Case (28)

[Doctoor]

A 67-year-old male is admitted to the hospital with chief complaint of generalized weakness and potassium level of 6.5 mEq/L.
His laboratory results show acute renal failure (ARF).
The patient has severe osteoarthritis and takes high-dose NSAID.
In the recent heat wave, he noticed that he did not go to bathroom as often as he used to for the last 2-3 days.
The patient looks ill with dry mouth, he is also obese and hypertensive.
His chest is clear and heart sounds are normal.
The abdomen is soft with no lower limb edema.

Questions:
1- What is the most likely diagnosis?
2- How to confirm the diagnosis?
3- What other tests would you order?
4- What treatment would you start for this patient?
Doctoor

[Mustafa]

Assalam aleikum dr.,

1. Prerenal ARF due to dehydration ( the problem is impaired renal blood flow as a result of true intravascular depletion, decreased effective circulating volume to the kidneys or agents that impair renal blood flow.) most probably caused by nonsteroidal anti-inflammatory drugs by blocking prostaglandin production, which alters local glomerular arteriolar perfusion.

2. Urine Analysis ( Urinary NaCl and creatinine to calculate the fractional excretion of sodium )
3. a. Basic Metabolic Panel in 6 hours and then 24 hours
   b. Renal untrasound to rule out nephrolithiasis and urinary obstruction
4. The keys to therapy are treating the underlying disorder, maintaining euvolemia and eliminating offending agents.
intravenous insuline  ( start with 10 IE ) with dextrose ( D50 ). Avoid fluid overload and adjusting the rate of intravenous fluid. Normalize the hyperkalemia by administering KAyexalate per os. Stop NSAID. If the patient also uses ACE inhibitor , it should also be avoided. These are the  primary agents that cause prerenal acute renal failure.

Hoping to have answered correctly based on my arguments for coming up with this diagnosis,

wa assalam

[Dr.Hersi]

diagnosis

1-comlicated SLE to ARF , and hyperkalemia dou to NSAIDRs
2-to confirm the diognosis you need some of the fallowing 11 creteria
    The 11 criteria used for diagnosing systemic lupus erythematosus are:
1-malar  "butterfly" rash
2-discoid skin rash:
3-photosensitivity:
4-mucus membrane ulcers:
5-arthritis: two or more swollen, tender joints of the extremities
6-pleuritis/pericarditis:
7-kidney abnormalities:
8-brain irritation: manifested by seizures (convulsions) and/or psychosis
9-blood count abnormalities: low counts of white or red blood cells, or platelets
10-immunologic disorder:
abnormal immune tests include anti-DNA or anti-Sm (Smith) antibodies, falsely positive blood test for syphilis, anticardiolipin antibodies, lupus anticoagulant, or positive LE prep test
11-antinuclear antibody: positive ANA antibody testing


3=other tes  ESR , blood chemistry testing, direct analysis of internal body fluids, and tissue biopsies. Abnormalities in body fluids and tissue samples (kidney, skin, and nerve biopsies) can further support the diagnosis of SLE.
4 treatment : -accordingt to this pt stop of NSAIDs ,
                   -Treatment of hyperkalemia may include any of the following measures, either singly or in combination:

A diet low in potassium (for mild cases).
Discontinue medications that increase blood potassium levels.
Intravenous administration of glucose and insulin,
Intravenous calcium to temporarily protect the heart and muscles from the effects of hyperkalemia.
Sodium bicarbonate administration to counteract acidosis and to promote movement of potassium from the extracellular space back into the cells.
Diuretic administration to decrease the total potassium stores through increasing potassium excretion in the urine. Please note that most diuretics increase kidney excretion of potassium. Only potassium sparing diuretics mentioned above decrease kidney excretion of potassium.
Medications known as cation-exchange resins, which bind potassium and lead to its excretion via the gastrointestinal tract.
Dialysis, particularly if other measures have failed or if renal failure is prese

[Doctoor]

Well done mustafa and good try dr.hersi
You gave the correct answers for all the questions
This man is suffering from renal failure due to dehydration and the key of treatment is to correct the dehydration and potassium loss by giving insulin (10) IV with dextrose (D50).
Doctoor

[Admin]

This case is closed and 15 points goes to Mustafa.