Case study: acute renal failure

Bruce R. Wall, MD, FACP

4/3/06
Renal resident conference

Patient P B

80 yo white female with history of HBP for 20 years, and

previous Left hemispheric CVA
CC: Doc, I was playing bridge 2 weeks ago
Known lumbosacral spine stenosis/listhesis with
increasing back pain and loss of strength in lower legs
1 week of nausea and vomiting with minimal abd pain
Two year history of ibuprofen use; recent conversion of
naprosyn for 1 month
No abd distension; no hematemesis; occasional pink
tinged sputum, while on Plavix
Conversion to Ultram, then narcotics, which caused
constipation

H & P continued

No previous documentation of creat in

caregate; current creat 2.5 to 3.5mg%
Iron deficiency anemia documented;
negative colonscopy 1 year ago
GI consulted for nausea, vomiting, anemia
after naprosyn exposure; EGD WNL
Renal consulted for ARF? CRF?
Lower leg weakness, poor gait, and GI
symptoms were her main concerns

PAST HISTORY

Hypertension 20 yrs
Coronary artery stent 2002
CVA with mild expressive aphasia
Anemia
CKD
Diverticulae and internal hemorrhoids
Lumbar stenosis, moderate, at L3-4
Cholecystectomy, appy, & TAH

History: continued

FH: HBP, CVA & ASCVD at young age

SH: remote smoker, very active, no
ETOH
ROS: ataxia with abnormal gait,
requiring walker; GI symptoms; no
history of CHF; no nephrolithiais, no
endocrinopathy, no diabetes; able to
drive

Medications:

Amitriptyline
Aspirin 81 mg
Atorvastatin
Clonidine TTS
Plavix
Iron
Lisinopril
Metoprolol

Protonix
Morphine
SL nitroglycerin
Vitamin K
Centrum
ALLERGY:Voltaren
(nausea)

Physical exam

140/88 90 14 afebrile
Awake, alert, preserved muscle mass;
HEENT: minimal facial asymmetry
NECK: no nodes, chronic stiffness
LUNGS: no hemoptysis; no rales
COR: RRR, no murmur, no gallop
ABD: soft, benign, no hepatomegaly
GU: positive stool occult blood, no mass
EXT: impressive 3+ edema; no purple toes
NEURO: expressive aphasia; abnormal gait; no
hyperreflexia

Laboratory exam

Hgb 9gms; normocytic; plts WNL

Serum iron 20, ferritin 325, sat 18%
Nomal LFTs and normal coags
Sodium 128
Potassium 5.1
Chloride 100
BUN 34
creatinine 2.8
Glucose 100
bicarbonate 23
calcium 7.6
albumin 2.7
cholesterol 225

Labs: continued

CXR - borderline cardiomegaly

Urinalysis: yellow hazy SG 1.01
pH 5 large blood negative ketones
RBC 25/HPF WBC 35/HPF 2+protein
Sonography: left 10.7cm, right 11.9cm
isoechoic with the liver
24 hour urine: clearance 9ml/min; total
protein = 1100mg per day

Additional information

Any additional history required?

Any additional physical exam?

Labs pending: repeat 24hr urine,

complements, myeloma markers,
lupus markers, vasculitis markers

Differential diagnosis:

This slide intentionally left blank

Approach to kidney

Acute vs chronic disease

Nephritic vs nephrotic syndrome
Glomerular disease:acute vs chronic GN
Interstitial disease: infiltrative, AIN
Renal artery disease: stenosis or emboli
Obstructive disease: tubules, stones,
retroperitoneum, BPH vs prostate CA

dont fall in love with your first

diagnosis
TOXIC EFFECTS of NSAIDS
GI toxicity upper and lower
Modest worsening of chronic hypertension
ARF 2 different types
CV effects blocks beneficial effect ASA
Hepatic injury
Bone marrow toxicity aplasia
Anti-platelet effect stop 5 days prior to surgery
CNS changes tinnitus
Skin - TEN

NSAID induced renal failure

Hemodynamic mediated ARF: not a

concern in normal individuals; yet
patients with underlying GN, CKD, or
hypercalcemia all need prostacyclin and
PGE2
Patients with increased vasoconstrictors
AII or NE states of volume depletion
CHF, cirrhosis, & DM are at greatest risk

NSAID induced ARF

Inhibition of PG by any NSAID in state of

vasoconstriction may lead to reversible
renal insufficiency or ARF
Indocin, ibuprofen, and toradol most
common causes
COX II inhibition reported cause ARF
Sulindac/clinoril less suppression & ARF

AIN: allergic interstitial nephritis

Fenoprofen and Indocin relatively

common cause hematuria, pyuria,
proteinuria; yet the full blown
syndrome of fever,rash, eosinophilia is
extremely uncommon
Nephotic range proteinuria is reported
Biopsy is uncommon since pts improve
Prednisone not helpful (retrospective)

Lab profile
Date
2/13/06
2/27/06
3/14/06
3/20/06
3/26/06
3/30/06
4/02/06

BUN
34
40
50
55
86
85
90

Creatinine
2.6
4.0
6.3
7.2
8.0
7.3
6.0

Renal biopsy

Indication
Risk
Solitary kidney?
Complications
Follow up monitoring

Additional serology

Anti GBM negative

ANA 1:40 speckled
PANCA 1:32 with positive MPO
(Myeloperoxidase IgG) of 55 units

biopsy

Overview to classification of RPGN

RPGN is the syndrome; crescentic GN is the

pathologic entitiy
Crescent formation is a nonspecific response to
injury of glomerular capillary wall
>80% crescents present -- severe ARF
Types of crescentic GN:
type I: anti-GBM disease
type II: immune complex disease
type III: pauci-immune disease
Pauci-immune present with necrotizing GN with few
or no immune deposits by IF or EM. Majority of
patients with renal-limited vasculitis are P-ANCA
positive with 75% MPO positive.

Overview to classification of
RPGN

Spectrum of ANCA

Described in 1982
Technical issues: indirect IF assay is
more sensitive & ELIZA more specific
C-ANCA pattern staining is diffuse @
cytoplasm (most are PR3 positive)
P-ANCA stains around the nucleus,
(most are MPO positive)

Clinical applications of ANCA

Is a positive result a true positive?

Yes, if ELIZA (+), fairly good PPV.
Does (-)ANCA exclude ANCA vasculitis?
No, since 40% test (-) in Wegeners.
Does presence of (+)ANCA establish the
diagnosis (no biopsy required)?
No, tissue confirmation is standard.
Does rising ANCA titer correlate with flare?
No, not a reliable indicator of disease.
Does persistant (-)ANCA mean quiescence?
No

Disease associations

ANCA are associated with may cases

of WG, MPA,Churg-Strauss syndrome,
renal-limited vasculitis and certain
drug-induce syndromes (PTU,
hydralazine, minocycline)

therapy

Initial dosing with 1000mg solumedrol

for 3 days
Intravenous cyclophosphamide every
month has less toxicity than PO
Once in remission, consider PO
imuran, methotrexate, or ENBREL?

Lab profile
Date
2/13/06
2/27/06
3/14/06
3/20/06
3/26/06
3/30/06
4/02/06

BUN
34
40
50
55
86
85
90

Creatinine
2.6
4.0
6.3
7.2
8.0
7.3
6.0