Acute Renal Failure on Chronic Renal Failure

Case: A 60-year-old man is in the ED where youre working as HMO. He has been complaining of nausea, tiredness, and
confusion. He is also hypotensive. He is a known case of chronic renal failure and is taking furosemide and lisinopril. The
doses of these drugs were increased by the doctor. He is also taking indomethacin for gout.

Task
a. History (symptoms since 3 or 4 days with loss of concentration; had 1 episode of vomiting; didnt pass urine for the
last 12 hours; furosemide 40-80mg, lisinopril not sure; palpitations)
b. Investigation findings from examiner (urea and creatinine high, FBE Hgb low)
c. ECG from examiner (hyperkalemia with increased T wave)
d. Advise patient about further management

Indications for dialysis

- Fluid overload
- Hyperkalemia
- Encephalopathy
- Pericarditis
- Metabolic acidosis

Chronic renal failure

- Anemia
- Gastrointestinal bleeding due to platelet-induced dysfunction

History
- Is my patient hemodynamically stable?
- Since when? Can you describe the confusion? Did you vomit? How many episodes? Was there blood? When
were you diagnosed with CRF? Since when did you take the drugs? Why were the dose increased?
- Since when did you suffer from gout? How long were you taking indomethacin? What dose? How many times?
Any other medications?
- Since when did you last pass urine? Any SOB? Swelling of limbs? Palpitations? Other cardiac problems before?
Chest pain? Cramps? Have you had dialysis before?
- Do you have DM? Have you checked your lipid levels lately? SADMA?

Management
- From history and investigations provided to me you have acute renal failure on chronic renal failure. Your kidneys
are unable to filter the toxins and waste products from your blood and that is the reason for your symptoms.
- I need to admit you in the nephrology unit where you will be seen by the nephrologist. You will be given some
fluids to help increase your blood pressure and urine output under strict monitoring.
- You also have hyperkalemia which is a potentially serious problem and is one of the indications for dialysis, but
the urgent treatment for this is calcium gluconate which protects the heart from any rhythm disturbances.
- The other things that can be given are: Calcium gluconate: cardioprotective (20ml of 10%); 50ml hypertonic
glucose and 25u of regular insulin, 20ml of NaHCO3 can also be given.
- STOP ALL DRUGS (lisinopril causes hyperkalemia, furosemide exacerbates hypotension, and indomethacin
causes kidney damage) because it can further lead to deterioration of your condition!!!