Acute renal failure

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1) The patient presented with fever, anemia, and acute renal failure. Initial workup showed features of autoimmune hemolytic anemia, pancreatitis, and hepatitis with normal renal function tests. 2) A positive ANA and low C3/C4 indicated systemic lupus erythematosus (SLE) with autoimmune hemolytic anemia. Renal biopsy was delayed due to the patient's instability. 3) After 3 weeks of intensive care and dialysis, the patient's condition stabilized and renal function gradually recovered with steroid therapy. Renal biopsy was performed and showed no evidence of lupus nephritis.

A = A
R = REAL
F = FIX
Dr.S. KRISHNAN / DR.RAVI ANDREWS

APOLLO HOSPITALS

SUNDAY,17TH DEC. 2006
(Day 1)
16/F
Anuric ARF preceded by hematuria for
a day (Ser. Cr. – 10.8 mg/dl)
Anemia (Hb – 3.0 gm/dl) [ 4 units of
blood 2 weeks ago]
Unexplained fever since 2 months
Backache
Headache,Irritability – Off/On
Skin Rash / Alopecia – 1½ years ago
(Homeopathy)

O/E:-

Obtunded, Febrile, Pale
Pedal edema(+),JVP - Elevated
Bilateral crackles
Tender Hepatomegaly
No icterus / Lymphadenopathy
No focal neuro. signs

FEVER + ANEMIA + CHF + ARF
Clinical possibilities:-

SEPSIS
MALARIA
TMA (HUS)
RPGN
Hematologic Malignancy
Drugs

Primary Action:-
ICU  JUGULAR  HD + Blood + ANTIBIOTICS

PRELIM. LABS………
Hb – 2.8 gm/dl
RBC Count < 1 million/mm3
PBS –Macrocytic Hypochromia &
Spherocytes
LDH – 3012, Bilirubin – 3.0
(Indirect–2.1)
Plasma Supernatent – Pink

Hemolytic Anemia
 Retic count – 3%
 TLC – 7400, Platelets – 1.6 lakh
 ESR – 150
 MP X 3 - Negative

CLINICAL SITUATION

Auto – immune Hemolytic Anemia

Pancreatitis

ARF

Hepato- splenomegaly

MONDAY,18TH DEC. 2006
(Day 2)
Some possibilities ruled out………
Malaria - Neg X 3
HUS – Normal platelets,no schistocytes
Drugs – No rashes, patient too sick
Sepsis – CRP – 16
Lactate - WNL
Procalcitonin – WNL
Prelim. Cultures – Sterile
RPGN – POSSIBLE
Hemat. Malignancy - POSSIBLE

$MONDAY,18TH DEC. 2006 (Day 2) Morning- Dialysis, Blood Evening – Refractory Pulmonary Edema  Ventilation Hypotension  Volume, Inotropes, CRRT 2D Echo-WNL Empiric I.V Methylprednisolone pulses started$

TUESDAY,19TH DEC. 2006
(Day 3)
Patient better
Less inotrope requirement
Less FiO2 requirement
However still anuric, CRRT – dependent
Labs…ANA (1:100) +++, Granular (1F) Anti – ds
DNA – Neg, C3, C4 – WNL CRP – 16 mg/L, cANCA,
pANCA – Neg. Bone Marrow Aspiration – WNL
Cultures - Sterile,G6PD,B12,Folate-WNL
I.V METHYLPREDNISOLONE CONTINUED

TUESDAY,19TH DEC. 2006
(Day 3)
DIAGNOSIS……….
SLE + Autoimmune Hemolytic Anemia
? Lupus Nephritis (Presenting as ARF)
But…
 No e/o Renal Lupus Activity
 Presence of Renoprotective Auto–antibodies
 No HTN
? ARF sec. To Hemolysis  Pigment
Nephropathy
KIDNEY BIOPSY NEEDED !!

WEDNESDAY,20TH DEC. 2006
(Day 4)

Better – CRRT stopped

THURSDAY,21st DEC. 2006
(Day 5)

Off Ventilator
Off Inotropes
Conscious, Tolerating oral feeds
But ANURIC ( Ser.Cr > 5mg/dl)

FRIDAY,22ND DEC. 2006 -
WEDNESDAY,3RD JAN. 2007
(Day 6- DAY 18)
Shifted to wards, oral steroids
Hypercatabolic, Anuric, Daily Dialysis
Dependent
Transfusion dependent – 10 units
Perpetual postponement of Renal Biopsy
(Too sick  Generalised Rash  Line Sepsis 
Prolonged PTT)

THURSDAY,4TH JAN. 2007
(DAY 19)

RENAL
BIOPSY
DONE
(FINALLY) ! !

FRIDAY,5TH JAN. 2007 -
TUESDAY,9TH JAN. 2007
(DAY 20- DAY 24)

 Small amount of
chocolate urine  Clear urine
Daily dialysis
Blood – 2 units
Steroids reduced to 40
mg/day

DISCHARGED ! !

WEDNESDAY,10TH JAN. 2007 -
THURSDAY,25TH JAN. 2007
(DAY 25- DAY 40)

 Alternate Day Dialysis
 Urine output  500ml / day
 Oral Antibiotics
 Blood – 2 Units

3500
3000
2500
2000 Ser. LDH
1500 (mg/dl)
1000
500
0
16

19

41
1

4

6

8

FRIDAY,26TH JAN. 2007
(DAY 41 - YESTERDAY)

Urine output - 700ml
Hb - 7.6 gm/dl, TLC – 8900
Platelets – 2.6 lakhs mm3
Urea - 77, Creat. – 6.0 mg/dl
Electrolytes – WNL
LDH – 355, Bilirubin – 0.4 mg/dl
USG–Normal Kidneys,CRP–65 mg/L

Minimal Access Surgery (MAS) in children though late to start compared to adult MAS has Received 1 October 2013 now reached widespread application. Currently most of the surgeries are being carried out Accepted 13 November 2013 by -scopy surgeries, viz: laparoscopy, thoracoscopy, neuroendoscopy, etc. Newer advances Available online 15 December 2013 continue to be incorporated into pediatric surgery and include Robotic and Single Incision Laparoscopic surgeries. This article reviews the various applications and present status of Keywords: MAS in children.

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1. A = A R = REAL F = FIX Dr.S. KRISHNAN / DR.RAVI ANDREWS APOLLO HOSPITALS

2. SUNDAY,17TH DEC. 2006 (Day 1) 16/F Anuric ARF preceded by hematuria for a day (Ser. Cr. – 10.8 mg/dl) Anemia (Hb – 3.0 gm/dl) [ 4 units of blood 2 weeks ago] Unexplained fever since 2 months Backache Headache,Irritability – Off/On Skin Rash / Alopecia – 1½ years ago (Homeopathy)

3. O/E:- Obtunded, Febrile, Pale Pedal edema(+),JVP - Elevated Bilateral crackles Tender Hepatomegaly No icterus / Lymphadenopathy No focal neuro. signs

4. FEVER + ANEMIA + CHF + ARF Clinical possibilities:- SEPSIS MALARIA TMA (HUS) RPGN Hematologic Malignancy Drugs Primary Action:- ICU  JUGULAR  HD + Blood + ANTIBIOTICS

5. PRELIM. LABS……… Hb – 2.8 gm/dl RBC Count < 1 million/mm3 PBS –Macrocytic Hypochromia & Spherocytes LDH – 3012, Bilirubin – 3.0 (Indirect–2.1) Plasma Supernatent – Pink Hemolytic Anemia  Retic count – 3%  TLC – 7400, Platelets – 1.6 lakh  ESR – 150  MP X 3 - Negative

6. LABS……… Amylase 2387, Lipase 97 (N<60) LFT - WNL HIV,HCV,HBsAg – Negative USG – Normal Kidneys, Hepatosplenomegaly DCT – Positive, ICT – Negative Collagen Profile, ANCA - Awaited

7. CLINICAL SITUATION Auto – immune Hemolytic Anemia Pancreatitis ARF Hepato- splenomegaly

8. MONDAY,18TH DEC. 2006 (Day 2) Some possibilities ruled out……… Malaria - Neg X 3 HUS – Normal platelets,no schistocytes Drugs – No rashes, patient too sick Sepsis – CRP – 16 Lactate - WNL Procalcitonin – WNL Prelim. Cultures – Sterile RPGN – POSSIBLE Hemat. Malignancy - POSSIBLE

9. MONDAY,18TH DEC. 2006 (Day 2) Morning- Dialysis, Blood Evening – Refractory Pulmonary Edema  Ventilation Hypotension  Volume, Inotropes, CRRT 2D Echo-WNL Empiric I.V Methylprednisolone pulses started

10. TUESDAY,19TH DEC. 2006 (Day 3) Patient better Less inotrope requirement Less FiO2 requirement However still anuric, CRRT – dependent Labs…ANA (1:100) +++, Granular (1F) Anti – ds DNA – Neg, C3, C4 – WNL CRP – 16 mg/L, cANCA, pANCA – Neg. Bone Marrow Aspiration – WNL Cultures - Sterile,G6PD,B12,Folate-WNL I.V METHYLPREDNISOLONE CONTINUED

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15. TUESDAY,19TH DEC. 2006 (Day 3) DIAGNOSIS………. SLE + Autoimmune Hemolytic Anemia ? Lupus Nephritis (Presenting as ARF) But…  No e/o Renal Lupus Activity  Presence of Renoprotective Auto–antibodies  No HTN ? ARF sec. To Hemolysis  Pigment Nephropathy KIDNEY BIOPSY NEEDED !!

16. WEDNESDAY,20TH DEC. 2006 (Day 4) Better – CRRT stopped THURSDAY,21st DEC. 2006 (Day 5) Off Ventilator Off Inotropes Conscious, Tolerating oral feeds But ANURIC ( Ser.Cr > 5mg/dl)

17. FRIDAY,22ND DEC. 2006 - WEDNESDAY,3RD JAN. 2007 (Day 6- DAY 18) Shifted to wards, oral steroids Hypercatabolic, Anuric, Daily Dialysis Dependent Transfusion dependent – 10 units Perpetual postponement of Renal Biopsy (Too sick  Generalised Rash  Line Sepsis  Prolonged PTT)

18. THURSDAY,4TH JAN. 2007 (DAY 19) RENAL BIOPSY DONE (FINALLY) ! !

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25. FRIDAY,5TH JAN. 2007 - TUESDAY,9TH JAN. 2007 (DAY 20- DAY 24)  Small amount of chocolate urine  Clear urine Daily dialysis Blood – 2 units Steroids reduced to 40 mg/day DISCHARGED ! !

26. WEDNESDAY,10TH JAN. 2007 - THURSDAY,25TH JAN. 2007 (DAY 25- DAY 40)  Alternate Day Dialysis  Urine output  500ml / day  Oral Antibiotics  Blood – 2 Units

27. 3500 3000 2500 2000 Ser. LDH 1500 (mg/dl) 1000 500 0 16 19 41 1 4 6 8

28. FRIDAY,26TH JAN. 2007 (DAY 41 - YESTERDAY) Urine output - 700ml Hb - 7.6 gm/dl, TLC – 8900 Platelets – 2.6 lakhs mm3 Urea - 77, Creat. – 6.0 mg/dl Electrolytes – WNL LDH – 355, Bilirubin – 0.4 mg/dl USG–Normal Kidneys,CRP–65 mg/L

Acute renal failure

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