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Early diagnosis of acute kidney injury in a critically ill patient using a combination of blood and urinary physicochemical parameters.

Maciel AT, Park M - Clinics (Sao Paulo) (2012)

View Article: PubMed Central - PubMed

Affiliation: Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Intensive Care Unit, Department of Medical Emergencies, Brazil. toledomaciel2003@yahoo.com.br

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Acute kidney injury (AKI) is common among critically ill patients... Because it is associated with high rates of morbidity and mortality, efforts are being made to identify AKI early to increase the likelihood of successful intervention... By day 3, BUN and creatinine levels had increased only minimally... Urine output had decreased over the previous 24 h but did not fall below the normal range (Table 1)... Serum Na and Cl levels were evolutively similar, while NaU and ClU levels remained high... A significant increase in SIDu was observed, which resulted from increases in NaU and K (KU) levels and decreases in ClU levels (Figure 1)... An abrupt decrease in NaU and ClU levels occurred in parallel with the increases in KU levels... The SIDu decreased but remained very high... NaU and ClU levels fell further, but the KU and SIDu levels remained high... Finally, abrupt decreases in NaU, ClU, and their respective fractional excretions, occurring in parallel with increases in KU and its fractional excretion between days 4 and 6, might also signal severe renal hemodynamic compromise with exacerbated activity of the sympathetic and angiotensin system (a “pre-renal” pattern of AKI)... Cardiac output was not measured in this patient, but successive positive fluid balances argue against hypovolemia as the main cause of the urinary findings... In conclusion, the daily evaluation of changes in simple parameters such as consistent increases in serum phosphate levels, unmeasured anions, and KU, with decreases in NaU and ClU and a persistently high SIDu, could facilitate the early diagnosis of renal impairment before major decreases in urine output or increases in creatinine are observed.

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Daily changes in electrolyte levels in spot urine samples.
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f1-cln_67p525: Daily changes in electrolyte levels in spot urine samples.

Mentions: A 45-year-old male was admitted to our intensive care unit (ICU) from the ward, where he was concluding antibiotic treatment for a urinary tract infection and being treated with oral anticoagulants for antiphospholipid syndrome. On the day of ICU admission (day 0), the patient was found unconscious on the floor of the ward. A cranial CT scan revealed an acute subdural hematoma. The patient was immediately transferred to the ICU and intubated. The anticoagulant was reversed with vitamin K and plasma. Soon after, the patient was transferred to the operating room, where the hematoma was drained and an intracranial pressure (ICP) monitoring device was installed. After the surgery, the patient returned to the ICU. Because of his elevated ICP, the patient was kept sedated with thiopental. Norepinephrine was infused to maintain an adequate cerebral-perfusion pressure. Initial exams after surgery (day 1) revealed normal blood urea nitrogen (BUN) and creatinine levels and increased levels of serum Na+ and Cl- (Table 1). Blood gas analysis revealed a mild non-anion gap metabolic acidosis. A simultaneous spot sample of urine also revealed high levels of Na+ (NaU) and Cl- (ClU) as well as a high urinary strong ion difference (SIDu = [Na+]+[K+]–[Cl-]). By day 2, BUN and creatinine levels had decreased slightly. Urine output over the previous 24 h had been normal. Serum and urine levels of Na+ and Cl- remained elevated, and the SIDu remained high, but the blood gas analysis was normal. The ICP was controlled; thiopental was replaced by dexmedetomidine, and the dose of norepinephrine was reduced. By day 3, BUN and creatinine levels had increased only minimally. Urine output had decreased over the previous 24 h but did not fall below the normal range (Table 1). Serum Na+ and Cl- levels were evolutively similar, while NaU and ClU levels remained high. A significant increase in SIDu was observed, which resulted from increases in NaU and K+ (KU) levels and decreases in ClU levels (Figure 1). Sedation was stopped, but norepinephrine was still necessary to maintain the patient's mean blood pressure above 65 mmHg. C-reactive protein levels and the degree of leukocytosis increased daily, and cultures were collected. On day 4, the patient developed tachycardia, and urinary flow continued to decrease, while norepinephrine levels increased to maintain the mean blood pressure. There was no fever. Treatment with broad-spectrum antibiotics was initiated empirically. During this time, creatinine levels had not increased, but the BUN level increased slowly each day to levels that did not exceed the normal range. Serum phosphate and unmeasured anions (Table 1) also increased daily. Serum Na+ and Cl- were still high, but NaU and ClU levels decreased; KU levels increased daily from day 2 onward. On day 5, the patient developed clear oliguria, although the creatinine measurements performed at the beginning of the day were normal. The BUN level continued to increase. An abrupt decrease in NaU and ClU levels occurred in parallel with the increases in KU levels. The SIDu decreased but remained very high. On day 6, the patient developed fever, severe metabolic acidosis, and refractory shock with overt multiple-organ failure. NaU and ClU levels fell further, but the KU and SIDu levels remained high. The patient's creatinine levels increased abruptly, and the nephrology team indicated the need for continuous renal-replacement therapy; however, the patient died before therapy could be initiated. None of the cultures collected revealed the presence of an infectious agent.


Early diagnosis of acute kidney injury in a critically ill patient using a combination of blood and urinary physicochemical parameters.

Maciel AT, Park M - Clinics (Sao Paulo) (2012)

Daily changes in electrolyte levels in spot urine samples.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3351253&req=5

f1-cln_67p525: Daily changes in electrolyte levels in spot urine samples.
Mentions: A 45-year-old male was admitted to our intensive care unit (ICU) from the ward, where he was concluding antibiotic treatment for a urinary tract infection and being treated with oral anticoagulants for antiphospholipid syndrome. On the day of ICU admission (day 0), the patient was found unconscious on the floor of the ward. A cranial CT scan revealed an acute subdural hematoma. The patient was immediately transferred to the ICU and intubated. The anticoagulant was reversed with vitamin K and plasma. Soon after, the patient was transferred to the operating room, where the hematoma was drained and an intracranial pressure (ICP) monitoring device was installed. After the surgery, the patient returned to the ICU. Because of his elevated ICP, the patient was kept sedated with thiopental. Norepinephrine was infused to maintain an adequate cerebral-perfusion pressure. Initial exams after surgery (day 1) revealed normal blood urea nitrogen (BUN) and creatinine levels and increased levels of serum Na+ and Cl- (Table 1). Blood gas analysis revealed a mild non-anion gap metabolic acidosis. A simultaneous spot sample of urine also revealed high levels of Na+ (NaU) and Cl- (ClU) as well as a high urinary strong ion difference (SIDu = [Na+]+[K+]–[Cl-]). By day 2, BUN and creatinine levels had decreased slightly. Urine output over the previous 24 h had been normal. Serum and urine levels of Na+ and Cl- remained elevated, and the SIDu remained high, but the blood gas analysis was normal. The ICP was controlled; thiopental was replaced by dexmedetomidine, and the dose of norepinephrine was reduced. By day 3, BUN and creatinine levels had increased only minimally. Urine output had decreased over the previous 24 h but did not fall below the normal range (Table 1). Serum Na+ and Cl- levels were evolutively similar, while NaU and ClU levels remained high. A significant increase in SIDu was observed, which resulted from increases in NaU and K+ (KU) levels and decreases in ClU levels (Figure 1). Sedation was stopped, but norepinephrine was still necessary to maintain the patient's mean blood pressure above 65 mmHg. C-reactive protein levels and the degree of leukocytosis increased daily, and cultures were collected. On day 4, the patient developed tachycardia, and urinary flow continued to decrease, while norepinephrine levels increased to maintain the mean blood pressure. There was no fever. Treatment with broad-spectrum antibiotics was initiated empirically. During this time, creatinine levels had not increased, but the BUN level increased slowly each day to levels that did not exceed the normal range. Serum phosphate and unmeasured anions (Table 1) also increased daily. Serum Na+ and Cl- were still high, but NaU and ClU levels decreased; KU levels increased daily from day 2 onward. On day 5, the patient developed clear oliguria, although the creatinine measurements performed at the beginning of the day were normal. The BUN level continued to increase. An abrupt decrease in NaU and ClU levels occurred in parallel with the increases in KU levels. The SIDu decreased but remained very high. On day 6, the patient developed fever, severe metabolic acidosis, and refractory shock with overt multiple-organ failure. NaU and ClU levels fell further, but the KU and SIDu levels remained high. The patient's creatinine levels increased abruptly, and the nephrology team indicated the need for continuous renal-replacement therapy; however, the patient died before therapy could be initiated. None of the cultures collected revealed the presence of an infectious agent.

View Article: PubMed Central - PubMed

Affiliation: Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Intensive Care Unit, Department of Medical Emergencies, Brazil. toledomaciel2003@yahoo.com.br

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Acute kidney injury (AKI) is common among critically ill patients... Because it is associated with high rates of morbidity and mortality, efforts are being made to identify AKI early to increase the likelihood of successful intervention... By day 3, BUN and creatinine levels had increased only minimally... Urine output had decreased over the previous 24 h but did not fall below the normal range (Table 1)... Serum Na and Cl levels were evolutively similar, while NaU and ClU levels remained high... A significant increase in SIDu was observed, which resulted from increases in NaU and K (KU) levels and decreases in ClU levels (Figure 1)... An abrupt decrease in NaU and ClU levels occurred in parallel with the increases in KU levels... The SIDu decreased but remained very high... NaU and ClU levels fell further, but the KU and SIDu levels remained high... Finally, abrupt decreases in NaU, ClU, and their respective fractional excretions, occurring in parallel with increases in KU and its fractional excretion between days 4 and 6, might also signal severe renal hemodynamic compromise with exacerbated activity of the sympathetic and angiotensin system (a “pre-renal” pattern of AKI)... Cardiac output was not measured in this patient, but successive positive fluid balances argue against hypovolemia as the main cause of the urinary findings... In conclusion, the daily evaluation of changes in simple parameters such as consistent increases in serum phosphate levels, unmeasured anions, and KU, with decreases in NaU and ClU and a persistently high SIDu, could facilitate the early diagnosis of renal impairment before major decreases in urine output or increases in creatinine are observed.

Show MeSH
Related in: MedlinePlus