Q70: Nephrology: PLAB/UK(MLA)/AKT Exam style question

A 64-year-old in-patient with a history of surgical removal of kidney stones is being seen by a urology registrar due to concerns about reduced urine output over the past 2 days. The patient's catheter was accidentally removed, and there is no record of urine output. They have been kept in the hospital due to a chest infection and have been treated with IV antibiotics. The patient denies pain and does not appear confused. Basic observations and blood results are as follows:

Respiratory rate: 14 breaths/min

Heart rate: 82 bpm

Blood pressure: 109/62 mmHg

Sodium: 146 mmol/L

Potassium: 4.1 mmol/L

Urea: 16 mmol/L

Creatinine: 110 µmol/L

Considering the patient's clinical and laboratory findings, what is the most appropriate next step in management?

A. Start continuous renal replacement therapy (CRRT)

B. Administer furosemide

C. Order a renal ultrasound

D. Administer intravenous (IV) fluids

E. Increase the dose of IV antibiotics

The answer is given below

The correct answer is D. Administer intravenous (IV) fluids.  Here's why:

• Prioritize Rehydration: The elevated sodium and slightly low blood pressure suggest dehydration. Fluid replacement is the initial priority to improve renal perfusion (blood flow to the kidneys).

• Volume Status Assessment: IV fluids will help assess whether the patient will respond by increasing urine output. This is a crucial diagnostic and therapeutic step.

Why Other Options are Less Suitable

• A. Start continuous renal replacement therapy (CRRT): This is too aggressive at this stage. CRRT is reserved for severe AKI unresponsive to fluids or those with significant electrolyte imbalances.

• B. Administer furosemide: Furosemide (a diuretic) can worsen dehydration and further compromise kidney function. It's not appropriate without first assessing volume status.

• C. Order a renal ultrasound: While an ultrasound is important to rule out obstruction, it's not the immediate priority. Fluid resuscitation takes precedence.

• E. Increase the dose of IV antibiotics: There's no indication to escalate antibiotic therapy. Focus first on improving renal function.

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References: 

• For the symptoms and signs of aortic stenosis, see section 1.1.2 of the NICE guideline on heart valve disease presenting in adults 1.

• For the role of echocardiogram in diagnosing and assessing aortic stenosis, see section 1.5.2 of the NICE guideline on heart valve disease presenting in adults 1.

• For the indications for intervention in aortic stenosis, see section 1.3.2 of the NICE guideline on heart valve disease presenting in adults 1.

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