서울병원 신장내과 Prof. 권 순 효/ R3 서대철 AKI CASE 1 서울병원 신장내과 Prof. 권 순 효/ R3 서대철

Patient identification Hospital No. : 001122832 Name : 김 O 덕 Age / Sex : 77 / F Admission date : 2013.01.04

Chief complaint Fever Onset ) 내원 당일 (2013.01.04)

Present illness 내원 2일 전 watery diarrhea, vomiting 발생하여 금강아산병원 입원, 당시 WBC 32,000, CRP 24, BUN/Cr 58/3.2 확인. 입원 후 보존적 치료 중 fever 발생하여 Ciprofloxacin 투여. BUN/Cr 상승 및 abd.USG 에서 Lt. APN c hydronephrosis, R/O obstructive lesion 소견 보여 본원으로 전원.(Foley catheter insertion은 본원 응급실에서 시행) 외부 abdomen USG 확인하기 Sepsis 기준 Temperature >38.3ºC or <36ºC Heart rate >90 beats/min---------환자 HR 94 Respiratory rate >20 breaths/min or PaCO2 <32 mmHg----RR 24 PaCO2 : 31.3 WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms-금강아산병원 WBC 32000

응급실 내원 당시 Vitalsign : 90/60mmHg–94회/min-24회/min-37.6도 Mental : Alert Urine output(?) CBC 31,800(N 97.5%)-12.0/36.0-32k BUN/Cr 70/3.84 Electrolyte : 134/4.4/97 T-CO2 : 16 aBGA 7.342-67-31.3-17.0-92% Urine analysis : Glucose 2+ Protein 1+ Blood 2+ Leukocyte -

Fact? Question?

Past history DM (+) : Humulin-N 30IU HTN (+) : Irbesartan 150mg 1T Tuberculosis (-) / Hepatitis(-) Social History Alcohol drinking : (-) Cigarette smoking : (-) Hospitalization / Op. History EGC (Subtotal gastrectomy, 1998’) Cholecystitis (Cholecystectomy, 3개월 전)

Problem List & Assessment Sepsis due to Lt. APN c hydroureter Fever/Chill, Dysuria, Urinary frequency Lt. dominant CVA Td(+) Leukocytosis, CRP의 상승 & Abdomen USG finding AKI 신장질환 과거력 없음(1주 전 BUN/Cr 16/0.93) 입원 당시 심한 Dehydration, Urine output 30cc/hr 이상 유지 R/O infectious colitis Fever/Chill, Abdominal pain, Diarrhea, Abdominal Td(+) But, 본원 내원 당시 Diarrhea, Abdominal Td 호전 Known DM, HTN

Questions Sepsis의 정의에 부합하는가? - Temperature >38.3ºC or <36ºC - HR>90 beats/min - RR>20 회/min or PaCO2 <32 mmHg Management of hydroureter - VUR(vesicoureteral reflux) - Recurrent urinary tract infection >> at least once / year : radiologic exam R/O infectious colitis Sepsis 기준 Temperature >38.3ºC or <36ºC Heart rate >90 beats/min---------환자 HR 94 Respiratory rate >20 breaths/min or PaCO2 <32 mmHg----RR 24 PaCO2 : 31.3 WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms-금강아산병원 WBC 32000 Recurrent urinary tract infection (UTI) refers to ≥2 infections in six months or ≥3 infections in one year

Diagnostic Plan Sepsis due to Lt. APN c hydroureter - CBC,Chemistry,Electrolyte,RUA - Blood culture, Urine culture - Abdomen USG or Non-enhanced CT AKI FeNA(Urine Cr,Na,Serum Cr,Na) Medication History 확인 R/O infectious colitis - Stool microscopy, culture - 신기능 회복 후, Enhanced Abdomen CT or Colonoscopy FENA : 105x2.84/131x23.69=9.6 >> 이후 CT 소견 확인

Treatment Plan Sepsis due to Lt. APN c hydroureter AKI - Non-enhanced CT에서 Obtructive uropathy를 의심할 수 있는 병변 없음 - Dehydration state Urine output이 시간당 30cc/hr 이상 유지되어, Hydration 시행 Empirical antibiotics After Blood culture check > Meropenem IV

Hospital course ESBL : Blood culture Urine culture : negative

Laboratory finding

CASE 2

Patient identification Hospital No. : 001629401 Name : 장 O 남 Age / Sex : 80/F Admission date : 2013.01.12

Chief complaint Mental change Onset ) 내원 3일전

Present illness 내원 15일전 정도부터 Back pain 악화되며 자세변화 시 통증 심하여 Nearly Bed ridden으로 지내며 식사 잘 못함 내원 3일전부터는 drowsy하며 자는 모습 지속되어 local 병원에서 보존적 치료 환자 lab에서 Hyperkalemia, elevated Cr 소견 있다는 연락 받아 further treatment위해 내원. 평소에 수 많은 약제를 임의로 복용

응급실 내원 당시 Vitalsign : 120/70mmHg-80회/min-20회/min-36.4 도 Mental status : Drowsy Urine Output : 300cc/hr CBC : 8,300-9.8/30.2-307K BUN/Cr : 92/8.53 Electrolyte : 142/6.8/105 aBGA : 7.332-32.3-81-17.1-95% Urine analysis : protein – trace

Fact? Question?

Past medical history DM (+) : 5yr Hypertension (+) : 5yr Tuberculosis (-) / Hepatitis(-) Social History Alcohol drinking (-) Cigarette smoking (-) Hospitalization/Operation History 2010/5 T6 Kyphoplasty 2011/12 L4 Kyphoplasty

Medications Once daily - Acarbose 100mg - Aspirin 100mg - Irbesartan 150mg + Hydrochlorothiazide 12.5mg TID - Domperidone maleate 12.72mg - Tizanidine 1mg - Tramadole HCl 37.5mg + Acetaminophen 325mg Other medications - 민들레, 질겅이, 쇠비듬을 말려 환으로 만든 한약

Problem List & Assessment AKI d/t R/O Toxic nephrotoxic agent(Caused by herb) - Underlying kidney disease(-) - 민들레,질겅이,쇠비듬을 말려 환으로 만든 한약 간헐적으로 복용(4개월 전부터) - 2012년 3월 BUN/Cr 11.4/0.67 내원시 BUN/Cr 92/8.53 Hyperkalemia - Electrolyte : 142/6.8/105 Known DM, HTN

Evaluation of AKI Kidney International Supplements (2012) 2, 19–36

Diagnostic Plan AKI d/t R/O Toxic ATN(Caused by herb) Hyperkalemia -FeNA -TTKG -aBGA -24hr urine collection -Abdomen USG -Renal biopsy FeNa : 142x24.35/125x8.53=30.8 >>이후 영상 소견 확인

Treatment Plan AKI d/t R/O Toxic ATN(Caused by herb) Hyperkalemia -Hyperkalemia, Total CO2저하, 급성 Cr 상승 소견 있음 -Emergency HD 시행함 - 추후 Urine output에 따라 HD 유지 여부 결정 Known DM, HTN -DM medication : Acarbose 100mg 1T -HTN medication : Irbesartan 150mg, Hydrochlorothiazide 12.5mg -신기능에 영향을 줄수 있는 ARB,Thizide는 복용중단하였고 혈당은 안정적이고 식사량 적어 DM medication하지 않음

Timing to RRT in AKI Hyperkalemia Acidemia Pulmonary edema Uremic complications Removal of nephrotoxic agent

Hospital course ↑ ↑ Hemodialysis

Laboratory finding

Definition of AKI Increase in SCr by ≥0.3mg/dl(≥ 26.5umol/l) within 48hrs Increase in SCr to 1.5 times baseline within the prior 7days Urine volume < 0.5 mg/kg/h for 6hrs Kidney damage is not required for diagnosis of AKI

Definition of AKI

Cause of AKI Cause of AKI d/t decreased kidney perfusion (Prerenal) Decreased intravascular fluid volume Decreased cardiac output Peripheral vasodilation Severe renal vasoconstriction Mechanical occlusion of renal arteries