Prerenal Acute Renal Failure due to Volume Depletion

Author: V. Dimov, M.D.

Reviewer: S. Noor, M.D., Cleveland Clinic
A 67-year-old African American male is admitted to the hospital with chief compl
aint of generalized weakness and potassium level of 6.5 mEq/L. His laboratory re
sults show acute renal failure (ARF). The patient has severe osteoarthritis and
takes high-dose nonsteroidal antiinflammatory drugs (NSAIDs). In the recent heat
wave, he noticed that he did not go to bathroom as often as he used to for the
last 2-3 days.
Past medical history (PMH)
Obesity, obstructive sleep apnea (OSA), hypertension (HTN), osteoarthritis (OA).
Medications
Motrin (ibuprofen), Percocet (oxycodone with acetaminophen), oxycodone, lisinopr
il.
Physical examination
VSS.
HEENT: Dry mucosal membranes (MM).
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, +BS.
Extremities: no c/c/e.
Laboratory results
BMP shows acute renal failure. BUN/Cr were normal several months ago.
BMP in prerenal ARF (click to enlarge the image).
What is the most likely diagnosis?
Prerenal ARF due to volume depletion.
How to confirm the diagnosis?
UA.
Urinary sodium and creatinine to calculate the fractional excretion of sodium (F
ENA).
What other tests would you order?
BMP in 6 and 24 hours.
Renal ultrasound to rule out urinary obstruction and nephrolithiasis.
What treatment would you start for this patient?
Insulin 10 units IV with D50, 1amp. IV x 1.
Kayexalate 45 gm po x 1.
Foley catheter.
Strict I/O.
NS at 150 cc/hr x 2 L, then 125 cc/hr, adjust the rate of IVF according to I/O,

avoid fluid overload.

Hold ACEi and NSAIDs
What happened?
FENA of 0.77 % confirmed the diagnosis of prerenal failure.
Renal U/S ruled out urinary obstruction.
The patient had good urine output with IVF and was in a positive fluid balance.
Potassium normalized after treatment with Kayexalate, Insulin and D50.
There was a downward trend in BUN and creatinine.
BUN and Cr in prerenal ARF (click to enlarge the image).
BUN and Cr improvement with IV hydration in prerenal ARF (click to enlarge the i
mages).
Renal ultrasound in prerenal ARF (click to enlarge the image).
Final diagnosis
Prerenal Acute Renal Failure due to Volume Depletion.
What did we learn from this case?
ARF is frequently defined as an acute increase of the serum creatinine level by
25 % from baseline.
The fractional excretion of sodium (FENa) is useful in diagnosing pre-renal ARF.
FENa is less than 1 % in many patients with prerenal ARF. Intravenous hydration
is the mainstay of treatment.
References
Acute Renal Failure. M. Agrawal, R. Swartz. American Family Physician, April 1,
2000.
Related reading
Hypovolemia versus Dehydration. Renal Fellow Network, 2009.
Published: 08/23/2006
Updated: 04/20/2010
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Labels: Nephrology
14 comments:
PGY-310/02/2008 6:12 PM
This is a good practical case and very useful for new clinicians.
For any clinician:
No foley catheter unless oliguric, anuric, obstructed since any catheter is a fo
reign body and increases infection risk.

Rehydrate if U/A has high spec gavity, mucous membranes dry, or if BUN is >30 ti
mes the creatinine as in this case. Even CHF pts get dry if not in heart failure
. If in doubt, do CXR, BNPT, listen for crackles.
Start with 250cc IVF if BNPT not less than 150 or give carefully while checking
lung bases posteriorly after each bolus along with pulse ox, etc as above.
Half of pts in acute renal failure are septic. Look for and eliminate source suc
h as pneumonia, foreign body, pyelonephritis, joint infections. May be afebrile/
low temp or low WBCs with sepsis.
Do cultures, check lactate ASAP to detect sepsis BEFORE the BP drops. Lactic aci
d "the troponin of sepsis." If septic, give a lot of fluids (up to 10 liters oft
en) since capillary leak syndrome will lead to severe hypotension. If septic exp
ect edema to develop with IV boluses yet be aware pt is intravascularly depleted
. No pressors without fluids "pressors are not your friend" as per lecturers on
Surviving Sepsis campaign.
Reply
Anonymous11/18/2008 3:09 PM
Be careful about using the term "dehydration" when you mean volume depletion. De
hydration refers to water loss alone. Volume depletion more accurately describes
that there are electrolyte losses as well, as is always the case. You certainly
can have situations where there is more free water loss as compared to isotonic
losses (this causes hypernatremia), but it's still called "volume depletion".
Reply
Anonymous11/18/2008 3:14 PM
Agree. Volume depletion is the correct term for most such cases.
Reply
Anonymous7/30/2009 4:47 PM
dr.Ahmed
why pre renal ARF? what is the cause in this case why ARF not from intersticial
nephritis from NSAIDS (Acute intersticial niphritis)it is logic.ther is no bleed
ing or starvation??so what is the cause??
Reply
Anonymous7/30/2009 4:51 PM
"why pre renal ARF?" - because of history, FeNA, clinical response to fluid repl
acement, etc.
"what is the cause in this case why ARF not from intersticial nephritis from NSA
IDS (Acute intersticial niphritis)it is logic."
UA did not show evidence of nephritis. Also, if would have different clinical re
sponse.
"ther is no bleeding or starvation??so what is the cause??" - Cause of pre-renal
ARF in this case is most likely poor PO intake in hot climate.
Reply
abbas4/20/2010 10:59 PM
hi.how i download these cases?thanks

Reply
Anonymous4/20/2010 11:16 PM
There is no way to download the cases short of using the "Save As" in the browse
r and save pages one by one. I think they may be working on a downloadable PDF b
ook but this is not yet available.
Reply
Anonymous5/25/2010 12:12 PM
Another interesting discussion that can be had about this case is with regard to
the disproportionately high potassium seen at presentation.
Reply
Anonymous5/25/2010 1:53 PM
RE: "disproportionately high potassium seen at presentation"
Lisinopril (ACE inhibitor) is the likely contributing factor.
Reply
Anonymous12/23/2010 6:28 PM
Good Case, indeed
Reply
Anonymous1/29/2011 4:00 PM
Great case!! I just wish there were many more.
Reply
Anonymous2/08/2011 7:01 AM
Hey there.
Great to find these cases. :-)
Just have one complaint..
We are students from Denmark, and some of your "codes" are pretty deficult to un
derstand when English are not your main language. Especially under the psysical
examination we got kinda lost. Could you post a "translation", not as much an ex
plation, but maybe just in full words?
Thx alot for this bookmark though.
Reply
Anonymous2/08/2011 11:54 PM
All medical abbreviations are available here:
http://en.wikipedia.org/wiki/List_of_medical_abbreviations
Try searching by first letter (at the top), or just use the search box of Wikipe
dia.
Reply
Anonymous7/11/2012 2:02 AM
is the NSAID affect the renal performance ?

if it yes why u didnt change the drug ?

(:
Reply
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