Abdominal Pain- Renal Disease
A 72-year-old male with multiple medical co-morbidities presents with several weeks of right-sided abdominal pain. His family reports he hasn't been eating or drinking much. He has a slightly altered mental status and was unable to provide any more detailed history of his symptoms, such as aggravating/ alleviating factors or the relationship of his pain to meals. His medical history is significant for poorly controlled diabetes with neuropathy and renal insufficiency. He has not seen a primary care provider in over 6 months.
On exam, he is uncomfortable but not in acute distress. His heart rate is in the 100s, and his blood pressure is normal. He is febrile to 101. He has dry mucous membranes. He has tenderness in the right upper quadrant with a positive Murphys sign. His exam was otherwise unremarkable.
Workup?
Imaging- right upper quadrant ultrasound
Laboratory evaluation- CBC, basic metabolic panel, AST/ALT, bilirubin
His labs are remarkable for mild leukocytosis and an elevated Cr (baseline 1.2, currently 2). Imaging was remarkable for cholelithiasis and gallbladder thickening. The EGS team is consulted and the patient is admitted to the surgical ICU given his acute on chronic renal insufficiency.
What are the possible etiologies of his renal insufficiency and the initial treatment strategies based on the underlying cause?
Pre-renal causes, such as hypovolemia, lead to decreased renal perfusion. Treatment involves volume repletion.
Intra-renal causes, such as medication and acute tubular necrosis from sepsis, requires treatment of the underlying cause concurrent with volume repletion, treatment of electrolyte derangements and avoiding further nephrotoxin exposure.
Post-renal causes, such as kidney stones or foley catheter malfunction, require relief of the obstruction.
Based on the patient's history of decreased oral intake, he is at risk for acute hypovolemia, which can worsen his baseline chronic renal insufficiency. He was treated with volume resuscitation and close monitoring of his urine output.
When should he undergo cholecystectomy?
If cholecystitis was the precipitating cause, he would likely continue to worsen if his surgery was postponed.
If hypovolemia was the precipitating cause, it would benefit from volume resuscitation, which can be administered throughout the operative course.
If his renal insufficiency was not an acute change, and it was a slow decline since his last clinic visit, it was unlikely to significantly improve in a short time.
The ICU team, EGS team and anesthesiology discussed the risks versus benefits of proceeding with surgery. Regardless of the etiology, postponing his surgery would be unlikely to improve his operative risk profile. We proceeded with laparoscopic cholecystectomy, and he returned to the ICU postoperatively for ongoing resuscitation and monitoring.
Management of Renal Failure
The causes of renal failure can be categorized into pre-renal, intra-renal, or post-renal. Acute infection can precipitate renal insufficiency, which is associated with poorer outcomes.Â
Pre-Renal
Caused by hypovolemia (dehydration) from decreased intake, nausea/ vomiting, excessive diuresis, third-spacing from acute inflammatory processes (pancreatitis), blood loss, inadequate replacement of insensible losses. The common final etiology in pre-renal causes is decreased renal perfusion. Treatment- volume replacement.
Intra-Renal
Multiple different intra-renal causes, including vascular or micro-vascular etiologies, glomerular disease, and interstitial disease (acute tubular necrosis, medications, and various precipitates such as myoglobin and crystals). The most common acute causes are medication and ATN from ischemic/ sepsis. Treatment involves management of the underlying etiology and supportive care.
Post-Renal
Caused by any obstruction from the renal pelvis to the urethra, including kidney stones, malignancy (can obstruct anywhere from the ureter to the bladder), retroperitoneal fibrosis, prostate enlargement, blood clots in the bladder or foley catheter malfunction. Treatment involves relief of the obstruction.
Acute Cholecystitis with Renal Dysfunction
     Diabetes and severe cholecystitis (Grade III- organ dysfunction) are risk factors for increased mortality in patients with acute cholecystitis.[1] As noted in the discussion above, it is crucial to weigh the risks and benefits of operative intervention. If there is a modifiable risk factor, such as an acute cardiac event that is amenable to intervention.