1. Title : ACUTE KIDNEY INJURY (AKI)
NURUL IZNI ROSMAN
(2011612622)
TRAINING VENUE: HOSPITAL TUANKU JA’AFAR,
SEREMBAN
SECTION: CLINICAL CHEMISTRY
BACHELOR IN
MEDICAL LABORATORY TECHNOLOGY
UiTM PUNCAK ALAM
SEPTEMBER 2014

2. INTRODUCTION
Background of case study
Kidney is one of the most important body’s organ. It basically function to excrete
waste product such as uric acid, creatinine and urea in form of urine. Other than that,
kidney also secrete erythropoietin for production of red blood cell (RBC) and, balance
blood pressure, acid-base and plasma volume.
Acute kidney injury, formerly known as acute renal failure, is a condition where the
kidneys suddenly stop function properly and usually happen if one’s being ill from other
disease and are often already ill in hospital. The kidney usually unable to maintain fluid,
electrolyte and acid-bas balance. It can also be characterized by fall in glomerular filtration
rate (GFR). Symptoms and signs of AKI includes oliguria, anuria, nausea, vomiting,
dehydration, confusion, hypertension and skin rashes.
Most of people that have AKI have pre-existing chronic kidney disease (CKD) with
estimated GFR (eGFR) less than 60 mm/hr. Present of months of fatigue, sleep
disturbance, nocturia, anorexia and weight loss are the characteristic of CKD that can be
distinguish from AKI. People with hypertension, chronic heart failure, diabetes and age
more than 65 are at higher risk of developing AKI. AKI also have high rate mortality as
about 25-80% and most people with AKI required renal replacement therapy. In United
States, 1% of patients have AKI at the time of admission to hospitals and the incidence
increase 2-5% during hospitalization.
CLINICAL HISTORY
Patient’s data
A 48 years old Malay man was admitted to Hospital Jelebu on 15th
July 2014. He
was referred from Hospital Jelebu to HTJS on 17th
July 2014. He had underlying
hypertension for one year. He also had cerebrovascular accident on Jan 2014. He is
treated as AKI secondary to persistent vomiting and recurrent stroke.
Clinical feature
Clinical features of this patient included persistent vomiting for four days in a week
( x4/7) prior to admission to Hospital Jelebu, generalized headache over one year,
lethargy and also hypertonia. He also unable to sleep and his headache is persistent.
Patient’s total white blood cells and hemoglobin was in normal range.

3. LABORATORY FINDINGS
Renal Profile Test
Test Normal range Result
Plasma urea 2.8 – 7.2 mmol/L 24.6 mmol/L
Plasma sodium 136 – 145 mmol/L 136 mmol/L
Plasma potassium 3.5 – 5.1 mmol/L 2.9 mmol/L
Plasma chloride 98 -107 mmol/L 97 mmol/L
Plasma creatinine 74 – 110 mol/L 251 mol/L
Plasma albumin 35 – 52 g/L 28 g/L
Plasma calcium
(total)
2.12 – 2.52 mmol/L 1.90 mmol/L
Liver Function Test
Plasma albumin 35-52 g/L 31 g/L
Total protein 66- 83 g/L 75 g/L
Globulin 25 – 44 g/L 44 g/L
Plasma alkaline
phosphatase (ALP)
30 – 120 U/L 201 U/L
Plasma alanine
transaminase (ALT)
< 45 U/L 60 U/L
Total bilirubin 5 – 21 mol/L 15 mol/L
Albumin/globulin
ratio
0.9 – 1.8 0.7
Urine FEME
Parameters Results Reference Range
Specific Gravity
(SG)
1.001 1.002-1.030
pH 11.0 4.8-7.4
Leukocyte (LEU) Negative <10Leuko/µl
Nitrite (NIT) Negative Negative
Protein (PRO) 3+ <0.1g/l
Glucose (GLU) Negative <1.7mmol/l
Ketone (KET) 2+ <0.5mmol/l
Urobilinogen (UBG) 1+ <17µmol/l
Bilirubin (BIL) 1+ <3.4mmol/l
Erythrocyte (ERY) Trace 0-5Ery/µl
All of the test were done in chemical pathology lab of HTJ. For renal profile and
liver function test, analyzer used was SIEMENS Dimension RXL Max. The analyzer use
the principle of spectrophotometry when analyzing the sample. Sample send for renal
profile and liver function test was plasma in lithium heparin tube. Sample is spin for 10
minutes at 4000 rpm prior to tests. For urine FEME (full examination microscopic
examination) test was done using YEONGDONG URiSCAN PRO Urine Chemistry
Analyzer. Noted that in this lab, only full examination of urine was done. This analyzer
measure the sample, which is urine by method of reflectance photometer.

4. DISCUSSION
Glomerulus pressure depend primarily on renal blood flow (RBF) and controlled by
renal afferent and efferent blood vessels. In AKI, GFR decrease because there is
reduction in RBF. Prerenal, renal and postrenal AKI are important for evaluation and
treatment to be given to patient. In prerenal AKI, GFR is reduced due to decreased renal
perfusion with intravascular volume depletion such as vomiting or diarrhea. It can also
occur from decreased arterial pressure ( from heart failure or sepsis). Glomerulonephritis,
vaskulitis, eclampsia and acute tubular necrosis are several factors of renal AKI. In renal
AKI, the component of the kidney is being affected such tubular, glomerular, interstitial or
vascular. In postrenal AKI, kidney pelvis, ureters, bladder or urethra may be affected by
mechanical obstruction. Such obstruction are like stone disease, thrombosis and fibrosis.
As complained by patient, he had persistent headache and unable to sleep, which
are symptoms of AKI. He also had hypertension which increase the likelihood for him to
get the disease. Aside from that, he is also had persistent vomiting, a sign for both kidney
(prerenal AKI) and liver damage. Based on the laboratory findings, he had decreased
potassium level and elevated level of ALP and ALT. Because he keep vomit, there
occurred electrolyte imbalance and the potassium is excreted causing decreased level in
blood. Vomiting can also be a sign of liver damage. When liver is damage, ALP and ALT
is released into blood in huge amount, causing high level of both enzyme.
Other important features of AKI are present in this patient laboratory finding such
as increase of creatinine, urea and decreased of calcium, albumin and albumin-to-
globulin ratio. Low level of the last two parameters is a result from damage in filter part of
the kidney, causing it cannot absorbed the protein. High level of urea is due to kidney that
unable to remove the urea from blood properly. From urine FEME, high pH and presence
of ketones are due to the vomiting that disturb the balance of the electrolyte. High level of
protein is due to blood that leaked the protein (albumin and globulin) into urine, thus
elevated the level.
There are other tests that can be done to diagnose AKI such GFR test, complete
blood count, ultrasonography and renal biopsy. However, I cannot access result from
haematology laboratory for complete blood count.

5. CONCLUSION
AKI can to older people, those that had other illnesses, preexisting CKD and had
AKI before. As a conclusion, this patient is likely suffered from AKI based on all the
symptoms he had and the correlation between that and laboratory findings. The most
important parameter is highly elevated level of plasma creatinine and other supporting
result such as low potassium, low calcium, low albumin and albumin-to-globulin ratio and
increase urea level. He also can be suspected of having liver disease based on elevated
level of ALP and ALT, also presence of bilirubin and urobilinogen in urine FEME test.
However, this patient also had encounter a cerebrovascular accident and there might be
other test that should be considered.
REFERENCES
Workeneh, B. T. (n.d.). Acute Kidney Injury. Retrieved September 14, 2014 from
http://emedicine.medscape.com/article/243492-overview#aw2aab6b2b1aa
Mahboob Rahman. (2012). Acute Kidney Injury : A Guide to Diagnosis and Management.
American Academy of Family Physician, 86(7), 631-639. Retrieved from
http://www.aafp.org/afp/2012/1001/p631.html#sec-5