no murmur, no gallop
• ABD soft, benign, no hepatomegaly
• GU positive stool occult blood, no mass
• EXT impressive 3 edema no purple toes
• NEURO expressive aphasia abnormal gait no
  hyperreflexia

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Laboratory exam

• Hgb 9gms normocytic plts WNL
• Serum iron 20, ferritin 325, sat 18
• Nomal LFTs and normal coags
• Sodium 128 Potassium 5.1 Chloride
  100 BUN 34 creatinine 2.8
  Glucose 100 bicarbonate 23
  calcium 7.6 albumin 2.7
  cholesterol 225

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Labs continued

• CXR - borderline cardiomegaly
• Urinalysis yellow hazy SG 1.01 pH 5
  large blood negative ketones RBC 25/HPF WBC
  35/HPF 2protein
• Sonography left 10.7cm, right 11.9cm isoechoic
  with the liver
• 24 hour urine clearance 9ml/min total protein
  1100mg per day

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Additional information

• Any additional history required?
• Any additional physical exam?
• Labs pending repeat 24hr urine, complements,
  myeloma markers, lupus markers, vasculitis markers

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Differential diagnosis

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Approach to kidney

• Acute vs chronic disease
• Nephritic vs nephrotic syndrome
• Glomerular diseaseacute vs chronic GN
• Interstitial disease infiltrative, AIN
• Renal artery disease stenosis or emboli
• Obstructive disease tubules, stones,
  retroperitoneum, BPH vs prostate CA

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dont fall in love with your first diagnosis

• TOXIC EFFECTS of NSAIDS
• GI toxicity upper and lower
• Modest worsening of chronic hypertension
• ARF 2 different types
• CV effects blocks beneficial effect ASA
• Hepatic injury
• Bone marrow toxicity aplasia
• Anti-platelet effect stop 5 days prior to
  surgery
• CNS changes tinnitus
• Skin - TEN

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NSAID induced renal failure

• Hemodynamic mediated ARF not a concern in normal
  individuals yet patients with underlying GN,
  CKD, or hypercalcemia all need prostacyclin and
  PGE2
• Patients with increased vasoconstrictors AII or
  NE states of volume depletion CHF, cirrhosis,
  DM are at greatest risk

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NSAID induced ARF

• Inhibition of PG by any NSAID in state of
  vasoconstriction may lead to reversible renal
  insufficiency or ARF
• Indocin, ibuprofen, and toradol most common
  causes
• COX II inhibition reported cause ARF
• Sulindac/clinoril less suppression ARF

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AIN allergic interstitial nephritis

• Fenoprofen and Indocin relatively common cause
  hematuria, pyuria, proteinuria yet the full
  blown syndrome of fever,rash, eosinophilia is
  extremely uncommon
• Nephotic range proteinuria is reported
• Biopsy is uncommon since pts improve
• Prednisone not helpful (retrospective)

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Lab profile
Date BUN Creatinine
2/13/06 34 2.6
2/27/06 40 4.0
3/14/06 50 6.3
3/20/06 55 7.2
3/26/06 86 8.0
3/30/06 85 7.3
4/02/06 90 6.0
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Renal biopsy

• Indication
• Risk
• Solitary kidney?
• Complications
• Follow up monitoring

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Additional serology

• Anti GBM negative
• ANA 140 speckled
• PANCA 132 with positive MPO (Myeloperoxidase
  IgG) of 55 units

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biopsy
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Overview to classification of RPGN

• RPGN is the syndrome crescentic GN is the
  pathologic entitiy
• Crescent formation is a nonspecific response to
  injury of glomerular capillary wall
• gt80 crescents present -- severe ARF
• Types of crescentic GN type I anti-GBM
  disease type II immune complex disease type
  III pauci-immune disease
• Pauci-immune present with necrotizing GN with few
  or no immune deposits by IF or EM. Majority of
  patients with renal-limited vasculitis are P-ANCA
  positive with 75 MPO positive.

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Overview to classification of RPGN
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Spectrum of ANCA

• Described in 1982
• Technical issues indirect IF assay is more
  sensitive ELIZA more specific
• C-ANCA pattern staining is diffuse _at_ cytoplasm
  (most are PR3 positive)
• P-ANCA stains around the nucleus, (most are MPO
  positive)

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Clinical applications of ANCA

• Is a positive result a true positive? Yes, if
  ELIZA (), fairly good PPV.
• Does (-)ANCA exclude ANCA vasculitis? No,
  since 40 test (-) in Wegeners.
• Does presence of ()ANCA establish the diagnosis
  (no biopsy required)? No, tissue confirmation
  is standard.
• Does rising ANCA titer correlate with flare? No,
  not a reliable indicator of disease.
• Does persistant (-)ANCA mean quiescence? No

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Disease associations

• ANCA are associated with may cases of WG,
  MPA,Churg-Strauss syndrome, renal-limited
  vasculitis and certain drug-induce syndromes
  (PTU, hydralazine, minocycline)

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therapy

• Initial dosing with 1000mg solumedrol for 3 days
• Intravenous cyclophosphamide every month has less
  toxicity than PO
• Once in remission, consider PO imuran,
  methotrexate, or ENBREL?

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Lab profile
Date BUN Creatinine
2/13/06 34 2.6
2/27/06 40 4.0
3/14/06 50 6.3
3/20/06 55 7.2
3/26/06 86 8.0
3/30/06 85 7.3
4/02/06 90 6.0