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Acute kidney injury case study with questions and answers

Single best answer question based on renal clinical case:

 

Single best answer question 1.

  • A 50 year old alcoholic male presents with sepsis secondary to klebsiella pneumonia. His background includes IHD, previous pneumonia, hypercholesterolaemia and hypertension. Medications include: furosemide, enalapril, aspirin, clopidogrel, co-amoxiclav (current) and simvastatin
  • He is treated with IV antibiotics and is managed on an ITU setting for 1 week
  • On step down to a medical ward routine bloods reveal:
    • Sodium 132
    • Potassium 5.0
    • Urea 24 (from 8)
    • Creatinine 390 (from 60)
  • Clinically he is mildly dry, with a BP 135/83, HR 90, he is catheterised with a U/O 35ml/hr

 

Which one of the following is the best management option?

    1. Switch to high dose IV furosemide, stop enalapril, give IV fluids to maintain urine output, daily bloods
    2. Stop furosemide, stop enalapril, add in dopamine and maintain adequate hydration to maintain urine output, daily bloods
    3. Stop furosemide, stop enalapril, adequate fluids to maintain urine output, daily bloods
    4. Continue furosemide, stop enalapril, high dose corticosteroids and continue adequate fluids to maintain urine output, daily bloods
    5. None of the above

 

Click here to see the answer

  • Answer: 3 (stop furosemide, stop enalapril, adequate fluids to maintain urine output, daily bloods)
    • This man has risk factors for AKI (hypertension and dehydration) and is on various renotoxic medications including aspirin, enalapril (ACE-I) and furosemide (loop diuretic).
    • The key is to maintain hydration to keep urine output reasonable (>0.5ml/kg/hr) while stopping as many renotoxic medications as possible.
    • Fluids should be given and frusemide and enalapril stopped. He has a history of ischaemic heart disease so stopping aspirin is not ideal. Daily bloods to monitor response is advised.
    • There is no¬†evidence¬†for dopamine (mentioned in option 2) or hydrocortisone (mentioned in option 4).