Reference no: EM133546181
Your patient is a 34-year-old male who is hospitalized with nausea, vomiting, and abdominal pain of 3 days duration. His current weight is 198lb. and his height is 6'2". He has a history of alcohol and drug abuse. His medical history is unremarkable, but he has not seen a doctor in his adult life. He is not on any medications.
Admission laboratory values reveal a serum sodium level of 152 mg/dL. His potassium is 2.8 mg/dL, chloride is 124 mg/dL, and bicarbonate is 14 mg/dL. Blood urea nitrogen (BUN) is 96 mg/dL and serum creatinine is 3.7 mg/dL. Blood glucose is 856 mg/dL. Serum calcium is 7.4 mg/dL, and his leukocyte count is 8000/mm3. Amylase is 256 U/dL (normal, 0- 140 U/dL), and lipase is 400 U/L (normal < 140 U/L). Urinalysis reveals hyaline casts, glucosuria, and ketonuria; no blood, protein, leukocytes, or other casts are seen in the urine. The patient has a Foley catheter in place and his urine output approximately 50cc/hour.
The patient is hydrated vigorously. He is diagnosed with diabetic ketoacidosis and acute pancreatitis, and he is treated appropriately. A contrast-enhanced computed tomography (CT) scan reveals prominent ascites throughout the abdomen involving the perirenal spaces, transverse mesocolon, and colonic gutters. The pancreas is edematous, and fatty stranding can be seen. The ileum and sigmoid colon are thickened. A left pleural effusion is present.
Questions
1. This patient has an acute kidney injury. What is the most likely cause for the AKI he is exhibiting - prerenal, postrenal, intrinsic - and why?
2. What factors above point to this type of AKI?
3. Are there any variables above that make you question whether the patient has an AKI?
4. Are you willing to entertain any other differential diagnoses given the patient's history and diagnostic test results?
5. "The patient is hydrated vigorously" - what fluids would you have prescribed to provide this hydration?
6. What would be your therapeutic endpoint for "vigorous" as opposed to maintenance hydration?