A simple but an important measure in the management of acute renal failure

A simple but an important measure in the management of acute renal failure


Authors:

Seyed Seifollah Beladi-Mousavi11, Mohammad Javad Alemzadeh-Ansari2*, Mohammad Faramarzi1 1. Chronic Renal Failure Research Center, Ahwaz Jundishapur University of Medical Sciences, Ahvaz, Iran. 2. Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran

Correspondence:

Mohammad Faramarzi, student of Medicine, Jundishapour University of Medical Sciences, Ahvaz, Iran. Telephone: +98(916) 612-3980 E-mail: m.faramarzi89@yahoo.com

Background:

Acute renal failure is a syndrome characterized by deterioration of renalfunction over a period of hours to days, resulting in the failureof the kidney to excrete nitrogenous waste products and to maintainfluid and electrolyte homeostasis (1). This disease has a high mortality, approximately 50% in developed countries. Causes of ARF are classified to three groups: pre-renal (results from decreased renal perfusion, which leads to a reduction in glomerular filtration rate), Intrinsic renal (caused by ischemic or nephrotoxic injury to the kidney), and post-renal (due to obstruction of the urinary collection system by either intrinsic or extrinsic masses) (2, 3).

In approach to a patient with ARF, urinary tract obstruction must be reminded, although 5% of all causes of ARF are urinary tract obstruction. Early diagnosing and resolving obstruction can cause to completely return of renal function. But if neglected, it can cause to non-compensative complications.

 

Case presentation:

A 34 year-old woman, gravida 3, para 2 presented with a severe preeclampsia (blood pressure of 175/105 mmHg and proteinuria of 2.5 gr/day), at 31 weeks of gestation. She had a history of cesarean section. Ultrasonogram revealed placenta pervia. During recent cesarean section, severe bleeding occurred, because of penetration of placenta into the bladder. Hysterectomy and repair of bladder was done. In this surgery, 5 units pack cell and 4 units fresh frozen plasma were transfused.

After surgery, urinary output reduced and BUN and PCr reached to 40 mg/dl and 2 mg/dl respectively. Primary diagnosis was ATN. In next days, BUN and PCr more raised to 115 mg/dl and 10 mg/dl respectively. At this time, hemodialysis was started. Computed tomography and Serial ultrasonography of kidneys and urinary tract in 2, 4, 8, and 12 day after cesarean section revealed only mild hydronephrosis. Recoded urinary output was 300-350 ml/day. Therefore, it seen that ARF is due to ATN because of severe bleeding during cesarean section and hydronephrosis is secondary to recent pregnancy.

After 10 days, it revealed that urinary bag has not been empted in the end of each day by nurse. So that, during this period the patient has not been any urinary output. Then, the diagnosis was changed to urinary obstruction because of bilateral ureteral injury during hysterectomy. Cystoscopy preformed and revealed severe wall bladder edema. Therefore, Urologist could not insert double J catheter. Nephrostomy was done and approximately 2.5 liters urine was empted. In the next days, urinary output increased and BUN and PCr decreased. A week after nephrostomy, open surgery for repair of ureters was done and double J catheter was positioned in both ureters.

Conclusion:

In approach to a patient with anuria after pelvic operations, urinary tract obstruction must be reminded. Early diagnosing and resolving obstruction can cause to completely return of renal function. But if neglected, it can cause to non-compensative complications