Question AKI and HTN

[PharmRX0308]

Hi guys,

I would like to hear your thoughts in this case:

An 80yo patient was admitted into the hospital for AKI and Stage II hypertension. He is on lisinopril, HCTZ, and metoprolol for his HTN. He received 100mL NaCl to relieve AKI, but neither his AKI and HTN were improved.

At this point, do you think we should give him Lasix to help with his AKI, or should we give him more fluid? He has no signs of fluid overload.

Also, should lisinorpil be held until AKI is resolved?

Thanks.

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[BidingMyTime]

Do you know what is the cause of the AKI? Usually there is something identifiable behind AKI, so I would think the priority would be figuring out the cause, and correcting the cause. I think giving lasix would be a bad idea, without knowing the cause of the AKI it could possibly make things worse, double bad idea since patient has no signs of fluid overload. Is this a real case, or is this just a homework question where they haven't given you enough information to give a real answer?

 

[PharmRX0308]

Do you know what is the cause of the AKI? Usually there is something identifiable behind AKI, so I would think the priority would be figuring out the cause, and correcting the cause. I think giving lasix would be a bad idea, without knowing the cause of the AKI it could possibly make things worse, double bad idea since patient has no signs of fluid overload. Is this a real case, or is this just a homework question where they haven't given you enough information to give a real answer?

This is a homework case based on a real patient. It's also given that the patient has pneumonia, 10 urine Na and urine output was 100mL/24 hours. I'm still trying to figure out the cause. Dehydration or infection may be the possible causes, but we are not given enough information to be confident with our guess. Other labs are normal. They probably will give us more information when we go to class. Thank you though!

 

[mfdoom]

100ml bolus seems like nothing. Hold lisinopril, hctz. Does the pt have sepsis from the pneumonia?

Man, I'm rusty on therapeutics.

 

[wucool33]

100ml NS? That’s it? Are you sure they didn’t mean to order a 1000ml bag? Also, is the pt already on something for PNA?

Oh... it’s for your homework... nvm

 

[PharmFarmed]

Identifying the cause of the AKI is important. Is it due to execessive NSAIDs? Was it the lisinopril? Did they just get started on it? Remember AKI and CKD treatment is different. Ace inhibitors are renal protective and good for patients with CKD, but in AKI they should be held until resolved. AKI is often precipitated by a low blood volume or blood pressure so you should never be giving the patient diuretics or antihypertensives (specifically meds that act on the RAAS pathways such as ace inhibitors, arbs, AA) during treatment of AKI. There is way too many things going on and the case they gave you have too little information.

Also he has no signs of fluid overload because hes most likely dehydrated.

 

[TimeZero]

Vitals? Perhaps an admission and baseline Scr? The minimal information provided is not indicative of practice, but I'll take a crack at it. Just because a patient has a h/o of HTN does not mean they cannot become hypotensive, especially if septic. Given the low urine sodium and minimal urine output, this is likely prerenal AKI 2/2 dehydration 2/2 lack of PO intake 2/2 AMS 2/2 infection. This is quite common in older adults. 100 mLs of saline is nothing. Hold the anti-hypertensives and give the patient fluids until they pee.

 

[AlwaysContrary]

There is a lot of questions that need to be asked in this situation.

How high is his BP? Is his metoprolol really for blood pressure or does he also have HF or a history of NSTEMI/STEMI?

We need some lab values to see what the cause of the AKI is. We need to know if it's pre-renal, intra-renal, or post-renal.

Did he take any other drugs that can precipitate AKI such as NSAIDs, Aminoglycosides, Contrast solution, etc?

You should always hold Lisinopril in AKI. Its renalprotective in the long run but can cause an acute bump in SCr. If he was given fluids and did not show any signs of improvement he probably does not have a pre-renal type kidney failure.

As others have said, there are way too many possibilities and you were not given enough information.