Why the creatinine was elevated!
To recap:
At 4:30 am his repeat BMP returns
139
106
29
106
4.5
20
2.9
7.9
His creatinine kinase levels where 390 at 9 pm and 345 at 4:30 am
When I saw him at 9 am, he had normal BP lying and standing, with a pulse around 90 at all times. He had had a bladder scan that showed minimal urine, and his output was around 5 cc/hour.
So the question for you is what do you do now? You can order more tests. You can order treatment. You could get a consult. You can criticize the new intern and resident.
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My answer
We had excluded obstruction, and in my mind the differential diagnosis was predominantly volume contraction versus acute tubular necrosis. This differential is often complex, because volume contraction is a major risk factor for ATN. Had the patient become hypotensive enough to damage his kidneys?
I did criticize the intern and resident for not checking an FeNa at admission. I admit a major bias in favor of this test – but ONLY IN OLIGURIC PATIENTS. The original description in 1976 written by Dr. Carlos Espinel was published while he was my ward attending! He explained it to us, and I have used it ever since. A 1978 article – Urinary Diagnostic Indices in Acute Renal Failure: A Prospective Study – concludes:
A prospective analysis of the value of urinary diagnostic indices in ascertaining the cause of acute renal failure was undertaken. Our results show that in the setting of acute oliguria a diagnosis of potentially...
Source: DB's Medical Rants - Category: Health Medicine and Bioethics Commentators Authors: rcentor Tags: Acid-Base & Lytes Attending Rounds Source Type: blogs
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