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Presenting Complaint: “Nora is very unwell” History of Presenting Complaint: Nora Craddock (85 years old) collapsed at the nursing home this morning where she has lived for three years. The nursing staff reported that she had been complaining of nausea and loss of appetite for two or three days and that she had vomited earlier in the day before her collapse. Her heart failure had been controlled for some time on frusemide, nebivolol and irbesartan. Recently, her ankle oedema had become worse and her dose of frusemide was increased. A couple of days later she presented with acute gout for which she was given indomethacin. Past Medical History: Chronic kidney disease Hypertension Hyperuricaemia Heart failure Medications on hospital admission: Amlodipine tablets 5mg one each morning Furosemide 40mg two mane and one lunchtime Indometacin 25mg one three times a day, reducing as gout attack settles Irbesartan 150mg daily Nebivolol tablets 1.25mg two daily Allergies: Allopurinol – severe rash Colchicine – myalgia Physical Examination: A pale, tired looking woman with sunken eyes. Dehydrated No ankle or sacral oedema and no signs of pulmonary oedema. BP 105/70 (lying flat), pulse 120bpm, weight 56kgs, height 1.61m Laboratory Tests: Urea and Electrolytes Sodium : 131 mmol/L (137 – 145 mmol/L) Potassium : 5.6 mmol/L (3.6 – 5.2 mmol/L) Bicarbonate : 17 mmol/L (26 – 32 mmol/L) Urea : 37.2 mmol/L (3.8 – 7.8 mmol/L) Creatinine : 312 micromol/L (45 – 90 micromol/L) eGFR : 11mL/min/1.73m2 (>90 mL/min/1.73m2) Diagnosis and plan Renal failure, for normal saline 1000mL every 4-6 hours Request full blood count, Calcium (for heart and electrolyte), Phosphate (adjust body pH) Progress Day 2: 24 hour urine volume was 290mL. Oliguria Prescribed frusemide 250mg intravenously plus a further dose of 500mg after 6 hours if urine output did not increase. Daily fluid balance, daily weights, daily electrolytes. Repeat U&Es from Day 2 show: Urea and Electrolytes Sodium : 137 mmol/L (137 – 146 mmol/L) Potassium : 7.1 mmol/L (3.6 – 5.2 mmol/L) Bicarbonate : 19 mmol/L (26 – 32 mmol/L) Urea : 31.7 mmol/L (3.8 – 7.8 mmol/L) Creatinine : 567 micromol/L (45 – 90 micromol/L) eGFR : 5ml/min/1.73m2 (>90 mL/min/1.73m2) Other Biochemistry Calcium : 2.04 mmol/L (2.25 – 2.55 mmol/L) Albumin : 35g/L (35 – 50 g/L) Phosphate : 1.8 mmol/L (0.9 – 1.5 mmol/L) pH : 7.28 (7.36 – 7.44) Explain the mechanism by which Nora’s drug therapy precipitated her current renal problems. How else may drugs cause acute kidney injury? Calculate Nora’s creatinine clearance on admission using the Cockcroft-Gault equation. Is it reliable? Are there any changes you would want to see made to her drug regimen on admission? Why was high-dose furosemide intravenously used in this lady? When is it appropriate to use this diuretic, and when is it inappropriate in renal failure? Do the abnormal levels of calcium, potassium, phosphate and bicarbonate warrant treatment? Comment on the levels, do they indicate anything about her renal problems? What further chronic treatment will she possibly require if her renal function remains at the level of ~600micromol of creatinine?

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