A 39-year-old man is admitted to the hospital for acute alcoholic pancreatitis. His initial APACHE II score was 20, suggestive of severe disease. Within the first 48 hours, he received a total of 10 liters of intravenous fluid resuscitation. Because of decreasing oxygenation, he was intubated and started on mechanical ventilation. Due to increased oxygen requirements, both PEEP and FiO2 were progressively increased. Over the past 12 hours, his urine output decreased and his serum creatinine increased from 1.2 mg/dL at admission to 2.2 mg/dL at present.
His blood pressure is 110/70 mm Hg and pulse is 98/min. Jugular venous pressure is elevated. Lung examination reveals bilateral crackles at the lung bases. His abdomen is diffusely tender and tensely distended. Bowel sounds are diminished. There are no flank or periumbilical ecchymoses. There is 3+ pitting edema to mid-thighs bilaterally.
Urinalysis results are as follows:

Which of the following would most likely establish the cause of the acute kidney injury?

Question

A 39-year-old man is admitted to the hospital for acute alcoholic pancreatitis.  His initial APACHE II score was 20, suggestive of severe disease.  Within the first 48 hours, he received a total of 10 liters of intravenous fluid resuscitation.  Because of decreasing oxygenation, he was intubated and started on mechanical ventilation.  Due to increased oxygen requirements, both PEEP and FiO2 were progressively increased.  Over the past 12 hours, his urine output decreased and his serum creatinine increased from 1.2 mg/dL at admission to 2.2 mg/dL at present.
His blood pressure is 110/70 mm Hg and pulse is 98/min.  Jugular venous pressure is elevated.  Lung examination reveals bilateral crackles at the lung bases.  His abdomen is diffusely tender and tensely distended.  Bowel sounds are diminished.  There are no flank or periumbilical ecchymoses.  There is 3+ pitting edema to mid-thighs bilaterally.
Urinalysis results are as follows:

Which of the following would most likely establish the cause of the acute kidney injury?

Quizplus · Accepted Answer

11ec193a_9722_55b9_853d_01364fda3b46_MD0002_00 This patient's presentation is consistent with likely intra-abdominal hypertension (IAH) causing abdominal compartment syndrome (ACS). Intra-abdominal hypertension is defined as pressure > 12 mm Hg; and ACS is defined as IAH with new organ dysfunction. Primary ACS is due to abdominal pelvic disease, while secondary ACS is usually due to extra-abdominal conditions (e.g., burns). Abdominal compartment syndrome occurs in patients receiving large amounts of fluids and almost any organ can be affected (especially the kidney due to its anatomical position). While the exact pathophysiology is unknown, acute kidney injury is likely due to decreased renal blood flow and elevated renal venous pressure. A diagnosis of ACS can rapidly be confirmed by measuring hydrostatic pressure within the bladder, which is strongly correlated with intra-abdominal pressure. Lowering intra-abdominal hydrostatic pressure often quickly improves renal function; however, most patients require surgical decompression. Abdominal compartment syndrome has a mortality rate ranging as high as 40-100%. (Choice A) An abdominal CT scan in ACS patients is fairly non-specific (e.g., massive abdominal distention, direct renal compression or displacement, bowel wall thickening). An abdominal CT scan may help show pancreatic necrosis or a local complication from pancreatitis, but it is unlikely to establish the cause of this patient's acute kidney injury. (Choice B) The fractional excretion of sodium (FE_Na) can differentiate between poor kidney perfusion (FE_Na < 1%)) and renal tubular necrosis (FE_Na > 2%). However, FE_Na is neither sensitive nor specific in ACS and is usually < 2%. (Choice D) An ultrasound of the kidneys and bladder to further evaluate AKI would be indicated if the bladder pressure is normal, but it is unlikely to be of much help in this patient. (Choice E) Complement levels can help differentiate causes of rapidly progressive glomerulonephritis, but this patient's lack of proteinuria makes this less likely. Educational objective: Intra-abdominal hypertension and abdominal compartment syndrome often follow aggressive volume expansion in patients with trauma, septic shock, or other conditions. Abdominal compartment syndrome can cause multi-organ failure, including acute kidney injury. Measurement of hydrostatic pressure within the bladder is preferred to assess intra-abdominal pressure. Most patients require surgical decompression. __________ References: Intra-abdominal hypertension and abdominal compartment syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21184922) Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival? (http://www.ncbi.nlm.nih.gov/pubmed/20095067)

A 39-Year-Old Man Is Admitted to the Hospital for Acute