Sunday, March 7, 2004 - 7:30 p.m.
Rooms 2 & 3
Click here for the handout from this conference.
Vanderbilt University Medical Center
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KELLY D. SMITH
University of Washington
A 52-year-old female, who is status post cadaveric renal transplant for polycystic kidney disease and
end stage renal disease (one and a half years status post bilateral nephrectomies). Total ischemic
time was 13 hours and 32 minutes, and cold ischemic time was 12 hours and 58 minutes. The patient put
out a small amount of urine immediately postoperatively, but soon became anuric. Several renal
ultrasounds obtained in the post-operative period demonstrated excellent perfusion of the kidney.
She has been followed in transplant clinic for her delayed graft function, and is now 8 weeks status
post cadaveric kidney transplant. She continues to complain of marked fatigue and weakness. She has
been receiving intermittent transfusions of packed red blood cells, and regular hemodialysis. She has
very minimal urine output, and the urine has been relatively dark. Today, she has made 6 cc, and her
typical urine output ranges from 10-50 cc per day. She has not experienced dysuria, or noted any
change in her urine. She denies any fevers or chills, and has not had any headaches.
medications are tacrolimus (2 mg bid), sirolimus (5 mg per day), ganciclovir (500 mg per day),
clotrimazole (10 mg qid), Zantac (150 mg per day), Docusate (250 mg bid), Multivitamin (one per day),
Temazepam (30 mg hs), Trazodone (12.5 mg per day), Dilaudid (2 mg q 2-4 h prn), Fentanyl (patch 50 mcg
every 3 days), and PhosLo (two tablets tid).
On physical exam the patient is afebrile with a
blood pressure of 110/80 mmHg. Her abdomen is markedly distended with pain in several areas
(secondary to her polycystic liver disease), but her graft is relatively nontender. Her ankles show
symmetrical edema without any effusion in the joints or erythema.
Laboratory studies are notable
for a tacrolimus level of 4.4 (target 10), BUN 30, creatinine 3.8, and glucose 154, white blood cell
count 3.77, hematocrit 33, and platelet count 106,000. Sirolimus level 8.9 (target 10-15).
Clinical impression: Primary graft nonfunction. The patient's immunosuppressive levels have been
kept relatively low over the last several weeks with tacrolimus levels between 2.1 and 10, but mostly
in the 2-3 range. Sirolimus levels have been under the goal of 10-15, often times 8.9 to 9.1. She
has not had any evidence of obstruction. She is being dialyzed.
Beth Israel Deaconess Medical Center
A19-year old college freshman running in a 400 m race (no prior training) fell just before the end,
sustained abrasions, but completed the race. He had not eaten all day, drank minimally on the
nine-hour bus ride home, and vomited once. In the Emergency Room, he vomited again, and physical
examination was significant for mild hypotension and abrasions. Urinalysis revealed proteinuria (3+),
many RBC's, and no casts. He was admitted 3/28; biopsied 3/29.
| || CREATININE ||CREATINE KINASE|
|3/28 || 2: 41 AM|| 3.0 || 320|
|3/28 || 7:10 AM || 3.9 || |
|3/28 || 3:00 PM || 4.3 || |
|3/29 || 7:00 AM || 5.1 ||468|
|3/30 || 8:00 AM || 3.6 ||1104|
|3/31 || 6:35 AM || 2.4 ||1135|
|4/07 || 3:42 PM || 1.2 ||118|
CYNTHIA C. NAST
Los Angeles, CA
The patient is a 29 year old Vietnamese woman who initially presented an elevated serum creatinine
level of 2.3 mg/dl and hypertension. At that time she had normal size kidneys by ultrasound and a
normal serologic profile. She was treated with atenolol. One month later she developed nausea,
vomiting and generalized fatigue and was admitted. She had developed hematuria and dysuria 2 days
prior to admission. She denied arthralgias, hemoptysis and rash.
|BP 120/92 Pulse 88 Temp 99 |
| HEENT: || no retinopathy, malar rash or pharyngitis|
| Chest: || clear|
| Cardiac: || normal|
| Abdomen: || soft, no organomegaly|
| Extremities:|| no C,C, E|
| Laboratory Studies |
| WBC 7.4, Hct 19, Plt 189,000|
| Na 128, K 6.1, Cl 100, CO2, Glu 129, Cr 7.3, BUN 75|
| ANA < 1:40, Anti-ds DNA < 1:5, C3 170, C4 42|
| Urine analysis: Ph 5.0, 3+ protein, large occult blood, TNTC RBCs and WBCs, no casts|
A renal biopsy was performed.
XOCHI J. GEIGER
A 44 year-old African-American female presented with worsening renal function over a several month
period. Her serum creatinine had steadily increased from baseline of 1.9-2.0 mg/dL to 2.2, 2.7 and a
current value of 2.9 mg/dL over the past two months. At her previous visit she was noted to have left
maxillary sinusitis, for which she received antibiotics, but currently was without complaints, feeling
well and denied shortness of breath, lower extremity edema, hematuria or rash. Her past medical
history was significant for recurrent urinary tract infections, granulomatous hepatitis, sarcoidosis
and Crohn's disease. She was afebrile with blood pressure 118/80 mm Hg and weight 111 kg. Physical
exam revealed clear lungs, no hepatosplenomegaly and and no extremity edema. Laboratory examination
revealed serum creatinine 2.9 mg/dL, urine protein /creatinine ratio 0.15, platelets 258,000/uL and
hemoglobin and hematocrit 11.6 and 33.9 g/dL, respectively. Urinalysis showed trace protein and
moderate blood. Renal biopsy was performed.
VIVETTE D. D'AGATI
New York, NY
A 3 year-old African-American male (date of birth 4/2/94) was referred to a pediatric nephrologist in
May l997 for work-up of polydipsia, renal glycosuria and proteinuria. The child's height was in the
50th percentile and his weight was in the 25th percentile for age. Physical examination was
unremarkable, with BP 96/56. Urinalysis disclosed pH 7.0, 1+ protein, 3+ glucose (quantitated urine
glucose 500 mg/dl with simultaneous blood glucose 91 mg/dl), 3-4 rbc/hpf, 0 wbc. Blood chemistries
included Na 139 mEq/L, K 5.0 mEq/L, HCO3 18 mEq/L, BUN 14 mg/dl, and creatinine 0.8 mg/dl. By
ultrasound, the kidneys were normal sized with increased echogenicity. Further work-up disclosed
creatinine clearance 79 ml/min/1.73 m2, Uprot/Ucreat ratio of 0.8, serum albumin 4.8 g/dL, cholesterol
168 mg/dL, calcium 10.0 mg/dL, phosphorus 5.1 mg/dL (fractional excretion of PO4 17%), uric acid 2.7
mg/dL, amylase 195 (normal <80). The following were all negative or normal: liver function tests,
pyruvate, lactate, CH50, C3, C4, C5, C2, C1q, ANA, RF, anti-DNA, SSA, SSB, ENA, anti-Smith, anti-RNP,
lead (Pb) levels, sickle prep, slit lamp examination. A renal biopsy was performed at an outside
institution in October 1997. Because of inadequate tissue for immunofluorescence, a second renal
biopsy was performed in February 1998. The following slides are from this second biopsy.