Differential Diagnosis and

Management Plan
Kenneth T. Nuñez  Silver Group
Macy Miñoza
Martin Josephat Abringe Malana
Mitos Omilgo
Joshua Audric Ong
Key Features
History (Chief Complaint & History of Present illness)
● 68/M

● new onset azotemia

● HPI

● 3 days PTA admitted for unstable angina. His pain was refractory to maximal medical
therapy, so he underwent cardiac catheter and subsequently 3 vessel coronary
bypass grafting 48 hours prior to your call from the intern. His post-operative course
was complicated by a non-ST segment elevation myocardial infarction (NSTEMI)but
was otherwise unremarkable
Key Features
1 day PTA urine output began to diminish (total of 150 cc over 24 hrs), and his serum creatinine was
noted to be 3.5 mg/dl (previous creatinine was 1.2 on admission). The patient is intubated and can give
no history

History ( excluding Chief Complaint & History of Present illness)

● history of smoking

● Hypertension

● Osteoarthritis

● peripheral vascular disease

● Medications include furosemide, lisinopril, intravenous nitroglycerin, ibuprofen, and perioperative

cefazolin
Key Features
Physical Exam
●reveals an intubated alert man on ventilator in no acute distress

●Fundoscopy:  Grade 2 arteriosclerotic hypertensive changes  

●GuT:  Foley catheter in place 

●EXT: saphenous vein harvest site benign

Key Features
● HCO3 20, BUN 49, Cr 3.5, FBS 132 

● occasional hyaline casts, moderate pigmented 

● granular casts and many renal epithelial cells

● inverted T waves noted in the anterior leads. 

Problem Presentation

A 68-year-old man with multiple risk factors for kidney injury is experiencing acute onset
of azotemia
 Framework-Anatomic
Cardiac
Cardiorenal syndrome
 Framework-Anatomic
Renal

Vascular

● Renal vein thrombosis Intrinsic renal

● Malignant hypertension ● Glomerulonephritis

● Scleroderma renal crisis ● Tumor lysis syndrome

● Renal atheroembolic disease ● Myeloma

● Renal infarction
 Framework-Anatomic
Renal

Prerenal

● Cardiorenal syndrome Postrenal

● Hepatorenal syndrome ● Prostate hypertrophy

● Abdominal compartment syndrome ● Neurogenic bladder

● Hypercalcemia ● Retroperitoneal fibrosis

Primary Diagnosis
Hemodynamically
mediated Prerenal AKI
 Applying key features and tabulation
Features Vascular Intrinsic AKI Interstitial Intrinsic AKI hemodynamically mediated
Prerenal AKI

Medication: NSAIDS - + +

Medication: ACE - - +
Inhibitors

Medication: - + -
Cephalosporins

Cardiorenal - - +
Syndrome

Atheroembolic + - -
Disease
 Applying key features and tabulation
Features Vascular Intrinsic AKI Interstitial Intrinsic AKI hemodynamically mediated
Prerenal AKI

Casts Granular Granular Hyaline

Fundoscopy: + - -
hypertensive Findings

BUN:CREA <20 <20 >20

Working diagnosis
Vascular Intrinsic AKI
Diagnostics
● Complete blood count (CBC)

● Serum biochemistries

● Urine analysis with microscopy

● Urine electrolytes
Diagnostics
● Complete blood count (CBC)

● Serum biochemistries

● Urine analysis with microscopy

● Urine electrolytes
Diagnostics
● Fractional Excretion of Sodium and Urea

● Sodium

● Urea
Diagnostics
● Bladder Pressure
Diagnostics
● Renal Biopsy
Diagnostics
● Ultrasonography

○ Doppler ultrasonography
Diagnostics
● Nuclear Scanning

● Aortorenal Angiography
Management
● close collaboration among primary care physicians
● assuring adequate renal perfusion by achieving and maintaining hemodynamic
stability and avoiding hypovolemia
● Attention to electrolyte imbalances
● diuretics is management of volume overload
● Supportive therapies (e.g., antibiotics, maintenance of adequate nutrition,
mechanical ventilation, glycemic control, anemia managemen
Treatment
● Dialysis
○ Volume expansion that cannot be managed with diuretics
○ Hyperkalemia refractory to medical therapy
○ Correction of severe acid-base disturbances that are refractory to medical
therapy
○ Severe azotemia (BUN >80-100)
○ Uremia
Treatment
● Dialysis
○ Volume expansion that cannot be managed with diuretics
○ Hyperkalemia refractory to medical therapy
○ Correction of severe acid-base disturbances that are refractory to medical
therapy
○ Severe azotemia (BUN >80-100)
○ Uremia
Treatment
● Dialysis
○ Volume expansion that cannot be managed with diuretics
○ Hyperkalemia refractory to medical therapy
○ Correction of severe acid-base disturbances that are refractory to medical
therapy
○ Severe azotemia (BUN >80-100)
○ Uremia
Prevention
● Smoking Cessation
● Lifestyle Modification. Exercise regularly, maintain normal BMI, manage cholesterol,
control BP, control glucose, Manage stress