Nephrologic Emergencies

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Nephrologic Emergencies
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Case 1

• 81 y/o WF with poor responsiveness
• Family couldnt wake her up
• Saw FP day before and felt OK
• Squad found her unresponsive
• Monitor in squad showed HR 30
• Transcutaneous pacing initiated

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Case 1

• In ER, HR 20 without pacer
• Atropine given without improvement
• EKG with 3rd degree AV Block
• Transvenous pacer placed
• Labs sent, foley placed
• Respiratory failure and intubated

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EKG
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Case 1- Past Medical History

• CKD with Cr 1.9
• HTN
• Afib
• Cirrhosis- cause unknown
• Paracentesis this week for ascites

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Case 1- Meds

• Cardizem CD 300mg QD
• Lasix 40mg QD
• Digoxin 0.125mg QD
• Enulose 15cc QD
• Remeron 30mg QD
• Aldactone 100mg QD
• Neutraphos K 1 packet TID

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Case 1

• BP dropped and dopamine initiated
• Labs
• ABG 7.08/23/273/6.9 on vent
• CK 56, troponin 0.11
• Na 131 K 8.3 Cl 100 CO2 9 AG 22
• BUN 34 Cr 4.7
• Dig 2.3 Phos 12.1 Mag 2.4

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Case 1

• Bicarb, D50, Insulin
• Albuterol 4 puffs
• Kayexalate 30 gm
• Digibind 1 vial
• Repeat K and ABG
• Nephrology contacted

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Case 1

• Family gave consent for hemodialysis
• Catheter placed, transferred to ICU
• Hemodialysis on 0 K bath x1 hr then 2 K
• During dialysis rhythm became Afib in 90s
• TV Pacer turned off

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Case 1

• Admission day
• 0530 K 8.3
• 0730 K 7.5
• 1200 K 4.5
• 1300 K 4.3
• Next morning
• 0500 K 4.2

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Case 1 Summary

• Renal function improved to Cr1.9 with hydration
• DCd off neutraphos and aldactone
• Synthroid started for TSH 50.09
• Outpt followup for cirrhosis

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Case 2

• 65 y/o WF found unresponsive
• Had been depressed due to poor health
• History of alcoholism requiring admissions
• Various bottles of alcohol at scene per squad

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Case 2

• In ER completely unresponsive
• Vitals stable but no gag
• Intubated for airway protection
• Physical exam unremarkable except
• Thin, mildly malnourished
• open ulcers on legs
• Lungs scattered rhonci

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Case 2

• Past Medical History per niece
• Diabetes mellitus
• Chronic leg ulcers
• HTN
• Alcoholism
• Tobacco abuse
• Depression

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Case 2- Meds

• Glucotrol XL 10 mg QD
• Altace 5mg QD
• Zoloft 50mg QD
• Recently finished antibiotic for leg ulcers
• Home remedy- rubbing alcohol for legs

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Case 2- Labs

• ABG 7.29/32/365/17
• Na 130 K 3.9 Cl 108 CO2 14
• Glu 78 BUN 31 Cr 1.1 AG 8
• Acetone neg
• Lactic acid 1.3

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Case 2

• DOA neg, ASA neg
• EtOH 0.86

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Case 2

• Why doesnt this make sense?
• Metabolic (and respiratory) acidosis
• Nongapped with neg acetone, neg lactate
• Ethanol should give a gapped acidosis

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Case 2

• Calculated serum osmolality 275
• 2Na Glu/18 BUN/2.8
• Measured serum osmolality 353
• Osmolal gap 78
• Normal osmolal gap lt10

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Case 2- Increased Osmolal Gap

• Ethanol
• Ethylene glycol
• Methanol
• Isopropyl alcohol
• All should have an increased anion gap also
• except isopropyl

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Case 2

• Review of history-
• Pt was found with various bottles of alcohol
• Mostly vodka, some isopropyl
• When sober, would wipe legs ulcers with isopropyl
• When drunk, apparently would drink it

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Case 2

• Pt emergently dialyzed x 8 hrs
• Isopropyl, methanol, ethylene glycol levels sent
  out

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Case 2- Summary

• Pt began to wake up at end of dialysis
• Extubated the following day
• No long term neurologic adverse effects
• Renal function remained stable
• Psych and crisis evaluations

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Case 3

• 68 y/o AAM sent in from chronic hemodialysis unit
  where staff noticed
• a diffuse red rash/discoloration to skin of
  chest and face
• Hypertension uncharacteristic for this patient
  did not respond to clonidine 0.2 mg)
• Decreased mental staus

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Case 3

• PMH ESRD, DM2, PVD, HTN, CAD
• PSH b/l BKA, CABG, PTCA (8 months prior), Left
  UE A/V fistula, Penile implant
• All NKDA
• Soc married, no tobacco/EtoH, independent, high
  functioning

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Case 3

• Meds
• Phoslo 667 mg I TID meals
• Nephrocaps QD evening meal
• Accupril 10mg QD
• Atenolol 12.5 mg BID
• ECASA QD
• Glucotrol XL 2.5 mg qd
• Tylenol, Lomotil PRN
• Viagra 50 mg PRN

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Case 3

• Exam T-98, P-95, R-22, 170/63
• Skin diffuse redness to face, chest, hands
  (palmar) no macules, papules, ecchymosis,
  discrete lesions
• HEENT lips swollen, poss periorbital edema
• H RRR, L clear
• Abd soft, nontender, no hepatospleenomegaly, no
  rebound
• Ext L a/v fistula thrill/bruit

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Case 3

• ABG 7.43/43/54/29/88 on Room air
• CBC
• WBC 10.4
• RBC 1.21
• Hgb 7.0
• HCT 11.0
• MCV 86
• PLT 69,000
• Sample is grossly hemolyzed

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Case 3

• Na-139, K-3.8, Cl-102, HCO3-29
• BUN-38, Cr-6.0
• Glu 424
• CPK-545, CK-MB-22.8 (4)
• Troponin I 2.7

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Case 3

• Differential for Hemolysis
• Liver disease
• Hypersplenism
• Infection (Clostridial sepsis, babesiosis,
  malaria, bartonella, E. coli O157)
• Microangiopathies (TTP/HUS, Valvular prosthesis)
• Autoimmune (warm/cold Ab)
• Infusions IVIg, Rhogam, Hypotonic saline, blood
  transfusion
• Oxidant agents dapsone, nitrites, snake bites
• Hemoglobinopathies, Enzyme deficiencies, membrane
  deficiencies

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Case 3

• More lab results
• Albumin 3.1
• Total bilirubin 13.9, indirect 12.6
• Retic 3.2
• AST-238, ALP-43, ALT-37, GGTlt8
• LDH 4591
• Haptoglobin 36 (49-297)
• Myoglobin - 2017

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Case 3

• Intravascular hemolysis, thrombocytopenia,
  altered mental status in a renal failure patient
• Thrombotic Thrombocytopenia Purpura
• Pt received therapuetic plasmapheresis (TPE)
  alternating with hemodialysis. Stabilized in 4-5
  days. Suffered NQWMI day one

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Case 4

• 62 y/o CM presents with confusion and altered
  mental status
• Family states he was normal yesterday but has
  been unable to clear the cobwebs today. Seems
  as though he is getting progressively more sleepy
  as the day goes on.
• PMH DM2 diet controlled, HTN
• PSH Appy, L femur fx with internal fix
• All - NKDA

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Case 4

• Soc retired school teacher, married,
  independent, Tobbaco 60 pack-years, EtoH-social
  (daily)
• Meds
• Accuretic 10/12.5 md QD
• ASA QD

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Case 4

• Exam T-98.6 P-88 R 14 140/80 80kg
• Neuro sleepy, follows simple commands, poor
  historian, communications are incoherent. Pupils
  are 4 mm, equal and reactive. Neck supple.
  Reflexes brachial/patellar normal.
• H-RRR, no JVD, L-slight expiratory wheeze left
• Abd soft nontender no HSM
• Ext no edema

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Case 4

• CT Head normal
• ABG 7.41/40/98/25/99 on room air
• Na-108, K-3.2, CL-76, HCO3-23,
• BUN 23, Cr-0.8
• Glu-96
• CXR left upper lobe peripheral density
• Sosm 226, Uosm 560 mosm/kg

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Case 4

• Hyponatremia
• Hypo-osmolar, Euvolemic, but this patient has
  neurologic manifestations
• Treatment
• Restoration of serum sodium, goal 120Meq/L
• Na deficit (120-108Meq/L)(0.6)(80kg)
• 576 Meq of sodium needed to correct
• One liter of 3 NaCl has 513 Meq Na
• Correct 0.5 Meq/L each hour (12 Meq/L over 24
  hours)
• Hang one liter NaCl 3 at 40 cc/hr through
  central line.
• Monitor Na q2 hours, neuro checks
• Investigate underlying cause