Acute Kidney Injury - Post Esophageal Varices Bleed
Patient presentation:
S.K., a 65 yo male presented to the ED with black, melena stool x 2 days. Patient stated that he “felt weak for a few days then noticed increased weakness, diarrhea and low urine output.” S.K. has a history of ETOH cirrhosis, esophageal varices, hypertension, and tobacco use. Patient was AAOx3 but lethargic on admission to the ED. Skin was diaphoretic, pale, and cool to the touch. Patient complained of abdominal pain 7/10 on a 10 point scale with increased distention. VS: HR 125, BP 88/54, RR 20, O2 Sat 98% on RA, temp. 37.3 C. Labs drawn, EKG done, patient placed on 2 L NC and transferred to ICU.
Differential List:
stomach ulcer, esophageal varices, hepatorenal syndrome, acute kidney injury due to hypovolemia
Significant Labs:
BMP: K+ 5, Na+ 149, Cl- 102, BUN 38, Cr 1.9
CBC: Hgb 6.5, HCT 17.6, WBC 7.5
PT 21.9, INR 2.0, PTT=41.3
EKG= sinus tachycardia
Treatment/ Outcome:
In the ICU, a foley catheter, arterial line and Cordis® were placed upon arrival. S.K.’s blood pressure remained low at 75/45 and a Levophed® gtt was started at 5 mcg/min. The patient received 5L NS bolus, 3 units of PRBCs and 2 units FFP within the first 2 hours on the unit. The patient continued to have melena stool and received q4 hour CBC to monitor hematocrit and hemoglobin. A diagnostic EGD was done at the bedside and 2 esophageal varices were banded by the GI attending. The patient’s blood pressure remained low and fluids were started at 200 mL/hr. The patient remained oliguric with output at 5-10 mL hour despite vasopressors and aggressive fluid resuscitation. A renal consult was placed and a urinalysis, urine studies and renal ultrasound to rule out obstruction were ordered. The renal ultrasound was unremarkable. The urinalysis was negative for protein, specific gravity of the urine = 1.013, urine osmolality = 290, urine urea = 138 mg/dL, urine creatinine = 88 mg/dL. At day 3, there was no improvement in renal function and I&O’s were 13 L positive. BUN = 80, creatinine = 3.3, and there were no further signs of bleeding. S.K was diagnosed with acute kidney injury due to hypovolemia following a GI bleed. The Cordis® catheter was replaced for a dialysis catheter and CVVH (continuous veno- venous hemofiltration) was initiated. The patient continued on CVVH for 7 days until Levophed® could be stopped and the patient could transition to hemodialysis. The patient was anuric at this point and the foley catheter was removed. The patient was transitioned out of the ICU to a step down unit on day 14 and continued with hemodialysis.
Case created by Sarah Keller, 2012.