The clinical scenario: a 50 year-old male with a history of hepatitis C liver disease who was admitted with altered mental status and a rising bilirubin. About a week into his hospital stay, his creatinine began rising from its baseline of about 0.8 to as high as 3.5 mg/dL. His T-bili had made it up to 18 and he was being evaluated for a liver transplant. He had received some iv contrast a day before his creatinine started rising, and before we examined the urine sediment I was pretty certain the diagnosis was going to be either hepatorenal syndrome or contrast-induced nephropathy.
Interestingly, his urine showed the following (this is a photo of the actual sediment): WBC casts!
The WBC casts were not difficult to find and there were plenty of WBCs present in a non-Foleyed specimen. It turns out that the patient had had a single blood culture which was positive for MSSA and was being treated with iv nafcillin. The diagnosis here is acute interstitial nephritis (AIN), and we are recommending a short course of oral steroids (though I realize that this is certainly a controversial topic).The hospital's automated urinalysis--which over the course of this year I have learned to not put much faith in outside of the dipstick analysis--did not make note of any casts, and is a clear example that a nephrologist's evaluation of the urine sediment still is an essential part of the consult evaluation.
No comments:
Post a Comment
Renal Fellow Network encourages comments and discussion regarding the posts. Do not post any comments that are commercial or advertising in nature. Posts will be deleted if commercial or advertising comments are made. Internet users commenting on the Renal Fellow Network must post information which is true and correct to their knowledge. Sources to health/medical claims must be provided when relevant. Moderators reserve the right to erase, without notification, any comment they would judge inappropriate.