Prerenal ARF due to volume depletion.
How to confirm the diagnosis?
UA.
Urinary sodium and creatinine to calculate the fractional excretion of sodium (FENA).
What other tests would you order?
BMP in 6 and 24 hours.
What other tests would you order?
BMP in 6 and 24 hours.
Renal ultrasound to rule out urinary obstruction and nephrolithiasis.
What treatment would you start for this patient?
Insulin 10 units IV with D50, 1amp. IV x 1.
Kayexalate 45 gm po x 1.
Foley catheter.
Strict I/O.
NS at 150 cc/hr x 2 L, then 125 cc/hr, adjust the rate of IVF according to I/O, avoid fluid overload.
Hold ACEi and NSAIDs
What happened?
FENA of 0.77 % confirmed the diagnosis of prerenal failure.
Renal U/S ruled out urinary obstruction.
The patient had good urine output with IVF and was in a positive fluid balance.
Potassium normalized after treatment with Kayexalate, Insulin and D50.
There was a downward trend in BUN and creatinine.
What treatment would you start for this patient?
Insulin 10 units IV with D50, 1amp. IV x 1.
Kayexalate 45 gm po x 1.
Foley catheter.
Strict I/O.
NS at 150 cc/hr x 2 L, then 125 cc/hr, adjust the rate of IVF according to I/O, avoid fluid overload.
Hold ACEi and NSAIDs
What happened?
FENA of 0.77 % confirmed the diagnosis of prerenal failure.
Renal U/S ruled out urinary obstruction.
The patient had good urine output with IVF and was in a positive fluid balance.
Potassium normalized after treatment with Kayexalate, Insulin and D50.
There was a downward trend in BUN and creatinine.
Prerenal Acute Renal Failure due to Volume Depletion.
What did we learn from this case?
ARF is frequently defined as an acute increase of the serum creatinine level by 25 % from baseline.
The fractional excretion of sodium (FENa) is useful in diagnosing pre-renal ARF. FENa is less than 1 % in many patients with prerenal ARF. Intravenous hydration is the mainstay of treatment.
Hector Contreras
ResponderEliminarEste caso es una clara muestra de como el calculo de la fraccion excretada de sodio puede ayudarnos a discernir en donde se encuentra la causa de la falla renal, ya que el uso de farmacos como los AINES pueden presentar un efecto dañino al interactuar con las prostaglandinas y la perfusion renal ademas de que tambien puede causar un efecto toxico directo en los tubulos renales.
ENRIQUE CABRERA
ResponderEliminarLos aines son los fármacos mas frecuentes como causa de IRA prerrenal por hipoperfusion, ademas agregandole a estos fármacos los IECAS son otro grupo como causa común de IRA prerrenal. En pacientes con uso crónico de estos medicamentos debe cuidarse rutinariamente la función renal. Un buen diagnostico diferencial es la necrosis tubular aguda, y efectivamente la FeNA es muy útil para diferenciar entre causa intrínseca y prerrenal.