QW04-09-24 – Nephro Critical Care Society

Question 1: Select each option to validate with explanations

Question 1

A 60-year-old male patient with a history of diabetes mellitus and chronic kidney disease is admitted to the ICU with acute kidney injury (AKI). He also has a recent history of severe diarrhea.
His arterial blood gas analysis is as follows:
pH:7.25,
HCO3: 17 mEq/L,
Na: 142 mEq/L
K: 3.3 mmoL/L
Cl: 112 mEq/L
Albumin: 3.0 mg/dL Random blood sugar: 5 mmoL/L
Lactate: 2.3 mmoL/L

Which of the following is the most likely cause of his metabolic disorder?

A. Hemodynamic shock and renal tubular acidosis

B. Hypovolemia and diarrhoea

C. Septic shock and renal tubular acidosis

D. Diabetic ketoacidosis and diarrhoea

E. Uremia and diarrhoea

Wrong Answer: A. Hemodynamic shock and renal tubular acidosis: Hemodynamic shock can cause hyperlactatemia and HAGMA, however, lactate is borderline normal, and there is no information about vitals in the question.

Wrong Answer: B. Hypovolemia and diarrhea: Similarly severe hypovolemia can result in AKI and a shock state leading to hyperlactatemia, which can cause HAGMA. Again, we do not have any information about the volume status of the above patient, However severe inflammatory diarrhea can result in NAGMA.

Wrong Answer: C.Septic shock and renal tubular acidosis: From the question, septic shock can not be ascertained, and for the diagnosis of renal tubular acidosis, urine biochemical analysis along with urine pH is needed.

Wrong Answer: D. Diabetic ketoacidosis and diarrhea: Random blood sugar is normal, DKA is ruled out.

Right Answer:E. Uremia and diarrhoea: In this patient, the high anion gap metabolic acidosis is likely due to uremia from acute kidney injury, while the normal anion gap metabolic acidosis is due to bicarbonate loss from severe diarrhea. This combination results in a mixed acid-base disorder, which is common in critically ill patients with multiple underlying conditions.

Explaination:
Calculated AG: 13, Corrected AG: 15.5. Delta Gap: 15.5-12=3.5, Delta HCO3: 24-17=7; Therefore, delta-delta ratio in this case is calculated to be 0.5, which is suggestive of mixed high anion gap metabolic acidosis (HAGMA)+normal anion gap metabolic acidosis (NAGMA). Now let’s dive into the cause of HAGMA+NAGMA, in the options provided.

Question 2 - Select each option to validate with explanations

Clinical Case Scenario 2

A 45-year-old male presents to the emergency department with confusion and oliguria for one day. He has a history of discoloration of his eyes for the last five days.
Laboratory tests reveal: AST 320 U/L, ALT 410 U/L, GGT 229 U/L, INR > 1.5, Serum creatinine of 300 µmol/L.
Positive ANA (1:320), Positive Smooth Muscle Antibody (1:40), Elevated IgG levels.
Abdominal Ultrasound: Enlarged liver with mild hepatic inflammation, no evidence of cirrhosis or Budd-Chiari syndrome.
Other Tests: Negative viral hepatitis panel, normal ceruloplasmin, elevated ferritin. His GCS deteriorated from 13 to 7, for which the trachea was intubated and the patient was transferred to ICU. Inj Methylprednisolone 125 mg IV OD was started. Despite initial supportive measures, his condition continues to deteriorate.

Question: Which of the following extracorporeal therapies is most appropriate to manage this patient’s condition?

A. Molecular Adsorbent Recirculating System (MARS)

B. Single-Pass Albumin Dialysis (SPAD)

C. Continuous Renal Replacement Therapy (CRRT)

D. High-Volume Plasma Exchange (HVPE)

E. Bioartificial Liver Support System

Wrong Answer: A. MARS® remains the most established extracorporeal liver support. It offers supportive care that can improve the overall clinical condition of patients, potentially leading to better outcomes while waiting for liver recovery or transplantation. In severe cases like in the question, it must be combined with CRRT.[1]

Wrong Answer: B. Single-pass albumin dialysis (SPAD) helps remove albumin-bound toxins that can accumulate due to liver dysfunction, indirectly benefiting kidney function by reducing the overall toxin load in the body. However, SPAD is combined with CRRT to manage both ALF and AKI.

Wrong Answer: C. Continuous Renal Replacement Therapy (CRRT) may be effective in managing AKI however may not be effective in management of ALF.

Right Answer:D. High-Volume Plasma Exchange (HVPE) is an extracorporeal therapy that has shown promise in improving survival rates in patients with ALF by removing toxins and inflammatory mediators from the blood. It can also help manage coagulopathy and hepatic encephalopathy, common complications in ALF. As per an RCT, fewer HVPE patients required renal replacement therapy compared to those who received standard medical management.[2]

Nephro-critical care pearls:
● High-volume plasma Exchange (HVPE) can help manage coagulopathy and hepatic encephalopathy, common complications in ALF. ● HVPE addresses both liver and kidney dysfunctions in this critically ill patient. ● By removing ammonia and other neurotoxins from the blood, HVPE can help reduce the severity of hepatic encephalopathy, a common and serious complication of ALF.

Wrong Answer:E. Bioartificial Liver Support System: These systems incorporate hepatocytes (liver cells) to provide metabolic support and detoxification. They are still under investigation and not widely available

Reference:

[1] Trautman CL, Khan M, Baker LW, Aslam N, Fitzpatrick P, Porter II I, Mao M, Wadei H, Ball CT, Hickson LJ. Kidney Outcomes Following Utilization of Molecular Adsorbent Recirculating System. Kidney International Reports. 2023 Oct 1;8(10):2100-6.

[2] Larsen FS, Schmidt LE, Bernsmeier C, Rasmussen A, Isoniemi H, Patel VC, Triantafyllou E, Bernal W, Auzinger G, Shawcross D, Eefsen M, Bjerring PN, Clemmesen JO, Hockerstedt K, Frederiksen HJ, Hansen BA, Antoniades CG, Wendon J. High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol. 2016;64:69–78.

QW04-September 2024

Question 1: Select each option to validate with explanations

Question 2 - Select each option to validate with explanations