A 10-year-old boy with dark urine and acute kidney injury: question
- PDF / 69,958 Bytes
- 2 Pages / 595.276 x 790.866 pts Page_size
- 59 Downloads / 175 Views
CLINICAL QUIZ
A 10-year-old boy with dark urine and acute kidney injury: question Charles Joussain & Delphine Lamireau & Caroline Espil-Taris & Valérie De Précigout & Christine Vianey-Saban & Brigitte Llanas & Jérôme Harambat
Received: 20 October 2010 / Revised: 3 December 2010 / Accepted: 5 January 2011 / Published online: 27 January 2011 # IPNA 2011
Keywords Rhabdomyolysis . Acute kidney injury Abbreviations AKI acute kidney injury
Case summary A previously healthy 10-year-old boy presented to the Pediatric Emergency Unit during the winter with fever, myalgias, and muscular weakness since the previous day. The answer to this question can be found at doi:10.1007/s00467-0111767-3. C. Joussain : D. Lamireau : C. Espil-Taris : B. Llanas : J. Harambat (*) Service de Pédiatrie, Hôpital Pellegrin-Enfants, Centre Hospitalier Universitaire, place Amélie Raba Léon, 33076 Bordeaux cedex, France e-mail: [email protected] V. De Précigout Service de Néphrologie, Hôpital Pellegrin, Centre Hospitalier Universitaire, Bordeaux, France C. Vianey-Saban Maladies Héréditaires du Métabolisme, Hospices Civils de Lyon, Lyon, France C. Espil-Taris Centre de référence Maladies Neuromusculaires du Grand Sud-Ouest, Bordeaux, France V. De Précigout : B. Llanas : J. Harambat Centre de référence Maladies Rénales Rares du Sud-Ouest (SORARE), 33076 Bordeaux, France
The urine had turned a dark-brown color. The patient also had diarrhea and occasional vomiting for 2 days. The parents explained that a total dose of 2.1 g of ibuprofen (i.e., 60 mg/kg) had been administered as self-medication the day before. Upon admission, the patient’s blood pressure was 113/ 78 mmHg, and his heart rate was 123/min. Axillary temperature was 39.5°C. Physical examination showed muscular weakness in both legs and flank tenderness. The findings of the respiratory, cardiac, and neurological examinations were normal. The test results on admission were as follows: rapid testing for Influenza A was positive; urine dipstick was positive for bilirubin (3+), blood (3+), and protein (3+). Laboratory tests showed a creatine kinase level of 318,000 U/l, urea nitrogen 18 mmol/l, creatinine 214 μmol/l, bicarbonate 16 mmol/l, and potassium 5 mmol/l. A diagnosis of massive rhabdomyolysis with acute kidney injury (AKI) was made. Rhabdomyolysis progressed with a peak creatine kinase level of 348,000 U/l, lactate dehydrogenase 124,000 U/l, serum myoglobin 42,873 μg/l, aspartate aminotransferase 7,122 IU/l, alanine aminotransferase 1,462 IU/l, metabolic acidosis, hyperkalemia of 5.2 mmol/l, hypocalcemia of 1.5 mmol/l, and hyperphosphoremia of 2.7 mmol/l. Ultrasound imaging showed enlarged kidneys with a loss of corticomedular differentiation. Despite aggressive intravenous hydration with normal saline and urine alkalinization with sodium bicarbonate, urinary output decreased, and the patient developed anuric renal failure on day 2 with a creatinine level of 663 μmol/l and urea nitrogen level of 35 mmol/l. Hemodialysis was initiated on day 2. Nine hemodialysis sessions we
