KUNWOR, BISHAL SGD: 8 SECTION: A2

SKILL BUILDING ACTIVITY: MODULE 16

1. What is the most likely diagnosis of this case?

Ans: While observing this case I found that there is intrarenal cause of acute renal
failure. And the most likely diagnosis is CONTRAST-INDUCED TUBULAR NECROSIS.
Generally, it can be called as contrast induced nephropathy.
2. What is the pathophysiology of the patient’s renal failure?

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Ans:
IODINATED CONTRAST
MEDIA

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RISK FACTORS
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a. Heart failure patients
b. Diabetic patient
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c. CKD patients
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RESPIRATORY BRUST TUBULAR CELL DAMAGE

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RENAL
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VASOCONSTRICTION

Fig1: Concept map for the pathophysiology of contrast media induced nephropathy

1. Woman was introduced with subsequent radiologic imaging to monitor her

progress after angioplasty surgery.
2. Radiologic imaging of artery required to inject the contrast media intravenously.
And the most common used is iodinated contrast media.
 3. The consequence of overuse of iodinated contrast media can lead to the renal
vasoconstriction, oxidative stress, tubular cell damage (Fig1). And the risk
factors are patients with CKD, heart failure, Diabetic patient etc.
4. If there is vasoconstriction of renal artery then there will be low perfusion to the
kidney which is directly related to the decrease Renal Plasma Flow (RPF)/Renal
Blood flow (RBF) and Glomerular Filtration rate (GFR).
5. If there is severe ischemia then, tubular cells are deprived of oxygen which is
very essential for the kidney normal physiological function as well as for the

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survival of the cell.
6. If there is not enough oxygen then, tubular cell dies slough off from the tubule
and can block the lumen of tubule sometime. Otherwise follow the urinary tract

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to the exterior which is the reason for the presence of muddy brown epithelial
debris in the urine of the patient.

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7. The other important key symptom oliguria is due to decreased plasma flow.
8. The other important key symptom high sodium concentration in the urine
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(about 3% which is equivalent to 3 g in 1 liter) is usually very high. In normal
condition there is maximum reabsorption of sodium from the tubule but in this
case as kidney function is impaired due to tubular necrosis, sodium reabsorption
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is also impaired.
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9. Other important key symptom is inability of patient to produced the urine of

high osmolality is due to impaired counter current mechanism which is very
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essential in concentrating the urine.

3. What is the reason behind the patient’s increased BUN and creatine?
Ans: As normal kidney function is to remove the blood urea nitrogen in the form of
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urea and other waste by products like creatine. If the kidney function is impaired
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these waste products will rise in blood and can be very toxic. The reason behind
this can be demonstrated from this equation:
GFR * Plasma Conc of Creatine = Creatine excretion rate
As creatine is not reabsorbed at all, its excretion is directly depending on GFR. If
GFR decreases, Renal system try to main the constant excretion rate and elevates
the plasma concentration of creatine. 50% decrease in GFR can increase the
plasma creatine level by double value.