Acute renal failure and the sepsis syndrome.

On day 6 (ATN-Liano score of 0.838; APACHE II of 23; APACHE II risk of 45%), continuous veno-venous hemofiltration and dialysis (CVVHD) was initiated and maintained for 3 days. Intermittent daily hemodialysis using a synthetic (polysulfone) membrane was then introduced. Fourteen sessions of hemodialysis were performed, and the blood urea and serum creatinine levels were kept below 180 and 5 mg/dL, respectively. Only one episode of hyperkalemia (5.8 mEq/L) with acidosis (pH of 7.21 and plasma HCO 3 of 14 mEq/L) was observed. Total parenteral nutrition was administered throughout this period. His urinary output dropped to 20 to 30 mL/h after the introduction of hemodialysis and began to increase (40 to 50 mL/h) after 10 days. During that period, weaning from the ventilator was started and the hyperbaric oxygen therapy was discontinued. By day 26 after admission, his urinary output had reached CASE PRESENTATION 110 mL/h and the serum creatinine had progressively decreased. A 56-year-old man was admitted to the hospital with acute He was discharged from the hospital on day 32 with a serum cresuppurative appendicitis. A laparotomy was performed, and he atinine of 1.2 mg/dL and a creatinine clearance of 70 mL/min. developed sepsis after the surgery. After seven days he was transferred to the intensive care unit of the Escola Paulista de Medicina with necrotizing fasciitis (Fournier’s syndrome), DISCUSSION respiratory distress, and increased levels of serum creatinine Dr. Nestor Schor (Dean, Postgraduate Programs and (2 mg/dL). At admission he had fever (38 C), normal blood Research; and Professor of Medicine, Disciplina de Nepressure (140/90 mm Hg), normal urinary flow with a FENa of frologia, Escola Paulista de Medicina, Universidade Fed0.9%, and was under mechanical ventilation. That same day eral de Sao Paulo, Brasil): In the present patient, the an exploratory laparotomy revealed significant necrosis of the abdominal wall and an intracavitary infection. A peritoneosdiagnosis of sepsis was readily made by the presence tomy was performed. of one major criterion, necrotizing fasciitis (Fournier’s Hemodynamic monitoring with a Swan-Ganz catheter regangrene), and two minor criteria: respiratory distress vealed normal pulmonary capillary wedge pressure (16 mm Hg) and fever. Acute renal failure (ARF), as often occurs, and a septic profile (high cardiac index and low systemic vascucomplicated the clinical condition [1]. lar resistance index). Despite a normal urinary output of 70 to Hemodynamic monitoring revealed a hyperdynamic 90 mL/h, the serum creatinine gradually increased to 5 mg/dL pattern, with low systemic vascular resistance and high over the following 6 days. During this period he underwent two cardiac output, both of which are characteristic of septic abdominal surgeries and daily hyperbaric oxygen therapy in a 2.5 atmosphere chamber, while receiving metronidazole, vanshock. The pulmonary capillary wedge pressure (PCWP) comycin, and a third-generation cephalosporin. No aminoglywas normal at 16 mm Hg, although PCWP can be a miscoside antibiotic was administered. No bacteria or fungi were leading index of left-ventricular pre-load (defined as volidentified in blood, urine, or even in the abdominal secretions. ume). But sequential measurements of end-diastolic volumes are not routinely available. Importantly, diastolic dysfunction, a common feature of septic shock, is attribThe Nephrology Forum is funded in part by grants from Amgen, uted, at least in part, to an interstitial myocarditis that Incorporated; Merck & Co., Incorporated; Dialysis Clinic, Incorporated; and Bristol-Myers Squibb Company. is a classic acute inflammatory response characterized by a polymorphonuclear cell infiltration and varying amounts