Acute Kidney Injury

PATIENT PRESENTATION:
M.M., a 39 year old male presented to the ED via ambulance with acute onset of hematemesis and a 2 day history of melena.  M.M. stated he had been feeling weak and lethargic at home for the past week.  States had some abdominal pain, no emesis until today.   Pt was A&O, no respiratory distress, skin pale and clammy.  Vitals:  BP 80/40,  HR 125 sinus tachycardia with no ectopy, RR 20, O2 sats 96% on 2L nasal cannula.

Significant Labs:
BMP: Na+ 145, K+ 4.8, Cl- 118, BUN 22, Cr 2.1, Ca++ 6.3
CBC: WBC 7.5, RBC 3.4, Hgb 6.8, HCT 19.2, Plt 89
Coags: PT/INR 19.4/2.1, PTT 36.5
Liver panel and other labs were within normal limits.

DIAGNOSIS:
Hypovolemia due to GI bleed, resulting in acute kidney injury.

TREATMENT:
M.M. was admitted to the ICU.  M.M. was transfused with packed red blood cells to a goal HCT of 30 and INR was corrected to 1.4 with 6 units of fresh frozen plasma.   Blood pressure remained low, IV pressors were started to get MAP > 65.  Gastric lavage was positive for blood.  Bedside EGD (esophagogastroduodenoscopy) was performed which revealed a gastric ulcer, which was treated with cautery and epinephrine injections.  M.M. had no further hematemesis after the EGD.  Hgb/HCT were checked every 4 hours and remained stable after transfusions and EGD. Coags remained normal and liver enzymes remained normal.  Admission labs showed a BUN/Cr ratio consistent with pre-renal failure secondary to hypovolemia from the active GI bleed.  M.M. was oliguric initially with urine output of less than 30mls/hr.  However, on day 3 he became anuric.  BUN/Cr were 30 and 3.2 respectively, specific gravity of urine was 1.012, Urine osmolarity 270, urine Na 24. Renal ultrasound was ordered to rule out hydronephrosis, which was negative.  Renal consult ordered on day 4 for acute tubular necrosis.  No improvement in renal function and I&Os were 12 liters positive by day 4.  Hemodialysis was ordered by the renal team.  A dialysis catheter was placed at the bedside in the ICU and M.M. underwent hemodialysis on day 4 and then every other day for the next 16 days.  By day 12 he was making 20-40 ml/hr of urine and BUN/Cr had improved to 24/1.9.  On day 16 of hemodialysis BUN/Cr were 21 and 1.3, urine output was greater than 30mls/hr and hemodialysis was discontinued.

OUTCOME:
M.M. recovered and was transferred to the medical floor with plan to discharge to home and follow up in clinic with nephrology.
Case created by Michelle Michaels, 2010.