There was a lot of excellent information discussed at today's M&M about metformin-induced lactic acidosis with renal failure complicated by AMS, hypoglycemia,hypothermia, hyperoxia (?) , colitis (?), pancreatitis (?), AFib (?)... the list keeps going since pretty much every system seemed affected in this patient!
So for your mental well-being, here's a quick recap and elucidation of some of the complications of renal failure for those of you as sleepy this morning as me!
The AEIOUs of kidneys:
* Altered Mental Status: Any and all of the parts of this mnemonic AEIOU TIPS may present similarly to or with acute renal failure.
* Secondary findings of ARF/CRF:
- Liver: generally doesn't change in ARF unless multi-organ failure (which does happen a lot)
* AST/ALT: generally lower in CRF
- So be especially suspicious if they're in the high normal or elevated range
* Alk Phos: elevated in CRF 2/2 renal osteodystrophy
* Lipase: elevated in ARF/CRF; highest in dialysis patients
- Proportional to degree of renal dysfunction
- Expect 3-5x increase from baseline but generally still less than three times the upper limit of normal
* Troponin: stable elevation;
- TREND IT
- Stable elevation of troponin is associated with poor long-term survival in CKD and we see this all the time! (https://www.uptodate.com/contents/serum-cardiac-biomarkers-in-patients-with-renal-failure/abstract/27-38)
- The effect of dialysis on troponin level is not well-elucidated. Be suspicious of ACS in ARF/CRF always, no matter what.
* Elevated in severe ARF due to increased production 2/2 stress on tissues/decreased perfusion AND decreased utilization 2/2 decreased hepatic and renal processing.
* When elevated and pH<7.1, there is gradually increased excretion through the kidneys but decreased hepatic processing.
* May be decreased in ARF especially with lactic acidosis; this is possibly renoprotective(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3381612/)
* Indications for EMERGENT dialysis: Renal failure is kind of a jerk- it's insidious and causes all sorts of systemic problems that can cascade when you least expect it.