서울병원 신장내과 Prof. 권 순 효/ R3 서대철

Presentation on theme: "서울병원 신장내과 Prof. 권 순 효/ R3 서대철"— Presentation transcript:

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

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

3 Chief complaint Fever Onset ) 내원 당일 ( )

4 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

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

6 Fact? Question?

7 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)

8 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

9 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

10 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

11 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

12 Hospital course ESBL : Blood culture Urine culture : negative

13 Laboratory finding

14 CASE 2

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

16 Chief complaint Mental change Onset ) 내원 3일전

17 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

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

19 Fact? Question?

20 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

21 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

22 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) 년 3월 BUN/Cr 11.4/0.67 내원시 BUN/Cr 92/8.53 Hyperkalemia - Electrolyte : 142/6.8/105 Known DM, HTN

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

24 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

25 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

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

27 Hospital course ↑ ↑ Hemodialysis

28 Laboratory finding

29 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

30 Definition of AKI

31 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