1. Nephrologic Emergencies

2. Case 1 81 y/o WF with poor responsiveness Family couldn’t wake her up
Saw FP day before and felt OK
Squad found her unresponsive
Monitor in squad showed HR 30
Transcutaneous pacing initiated

3. Case 1 In ER, HR 20 without pacer Atropine given without improvement
EKG with 3rd degree AV Block
Transvenous pacer placed
Labs sent, foley placed
Respiratory failure and intubated

4. EKG

5. Case 1- Past Medical History
CKD with Cr 1.9
HTN
Afib
Cirrhosis- cause unknown
Paracentesis this week for ascites

6. Case 1- Meds Cardizem CD 300mg QD Lasix 40mg QD Digoxin 0.125mg QD
Enulose 15cc QD
Remeron 30mg QD
Aldactone 100mg QD*
Neutraphos K 1 packet TID*

7. Case 1 BP dropped and dopamine initiated Labs:
ABG 7.08/23/273/6.9 on vent
CK 56, troponin 0.11
Na 131 K 8.3 Cl 100 CO2 9 AG 22
BUN 34 Cr 4.7
Dig 2.3 Phos Mag 2.4

8. Case 1 Bicarb, D50, Insulin Albuterol 4 puffs Kayexalate 30 gm
Digibind 1 vial
Repeat K and ABG
Nephrology contacted

9. Case 1 Family gave consent for hemodialysis
Catheter placed, transferred to ICU
Hemodialysis on 0 K bath x1 hr then 2 K
During dialysis rhythm became Afib in 90’s
TV Pacer turned off

10. Case 1 Admission day Next morning 0530 K 8.3 0730 K 7.5 1200 K 4.5

11. Case 1 Summary Renal function improved to Cr1.9 with hydration
DC’d off neutraphos and aldactone
Synthroid started for TSH 50.09
Outpt followup for cirrhosis

12. Case 2 65 y/o WF found unresponsive
Had been depressed due to poor health
History of alcoholism requiring admissions
Various bottles of alcohol at scene per squad

13. Case 2 In ER completely unresponsive Vitals stable but no gag
Intubated for airway protection
Physical exam unremarkable except
Thin, mildly malnourished
open ulcers on legs
Lungs scattered rhonci

14. Case 2 Past Medical History per niece Diabetes mellitus
Chronic leg ulcers
HTN
Alcoholism
Tobacco abuse
Depression

15. Case 2- Meds Glucotrol XL 10 mg QD Altace 5mg QD Zoloft 50mg QD
Recently finished antibiotic for leg ulcers
Home remedy- rubbing alcohol for legs

16. Case 2- Labs ABG 7.29/32/365/17 Na 130 K 3.9 Cl 108 CO2 14
Glu 78 BUN 31 Cr 1.1 AG 8
Acetone neg
Lactic acid 1.3

17. Case 2
DOA neg, ASA neg
EtOH 0.86

18. Case 2 Why doesn’t this make sense?
Metabolic (and respiratory) acidosis
Nongapped with neg acetone, neg lactate
Ethanol should give a gapped acidosis

19. Case 2 Calculated serum osmolality 275 2Na + Glu/18 + BUN/2.8
Measured serum osmolality 353
Osmolal gap 78
Normal osmolal gap <10

20. Case 2- Increased Osmolal Gap
Ethanol
Ethylene glycol
Methanol
Isopropyl alcohol
All should have an increased anion gap also
…except isopropyl

21. Case 2 Review of history- Pt was found with various bottles of alcohol
Mostly vodka, some isopropyl
When sober, would wipe legs ulcers with isopropyl
When drunk, apparently would drink it

22. Case 2 Pt emergently dialyzed x 8 hrs
Isopropyl, methanol, ethylene glycol levels “sent out”

23. Case 2- Summary Pt began to wake up at end of dialysis
Extubated the following day
No long term neurologic adverse effects
Renal function remained stable
Psych and crisis evaluations

24. Case #3
68 y/o AAM sent in from chronic hemodialysis unit where staff noticed
a diffuse red rash/discoloration to skin of chest and face
Hypertension uncharacteristic for this patient did not respond to clonidine 0.2 mg)
Decreased mental staus

25. Case #3 PMH – ESRD, DM2, PVD, HTN, CAD
PSH – b/l BKA, CABG, PTCA (8 months prior), Left UE A/V fistula, Penile implant
All – NKDA
Soc – married, no tobacco/EtoH, independent, high functioning

26. Case #3 Meds Phoslo 667 mg I TID meals Nephrocaps QD evening meal
Accupril 10mg QD
Atenolol 12.5 mg BID
ECASA QD
Glucotrol XL 2.5 mg qd
Tylenol, Lomotil PRN
Viagra 50 mg PRN

27. Case #3
Exam T-98, P-95, R-22, 170/63
Skin – diffuse redness to face, chest, hands (palmar) no macules, papules, ecchymosis, discrete lesions
HEENT – lips swollen, poss periorbital edema
H – RRR, L – clear
Abd – soft, nontender, no hepatospleenomegaly, no rebound
Ext – L a/v fistula + thrill/bruit

28. Case #3 ABG 7.43/43/54/29/88% on Room air CBC WBC – 10.4 RBC – 1.21
Hgb – 7.0
HCT – 11.0
MCV – 86
PLT – 69,000
Sample is grossly hemolyzed

29. Case #3 Na-139, K-3.8, Cl-102, HCO3-29 BUN-38, Cr-6.0 Glu 424
CPK-545, CK-MB-22.8 (4%)
Troponin I 2.7

30. Case #3 Differential for Hemolysis Liver disease Hypersplenism
Infection (Clostridial sepsis, babesiosis, malaria, bartonella, E. coli O157)
Microangiopathies (TTP/HUS, Valvular prosthesis)
Autoimmune (warm/cold Ab)
Infusions – IVIg, Rhogam, Hypotonic saline, blood transfusion
Oxidant agents – dapsone, nitrites, snake bites
Hemoglobinopathies, Enzyme deficiencies, membrane deficiencies

31. Case #3 More lab results Albumin – 3.1
Total bilirubin – 13.9, indirect – 12.6
Retic % 3.2
AST-238, ALP-43, ALT-37, GGT<8
LDH – 4591
Haptoglobin – 36 (49-297)
Myoglobin

32. Case #3
Intravascular hemolysis, thrombocytopenia, altered mental status in a renal failure patient
Thrombotic Thrombocytopenia Purpura
Pt received therapuetic plasmapheresis (TPE) alternating with hemodialysis. Stabilized in 4-5 days. Suffered NQWMI day one

33. Case #4 62 y/o CM presents with confusion and altered mental status
Family states he was normal yesterday but has been unable to “clear the cobwebs” today. Seems as though he is getting progressively more sleepy as the day goes on.
PMH – DM2 diet controlled, HTN
PSH – Appy, L femur fx with internal fix
All - NKDA

34. Case #4
Soc – retired school teacher, married, independent, Tobbaco 60 pack-years, EtoH-social (daily)
Meds
Accuretic 10/12.5 md QD
ASA QD

35. Case #4
Exam T-98.6 P-88 R /80 80kg
Neuro – sleepy, follows simple commands, poor historian, communications are incoherent. Pupils are 4 mm, equal and reactive. Neck supple. Reflexes brachial/patellar normal.
H-RRR, no JVD, L-slight expiratory wheeze left
Abd – soft nontender no HSM
Ext – no edema

36. Case #4 CT Head – normal ABG 7.41/40/98/25/99% on room air
Na-108, K-3.2, CL-76, HCO3-23,
BUN – 23, Cr-0.8
Glu-96
CXR – left upper lobe peripheral density
Sosm – 226, Uosm – 560 mosm/kg

37. Case #4 Hyponatremia Treatment
Hypo-osmolar, Euvolemic, but this patient has neurologic manifestations
Treatment
Restoration of serum sodium, goal 120Meq/L
Na deficit: ( Meq/L)(0.6)(80kg)
=576 Meq of sodium needed to correct
One liter of 3% NaCl has 513 Meq Na
Correct 0.5 Meq/L each hour (12 Meq/L over 24 hours)
Hang one liter NaCl 3% at 40 cc/hr through central line.
Monitor Na q2 hours, neuro checks
Investigate underlying cause