MGR Case Presentation 신장 내과

Admission Note Chief Complaint Fever with myalgia o/s 내원 2주전 12005077 송 O 석 (M/29) Adm via OPD 2008.10.01 Chief Complaint Fever with myalgia o/s 내원 2주전 Present Illness 평소 특이 병력 없는 29세 남자로 내원 2주전부터 열감과 근육통 있어 감기로 생각하고 지내다, 1주 전부터 피로감 심해지고, 입맛 이 없어 지는 증상 있어 근처 내과 내원하여 실시한 검사상 간수치 와 신장 수치 증가 소견 보여 정밀 검사 위해 내원. .

Admission Note Past medical history DM/HTN/TB/Hepatitis(-/-/-/-) Op. history (-)‏ Drug history (+), herbal medication history (-)‏ Travel history (-), Food history (-), Allergy history (-)‏ Family history No family history of kidney disease No family history of liver disease Personal history Occupation : 창고 및 물류 관리직 Married male Smoking(+)‏ : 10 pack-years Alcohol(+) : 소주 1병/회, 주 1회

Review of System G/A fatigue (+) weight loss (+) 7-8kg Febrile sensation (+)(-) chilling (+)  (-) sweating (-) Skin pigmentation(-) itching sense(-) H & N headache (-) neck stiffness (-) Eye/ENT visual disturbance (-) diplopia (-) hearing loss(-) nasal obstruction (-) rhinorrhea(-) sore throat(-) hoarseness(-)‏ Respiratory cough (-) sputum (-) dyspnea(-) pleuritic chest pain(-) hemoptysis(-)‏ Cardiovascular angina (-) palpitation (-) orthopnea(-) dyspnea on exertion(-)‏ 4

Review of System G-I Anorexia(+) Nausea(-) Vomiting(-) Constipation(-) Diarrhea(-) Hematemesis(-)‏ Hematochezia(-)‏ Melena(-) Abd .pain(+)  (-) : RUQ area, continuous Renal &Urinary dysuria(-) hematuria(-) urgency(-) nocturia (-) incontinence (-) hesitancy(-) oliguria(+) : 종이컵 한컵 분량 , 하루 3~4회 Musculoskeletal myalgia (+) numbness(-)‏ joint swelling(-)‏ joint pain (-) 5

Physical Examination Vital sign) 110/70mmHg – 64/min – 18/min - 36.0 ’C Height/Body weight : 170cm/76.9kg (BMI 26.6kg/m2) General appearance Alert mentality Acute ill looking appearance Skin Rash (-) Pigmentation (-) Jaundice(+)‏ eschar (-) Head and Neck Normocephaly LN enlargement(-/-)‏ Neck vein engorgement(-/-)‏ Thyroid enlargement(-)‏ Eyes and ENT Isocoric pupil with PLR(++/++)‏ EOM : full Pinkish conjunctiva, Icteric sclera PTH/PI (-/-)‏

Physical Examination Chest Symmetric expansion Clear breathing sounds without rale Regular heart beats without murmur Abdomen Soft and Flat abdomen Abdominal Tenderness/rebound tenderness(-/-) Hepatomegaly(-) Normoactive bowel sound Back and extremities CVA tenderness(-/-)‏ Pretibial pitting edema(-/-)‏

Initial lab findings CBC/DC (09/30 외부검사) 10770/mm² - 15.8 g/dl – 43.7% - 146K (seg : 38.1%, lympho : 44.8%) aPTT 35.8 sec PT(INR) 19.3(2.41) CBC/DC (10/01 adm) 16330/mm² - 16.1 g/dl – 44.3% - 131K (seg : 27.1%, lympho : 40%) aPTT 48.8 sec PT(INR) 16.9(1.42)

Initial lab findings Chemistry (09/30 외부검사) TB 4.9 mg/dL BUN/Cr 49.1/6.5 mg/dL (eGFR 10.8 ml/min/1.73m2) AST/ALT 3350/4802 U/L Ca/P 7.8/5.3 mg/dL ALP/r-GT 435/337 U/L LD 3340 mg/dL Pro/alb 5.9/3.7 g/dL Chemistry (10/01 adm) TB/DB 5.89/4.96 mg/dL BUN/Cr 57/8.9 mg/dL(eGFR 7.5 ml/min/1.73m2) AST/ALT 2236/4171 U/L Na/K/Cl 126/3.3/87 mmol/L ALP/r-GT 138/347 U/L Ca/P/Mg 7.8/3.2/2.7 mg/dL Pro/alb 6.4/3.5 g/dL Uric acid 16.5 mg/dL LD/CK 1748/96 mg/dL CRP 1.4 mg/dL ABGA 7.37 – 37.6 – 89.6 – 21.5 – 96.7%

Initial lab findings Urinalysis Occult blood +(10) Bilirubin +(0.5) Urobilinogen +-(0.1) Protein ++(100) pH 5.0 SG 1.012 Urine microscopy Micro RBC 10-29 Micro WBC 2-4 Spot urine Protein/Cr 1670 mg/g Na 24 mmol/dL (FeNa 1.57) Urea 128 mg/dL (FeBUN 46.59) 10

Initial lab findings EKG

Initial lab findings Chest PA 12

Initial problem lists Fever Jaundice Oliguria 13 환자 입원당일 첫 소변 500ml, 24hrs 500ml 로 RIFLE criteria 에 따라 시간당 kg 당 0.3 ml 이하로 Acute kideney injury 에 있어 oliguria 소견에 합당하고, 혈중 creatinine 8.9 mg/dL로 cock-gault Nonoliguria urine output >400ml/24hrs Oliguria = 100~400ml/24hrs Anuria , urineoutput <100ml/24hrs Azotemina A reduced GFR leads to retention of nitrogenous waste products (azotemia) such as urea and creatinine. retention of nitrogenous waste products (azotemia) 13

Initial assessment #1. Acute hepatitis with ARF R/O Viral hepatitis R/O Toxic hepatitis R/O Autoimmune hepatitis #2. Other infectious cause R/O Leptospirosis R/O Hantaan virus infection R/O R. tsutsugamushi, R/O R. typhi. #3. Acute cholangitis with ARF #4. R/O hepatorenal syndrome, underlying LC

Diagnostic plans #1. Acute hepatitis with ARF R/O Viral hepatitis Abd.US, If needed, Abd.CT Laboratory testings R/O Viral hepatitis Anti-HAV IgM, HBsAg and anti-HBc IgM, Anti-HCV If needed, Anti CMV IgM, EBV viral markers R/O Autoimmune hepatitis IgG/A/M/E, SMA, ANA ,anti-LKM1 etc. #2. Other infectious cause R/O Leptospirosis R/O Hantaan virus infection R/O R. tsutsugamushi. , R. typhi,. Leptospiral Ab, Hantaan viral Ab, Rickettsial Ab R/O Viral hepatitis R/O Toxic hepatitis R/O Autoimmune hepatitis

Diagnostic plans #3. Acute cholangitis with ARF Fever study, inculding blood culture Abd.US , if needed abd.CT #4. R/O Hepatorenal syndrome, underlying LC Alcohol history, medication history recheck Abd.US If needed, Abd CT Viral marker for r/o chronic viral hepatitis

Abdominal US

Additional lab findings Viral marker anti-HAV IgM Positive (15.14) HBs Ag Negative anti-HBs Ab Positive (51.32) anti-HBc IgM anti-HCV Ab

Additional lab findings Immunologic marker RPR Negative IgG 1460 mg/dL IgA 226mg/dL IgM 580 mg/dL IgE 139 mg/dL C-ANCA P-ANCA negative ANA Non reactive

Evaluaion of Azotemia Urinalysis (HD#1) Occult blood +(10) Bilirubin +(0.5) Urobilinogen +-(0.1) Protein ++(100) pH 5.0 SG 1.012 Urinalysis (HD#2) Occult blood +-(5) Bilirubin - Urobilinogen +-(0.1) Protein pH 5.5 SG 1.012 Urine microscopy Micro RBC 10-29 Micro WBC 2-4 Urine microscopy Micro RBC 0-1 Micro WBC 20

Evaluaion of Azotemia Spot urine HD #1 HD #2 Protein/Cr 1673 mg/g Na (FeNa 1.57) (FeNa 5.19) Urea (FeBUN 46.59) BUN/Pcr Ratio 6.4:1 Urine sodium 24 meq/L Urine osmolarity 168 mOsm/L FeNa 1.57 Urine/plasma creatinine (Ucr/Pcr) 11.67

Evaluaion of Azotemia

Diagnosis Acute renal failure Acute tubular necrosis --- associated with acute hepatitis A Bile salt가 renal tubular cell에 uptake되며 이에 의한 renal tubular damage의 결과로 acute hepatitis와 함께 그 sequelae로 acute renal failure가 온 것으로 생각해 볼 수 있겠습니다.

Therapeutic Plan Acute hepatitis A Hepatotonics Symptomatic care Nausea control, glucose supply Acute renal failure d/t HAV infection Urine output 유지 – diuretics 사용 , E’ F/U If needed Hemodialysis, 24

Clinical course

Clinical course

Clinical course HD HD HD HD HD