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CASE REPORT: ACUTE RENAL FAILURE
JOEL M. TOPF, M.D.
Clinical Nephrologist
248.470.8163
M O R N I N G
R E P O R T
Botsford Hospital Internal Medicine Residency Program
24333 Orchard Lake Road, Farmington Hills\u2022 telephone: 248.426.0955\u2022 fax: 248.426.0956\u2022 www.scsp.net
Case Report
I had chest pain and then fell off my bicycle

A 55 y.o. AA male was riding his bicycle down M5
when he developed severe chest pain and fell off his
bike. He then blacked out. The patient reports for the
last month he has been having episodes of chest pain
when he rode his bike. These were associated with
shortness of breath. He also reports decreased muscle
strength for the last few weeks. No NSAIDs, no recent
contrast.

Past medical history
Ill de\ufb01ned psychiatric disease.
No prior history of cardiac or renal disease. No hyper-
tension. No diabetes. No history of BPH.
Medications
Zyprexia
Simvastatin
No ACEi or ARB
Social history
positive for smoking and alcohol intake, denies street
drugs
Not a photo of the event in question
Not the actual patient
Community EMS to the rescue
Physical exam
Unremarkable except for diffuse tenderness over left lateral thigh. Normal neck veins. No rales. Unremarkable heart
exam. Slightly hypertensive and tachycardic.
ER Course
The patient is started on the acute coronary pathway and evaluated for trauma. The CT abdominal and pelvic CT
scan (without contrast) is unremarkable. Initial labs reveal:
Joel M. Topf, M.D.\ue000
Morning Report
2
Troponin 1.3
Cholesterol 131
LDL 65
HDL 41
Triglycerides 151
RUDS: clean, except
for opiates

Sp Grav 1.020
Color: amber
Protein: 1+
Blood: Large

pH: 6.0

WBC: 0\u20133
RBC: 0\u20133
Epithelial: 0\u20133
Casts: dirty granular

casts
15.2
45.6
11.3
223
134 104 20
4.3 23 2.5
Serum
Differential diagnosis: Increased creatinine
First question is this acute kidney injury or chronic kidney disease?
IN FAVOR OF CHRONIC KIDNEY DISEASE:
1. Age and race
2. History mental illness, on schizophrenia therapy
3. Smoker
4. High speci\ufb01c gravity
5. No evidence of volume depletion or volume over-
load
6. No contrast, ACEi/ARB, NSAIDs
IN FAVOR OF ACUTE KIDNEY INJURY:

1. Blood in the urine
2. normal hemoglobin (eGFR = 35)
3. No history of hypertension or diabetes

4. Granular casts in the urine
WHAT TESTS SHOULD YOU ORDER TO DIFFERENTIATE ACUTE FROM CHRONIC KIDNEY DISEASE?
1. Repeat creatinine
2. Renal ultrasound to look for size and echodensity
Results of secondary investigation:

1. Repeat creatinine was 3.0
2. Renal U/S still pending
3. Fractional excretion of sodium: 0.05

Differential diagnosis of acute kidney injury in this patient
1. Ischemic ATN from an undocumented hypoten-
sion
2. Cardiorenal syndrome from cardiogenic shock
3. Pre\u2013renal azotemia

4. Obstructive uropathy
5. Rhabdomyolysis
6. Rapidly progressive glomerulonephritis
7. Cholesterol emboli syndrome

Joel M. Topf, M.D.\ue000
Morning Report
3
Postrenal
17%
Intrarenal
11%
Prerenal
72%
Outpatient acquired AKI
of 00

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