Case Conference 신장내과 R2 우종신

한스 0 자 (F/69) adm : CC ) Poor oral intake (onset: 15days ago) P.I ) 2005 년 12 월 TKR Rt 받은 Hx 있는 자로, 당시 Cr = 1.8mg/dL 로 이상소견 발견하였으며, 수술후 fever 지속되어 antibiotics(ceftriaxone, clindamycin) 투여 후 Cr 증가 소견 보여, 2006 년 1 월 본원 외래 방문하여 F/U 중 15 일 전부터 poor oral intake, vomiting 있어 OPD 통해 입원함.

PMHx : DM /HTN/ TB / Hepatitis (-/-/-/-) Op Hx (+) 2005 년 12 월 TKR Rt travel Hx (-), drug Hx (+) : antibiotics FHx DM(-) HTN(-) renal disease(-) Personal Hx : Alcohol / Smoking (-/-)

Review of Systems General fatigue(+) fever(-) chill(-) Wt. gain(-) Skin rash(-) pigmentation(-) E & ENT visual disturbance(-) diplopia(-) nasal obstruction(-) Respiratory cough(-) sputum(-) hemoptysis(-) dyspnea(-) cyanosis(-) Cardiac angina(-) orthopnea(-) palpitation(-) dyspnea(-) exertional dyspnea(-) G-I A/N/V/D/C (+/+/+/-/-) abdominal pain (-) melena(-) hematochezia(-) Renal oligurina(-) dysuria(-) hematuria(-) incontinence(-) both flank pain(-) urgency(-) fequency(-) residual urine sensation(-)

Physical Examination V/S 130/80 mmHg – 90/min – 19/min – 36.3 ℃ B.W) 58kg Height) 152cm BMI) 25.1kg/m2 General Alert consciousness acutely ill-looking appearance Skin No rash, No pigmentation Head & neck No Neck vein Engorgement Eyes/ENT Isocoric pupil with PLR(++/++) Slinghtly pale conjunctivae Clear sclerae Dehydrated tounge Chest Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft and flat abdomen No tenderness or rebound tenderness Normoactive bowel sound No hepatosplenomegaly Back/extremity CVA tenderness(-/-) Pretibial pitting edema(-/-)

Initial Laboratory Finding CBC/DC 7410/mm g/dL – 35.4 % - 519X10 3 / ㎣ (Seg %) MCV 83.4 fL, MCH 27.3 pg Chemistry TB/DB 0.80/0.09 mg/dL AST/ALT 14/8 IU/L ALP/GGT 54/12 IU/L Prot/Alb 8.0/3.8 g/dL LD/CK 347/41 U/L Glucose 98 mg/dL Ca/P/Mg 10.7/7.0/2.5 mg/dL Uric acid 15.8 mg/dL BUN/Cr 47/6.3 mg/dL Na/K/Cl 130/5.2/98 mmol/L UA RBC many/HPF WBC 2-4/HPF O.B.:3+ Ketone(-) Glucose(-) Protein(-) SG: pH: 5.5

Lipid profile – Total cholesterol : 239 mg/dL Trigalyceride : 219 mg/dL LDL-cholesterol : 172 mg/dL HDL-cholesterol : 21 mg/dL Viral marker – HBsAg/HBsAb/HBcAb (-/+/-) Anti-HCV (-) anti-HAV lgM (-)

Chest PA

Simple abdomen

ECG

Problem list 1. Poor oral intake, nausea, vomiting 2. Azotemia 3. Hyperuricemia 4. Hematuria 5. Hypercholesterolemia 6. s/p TKR Rt

Initial Assessment Acute on chronic renal failure due to dehydration R/O drug or toxin R/O urologic abnormality R/O underlying malignancy Hematuria due to R/O stone R/O underlying malignancy

Initial Plan 1. Spot urine chemistry (Na, Cl, Creatinine, urea nitrogen) -> FeNa Serologic markers (IgA, IgE, IgG, IgM, C3, C4, RF, ANCA ANA, RF, ASO, Cryoglobulin) RBC morphorlogy 24hr urine collection abdominal US IVP If needed, renal biopsy

Laboratory Finding Spot urine chemistry 24hr urine collection Na 89 Protein 190 mg/day urea nitogen 465 Creatinine 621 mg/day Creatinine Urine volume 2370 mL/day FeNa 3.34 CrCl 6.2 mL/min FeBUN 41% Uric acid 289 mg/dL Ca 206 mg/day Urine RBC morphology <5% MCV non glomerular Serologic markers IgG 2810 mg/dL IgA 397 mg/dL IgM 75.9 g/dL IgE 109 mg/dL C3 114 mg/dL C4 19.2mg/dL C-ANCA (-) P-ANCA (-) ANA (-) RF<9.5 IU/mL ASO 1250 IU/Ml (< 200) Cyoglobulin (-)

Abdomen US

Clinical Course I Fliud challenge & diuretics for 7 days 2/283/13/23/33/43/53/6 BUN/Cr47/6.355/6.350/5.940/5.132/4.928/4.729/4.6 Uric acid Input Output

Percutaneous Nephrostomy( )

Clinical Course II 3/63/73/83/93/103/113/12 BUN/Cr29/4.623/3.528/3.035/2.4 Uric acid Input Output Nephro Nephrostomy and hydration

Final diagnosis Acute on chronic renal failure due to dehydration with partial ureter obstruction