Acute Renal Failure

Patient presentation
E.C. is a 68 year old female who returns to the hospital 3 weeks after a liver resection with an intra-abdominal abscess.  On admission she appears frail and states she has not been eating well.  Her vital signs are: T 38.6, RR 22, BP 100/64, HR 110, 94% on RA.  She is taken to interventional radiology and a tru-close drain is placed in the abdomen to drain the abscess.  The intra-abdominal fluid is sent to the lab for culture.  E.C. is initially started on IV Ancef® and IV vancomycin.  She is on this drug combination for almost a week, until her wound cultures grow out and show particularly virulent strain of extended-spectrum β-lactamase (ESBL)-producing Klebsiella, resistant to most antibiotics.  The infectious disease doctors recommended that IV gentamycin would be effective against this bacterium, and the patient is started on IV gentamycin.  Almost 48 hours after the initiation of E.C.’s course of IV gentamycin the nurse notices that her urine output has declined, only 200mls out in 12 hours.  E.C. reports she has not been drinking or eating for the past few days due to extreme nausea.  She states she has been vomiting up anything she eats. The doctors start NS IV at 50ml/hour, Zofran and Reglan, and encourage E.C. to drink more fluids.  Over the night shift E.C.’s urine output drops precipitously, only 60mls out in 10 hours.  Her vital signs are BP 104/78, HR 128, T 37.6, RR 22, 94% on RA.

Differential list
Dehydration, Acute Kidney Failure

Diagnosis
A BMP is completed with the following results: Na+ 145, K+ 4.7, Ca++ 8.8, Mg++ 2.5, Cl- 105, HCO3- 28, Phos 2.5, Creatinine 3, BUN 60

The doctors are concerned about E.C.’s elevated BUN and creatinine.  They bolus her 1L NS and recheck a BMP 6 hours later.  At this time her creatinine is 3.2 and E.C. has put out 15mls of urine.

Treatment
The doctors consult with the nephrology team; the nephrologist recommends that the patient be started on dialysis for acute kidney failure. E.C. has a temporary catheter placed for dialysis and is dialyzed the following morning.  The IV gentamycin is discontinued and the patient is started on an alternative IV medication.

Outcome
E.C. remained on dialysis for 3 weeks, but was able to come off the dialysis after that time.  She was started on TPN for hydration and nutrition.  She was discharged home after 4 weeks on IV antibiotic and TPN.