A 48-year-old man is hospitalized for shock after massive blood loss in a motor vehicle accident.
On the patient’s second day in the hospital, his blood urea nitrogen (BUN) and creatinine levels
begin to rise and he develops pitting edema to his knees. A subsequent urinalysis shows numerous
granular casts.
Which of the following is the most appropriate treatment?
(A) Angioplasty
(B) Broad-spectrum antibiotics
(C) Corticosteroids
(D) Fluids and dialysis
(E) Use of ultrasound to remove blockage
Answer And Discussion:
The correct answer is D. Fluids And Dialysis.
This man’s history indicates that he is suffering from acute tubular necrosis secondary to ischemia of the epithelial cells of the proximal convoluted tubule. Granular casts on urinalysis is also a significant sign that this is acute tubular necrosis. These cells, given their high metabolic rate, are particularly sensitive to a drop in blood pressure such as that experienced in hemorrhagic shock. In this patient, the immediate therapeutic plan is to correct the fluid and electrolyte imbalance. The fluid replacement should include both crystalloid (eg, normal saline, lactated Ringer’s) and blood products due to the
severity of blood loss. If recovery of renal function is delayed or if the kidneys never fully recover, dialysis is indicated. The epithelium will usually regenerate in a few weeks.
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