A Sore Arm & A Sore Head

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A Sore Arm & A Sore Head

  1. 1. Acute Renal Failure
  2. 2. Acute Renal Failure is Common (and not very nice … .) <ul><li>BMJ    2006;333:786-790   (14   October) Rachel Hilton. </li></ul><ul><li>A rapid fall in glomerular filtration rate, clinically manifest as an abrupt and sustained rise in urea and creatinine </li></ul><ul><li>Key points include: </li></ul><ul><li>1% of acute admissions dues to ARF, ARF complicates 7% of admissions. </li></ul><ul><li>If dialysis needed mortality about 50% </li></ul><ul><li>Previous studies have shown under-referral 1 </li></ul><ul><li>Nephrology advice may improve outcomes! 2 </li></ul>
  3. 3. Refs <ul><li>Khan IH, Catto GR, Edward N, Macleod AM. Acute renal failure: factors influencing nephrology referral and outcome. QJM 1997;90: 781-5. </li></ul><ul><li>Star RA. Treatment of acute renal failure. Kidney Int 1998;54: 1817-31 </li></ul>
  4. 4. A Sore Arm & A Sore Head <ul><li>Mr LB, aged 28 </li></ul><ul><li>Presented to A&E c/o sore swollen arm. </li></ul><ul><li>IVDU – has been speedballing </li></ul><ul><li>Last memory Wednesday night – woke Saturday Morning, attended A&E </li></ul><ul><li>A&E documented swollen left arm and area of pressure on elbow, with surrounding redness </li></ul><ul><li>S/B orthopaedics: </li></ul><ul><li>Dx Olecranon Bursitis </li></ul><ul><li>Admitted to CLDU for IV Abx </li></ul>
  5. 5. A Sore Arm & A Sore Head <ul><li>Minimal past history obtained. </li></ul><ul><li>Creatinine elevated Urea 20.3 creatinine 259 </li></ul><ul><li>CRP 21, WCC 14.1 </li></ul><ul><li>Referred to medics who reviewed Saturday night </li></ul><ul><li>Though to be dehydrated plus cellulitis – IVI commenced overnight. </li></ul><ul><li>Seen by consultant following day & referred to Renal SpR </li></ul>
  6. 6. A Sore Arm & A Sore Head <ul><li>Long history of IVDU </li></ul><ul><li>Left Prison 3/52 ago & only just started using drugs again. </li></ul><ul><li>Known Hep C positive but “ didn ’ t mention it ” to other teams! </li></ul><ul><li>Past history of epilepsy – last fit 2 weeks earlier when tablets “ ran out ” </li></ul><ul><li>Actually complaining of pain in left arm and leg, plus numbness in hand </li></ul><ul><li>Unkempt, bruising left ear and eye (old) </li></ul><ul><li>Swollen oedematous left arm & leg with multiple pressure areas and grazes </li></ul><ul><li>Chest clear </li></ul><ul><li>Abdo SNT </li></ul><ul><li>HS1 + 2 + ESM </li></ul><ul><li>Distal numbness left hand not conforming to a specific dermatome/ nerve distribution. </li></ul>
  7. 7. A Sore Arm & A Sore Head <ul><li>ECG lost (this is important) </li></ul><ul><li>CXR not done therefore requested </li></ul><ul><li>Arm X-rays NAD </li></ul><ul><li>Urine Dip Blood +++, Pro + </li></ul><ul><li>Blood cultures negative </li></ul><ul><li>Rhabdomyolysis +/- compartment syndrome in left hand </li></ul><ul><li>Renal impairment secondary to cardiovascular collapse or vessel problems (cocaine) </li></ul><ul><li>Endocarditis (Murmur plus skin changes) </li></ul><ul><li>Hep C Associated? </li></ul>
  8. 8. Results <ul><li>CK 22087 </li></ul><ul><li>ECHO – large anterior-septal infarct with hypokinesia & left ventricular thrombus </li></ul><ul><li>ECGs found – changes in keeping with above!!! </li></ul><ul><li>CK Mass 10 (normal 1-5) </li></ul><ul><li>Trop T 1.22 </li></ul><ul><li>No myoglobin achieved! </li></ul><ul><li>Renal & Abdo USS normal, as were arm & leg dopplers </li></ul><ul><li>Hb 16.6, WCC 14.1, Pts 108 </li></ul><ul><li>Na 137. K 4.9, Ur 20.3 Creat 259 </li></ul><ul><li>CRP 21 </li></ul><ul><li>ALT 1009, LDH 2936, </li></ul><ul><li>Bili 16, ALP 125, CCa 2.21 </li></ul>
  9. 9. Results continued … . <ul><li>ANCA, ANA, GBM, Cardiolipin negative </li></ul><ul><li>Complement normal </li></ul><ul><li>D-dimers raised, clotting normal. Hep B & C positive </li></ul><ul><li>HIV not tested </li></ul><ul><li>Cryoglubulins not tested </li></ul><ul><li>Nerve conduction studies were planned </li></ul><ul><li>Renal function improved with rehydration & bicarbonate </li></ul><ul><li>Warfarin commenced & ortho asked to review re: ?compartment syndrome </li></ul>
  10. 10. Progress <ul><li>Patient went on to be extremely difficult to manage, with needles secreted about his person & behaviour posing a risk to staff and other patients </li></ul><ul><li>Unfortunately behaviour meant he was discharged under Zero Tolerance rules. </li></ul><ul><li>Last bloods: urea 5.3, creat 59, ALT 131, CK 560, Hb 10.9, pts 643 </li></ul>
  11. 11. Cocaine, Ischaemia & Renal Failure <ul><li>Cocaine has been implicated as a trigger in Myocardial Infarction even in patients with normal coronaries 1 </li></ul><ul><li>Cocaine may cause Rhabdomyolysis even in the absence of muscle pain and signs, or pressure injury. 2 </li></ul><ul><li>Rhabdomyolysis has been considered to be related to a neuroleptic-malignant type syndrome – with agitated excitement, hyperthermia & rhabdomyolsis. 3 </li></ul><ul><li>Renal Infarction has also been reported with cocaine use. </li></ul>
  12. 12. Refs: <ul><li>Murray A, Mittel M et al, Circulation. 1999;99:2737-2741 </li></ul><ul><li>Welch R, Todd K, Krause G, Ann Emerg Med . 1991 Feb;20(2):154-7. </li></ul><ul><li>Dara M, Kakkouras L , Acta Neurol Scand . 1995 Aug;92(2):161-5. </li></ul>

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