AKI IN PATIENTS WITH ULCUS

DECUBITUS GRADE IV REGIO

LUMBAL-GLUTEAL AND
MYELOPATHY CERVICAL SUSP.
TRANSVERSE MYELITIS DD IDIM
TUMOR
ADITYA SATRIO FAREDISTO
Case Report

 Name : Mr. T
 Sex : Male
 Age : 58 y.o
 Address : Nganjuk
 Date of examination : Monday, April 12th 2021
 Consulted by: Neurology department (April, 11th 2021) with myelopathy
cervical susp. transverse myelitis dd intradular intrameduler (idim) tumor + ulcus
decubitus gr IV regio lumbal- gluteal + anemia + hipoalbumin + Hiperglikemia +
sepsis + ensefalopati sepsis + AKI dd ACKD + hyperglikemia
Anamnesis

 The patient presented with complaints of feel fatigue and and cannot move his
lower extremities for 2 weeks.
 In 2 weeks family said that the patient just take meal and drink in small portion
and have his weight down 3-5 kg
 Patient complained about can’t urinate and defecate well
 There was wound in his lower back until buttock for about 1 months. The
wound day by day become bigger and in last 2 weeks the wound size reach about
15 cm in diameter, bleeding, smelly and suppurate
 The patient feel fever in the last 2 weeks up and down every day
 No previous history of Hypertention, DM, same chief complaint before
 The patient was taken to RSUD Nganjuk 3 weeks before because couldn’t move
his exstremity, couldn’t feel urinate and defecate -> treated about 1 weeks and
then referred to dr Soetomo General Hospital
 When patient in RSUD Nganjuk the wound in his back and ankle had size about
1-2 cm in diameter but not bleeding, smelly and suppurate
 Physical Examination
Weak E4 V4 M5
Blood Pressure : 130/70 mmHg anemis, no icterus, no
Pulse : 115 x/m cyanosis
Temp : 38.5 0C
Sp02 : 99% (nc 3 lpm) Thorax Symmetrical and
Urine Output : 1000 cc/12 jam no retraction
Cardiac and pulmonary
within normal limit
Abdomen Soefl,, normal bowel
sounds, no tenderness

Extremities:
warm, dry, cappilary refill time< 2
second, edema
Localist Status
 Laboratories Finding
7 April 2021
Lab Result Lab Result Lab Result
Hb 6.8 g/dl BUN SK 69 /1,5 Ph 7,48
HCT 21% K/Na/Cl 6,1/129/101 pCO2 20
MCV 76,1 Ca 7,5 pO2 87 (free air)
MCH 24,6 Albumin 2,1 BE -8,6
MCHC 32,4 GDA 189 HCO3 14,9
WBC 13390 /uL Hbs Ag NR SO2 99%
Neutrofil 91,6 % Anti HIV NR P/F ratio 308
Lymphosit 3,1 %
Rapid Covid 19 NR
Plt 277.000 U//L
SGOT 100 U/L PPT 17,4
SGPT 104 U/L APTT 24,7
CRP 12,4
Procalcitonin 43 (11/4)
HbA1c 6,8 (9/4)
Microbiology Finding 13/4

 Pus culture
 Batang gram negative 2+
 Escherichia coli ESBL
 Blood culture
 Cocus gram positive
 Staphylococcus haemolyticus
 Radiology Finding
Thorax AP (7/04/2021) :
Cor dan Pulmo within normal limit
Lumbosakral AP/Lat (7-4-
21)
Spondylosis thoracolumbalis
Multipel opasitas bentuk
oval yg terproyeksi setinggi
VL 1-2 sisi kiri dapat
merupakan DD: 1. Fecalith
2. Nefrolithiasis kiri
Initial Assessment
 S. Myelopathy Cervical susp. Transverse Myelitis DD Tumor IDIM
(intradular intrameduler)
 Hiperkalemia corrected (6,1 -> 4,5)
 Anemia (hb 6,1)
 Hiperglikemi (GDA 220)
 Ulcus decubitus gr IV Regio lumbal- Gluteal
 Sepsis dengan ensefalopati sepsis
 AKI DD ACKD
 Transaminitis
 Hipoalbumin (2,0)
Treatment Goals:
 Treat infection
 Correction of Anemia, hyperkalemia, hipoalbumin,
metabolic asidosis
 preservation and optimization of renal function
Management
 O2 nasal 3 lpm
 Inf NaCL 0,9% 1000 ml/24 hours
 Albumin 20% Transfusion on 4 hours until alb > 2,5
 PRC transfusion 1 kolf/24 jam until Hb > 9 g/dl
 Inj Ceftriaxon 1 gr/24 jam
 Inj Metamizol 1 gr/ 8 jam
 Inj Furamin 2x1 amp
 NAC 3x200 mg
Follow-Up
9 April 2021
• S: decreased of consciousness, difficulty in
communicating, speak unclearly, weakness
in lower extremities
• O: GCS 445; BP 138/72; HR 113x; RR
25x; T 38.4 C ;SpO2 98% nasal 3 lpm
• Fluid Balance
• Input: Infus PZ 0,9% 1000 ml+ Kidmin
500 ml + water 1500 ml
• Output: UO 1500 ml + IWL 500 ml = 2000
ml
• Fluid balance: + 1000 ml
• Lab : GDP 139 GD2PP 147 HbA1C 6,8;
Uric acid 7,2; pH 7,35 pco2 25 po2 91; Be
-11,8; So2 97; alb 2,0
11 April 2021
• S: decreased of consciousness, fever, no
transfusion PRC because of fever, No
albumin because of fever
• O: GCS 445; BP 128/71; HR 114x; RR
24x; T 38.8 C ;SpO2 98% nasal 3 lpm
• Fluid Balance
• Input: Infus PZ 0,9% 1000 ml+ Kidmin
500 ml + water 1000 ml
• Output: UO 1500 ml + IWL 500 ml = 2000
ml
• Fluid balance: + 500 m
• Lab : Na 136, K 4,5 Cl 105 SGOT 71
SGPT 52 BUN 109 SK 2,7
Follow-Up
13 April 2021
• S: decreased of consciousness, fever, no
PRC transfusion because of fever, no
albumin transfusion because of fever
• O: GCS 445; BP 128/71; HR 114x; RR
24x; T 38.8 C ;SpO2 98% nasal 3 lpm
• Fluid Balance
• Input: Infus PZ 0,9% 1000 ml+ Kidmin
500 ml + water 1000 ml
• Output: UO 1500 ml + IWL 500 ml =
2000 ml
• Fluid balance: + 500 m
• Lab : Hb 5,7 WBC 3820 BUN/SK 93/2,4
Na/K/Cl 143/3,8/121 PCT 26,221 pH 7,33
pCO2 21 pO2 138 BE -14,8 HCO3 11,1
14 April 2021
• S: decreased of consciousness. Fever, have 2
PRC transfusion and 1 albumin transfusion
• O: GCS 4455; BP 130/74; HR 115x; RR 24x; T
37,2 C ;SpO2 98% nasal 3 lpm
• Fluid Balance
• Input: Infus PZ 0,9% 1000 ml + Kidmin 500 ml
+ water 1000 ml = 2500
• Output: UO 1500 ml + IWL 500 ml = 2000 ml
• Fluid balance: +500 ml
• Patient discharged from hospital because
want to be treated at home
DISCUSSION
ACUTE KIDNEY INJURY


Acute kidney injury (AKI) is abrupt reduction in kidney functions as
evidence by changed in
1. Laboratory values;
2. Serum creatinine,
3. Blood urea nitrogen(BUN)and
4. Urine output.

Makris K, Spanou L. Clin Biochem Rev. 2016

AKI CRITERIA

Poston J, Koynor J, 2019

CAUSE OF AKI

Makris K, Spanou L, 2016

CAUSE OF AKI

Makris K, Spanou L, 2016

CAUSE OF AKI

Makris K, Spanou L, 2016

SEPSIS

 Sepsis—Life threatening organ dysfunction caused by a dysregulated host

response to infection
 Septic shock—Sepsis with a requirement for vasoactive therapy to maintain
mean arterial pressure ≥65 mm Hg and lactate elevation to >2 mmol/L despite
adequate volume resuscitation
 qSOFA criteria
 Respiratory rate ≥22 breaths per minute
 Altered mentation
 Systolic blood pressure ≤100 mm Hg

Poston J, Koynor J, 2019

SEPSIS ASSOCIATED AKI

Poston J, Koynor J, 2019

PATHOGENESIS

Peerapornratana et al, 2019

MANAGEMENT

 Maintenance of volume homeostasis and

correction of biochemical abnormalities
(mainly supportive)
 Correction of fluid overload
 Correction of severe acidosis with
bicarbonate administration
 Correction of hyperkalemia
 Correction of hematologic abnormalities
(eg, anemia, uremic platelet dysfunction)
with measures such as transfusions and
administration of desmopressin

Medscape, 2020
MANAGEMENT

Poston J, Koynor J, 2019

CONCLUSION

Peerapornratana et al, 2019

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