Objectives:

• Anticipate complications of renal failure, including hypervolemia, hypocalcemia, platelet dysfunction, and renal osteodystrophy

A 33-year-old male presents to the ED complaining of shortness of breath and cough of 10 days duration. He must sleep in a chair due to orthopnea. He also complains of severe fatigue and a mild, diffuse headache. Four days ago, he was seen in an urgent care clinic and diagnosed with bronchitis. Currently, he is taking erythromycin, a cough suppressant, and a decongestant, but he took no medications prior to his diagnosis of bronchitis. He reports no medical problems or surgeries. He quit smoking 1 year ago and denies alcohol and drug use. He has a strong family history of hypertension. The review of systems is otherwise negative.

On physical examination, his temperature is 36.8º C, pulse 104, respiratory rate 16, and blood pressure 200/118. Oxygen saturation on room air is 98%. On chest exam, there are bibasilar crackles with dullness to percussion at the lung bases. The heart, abdomen, and extremities are unremarkable.

His chest x-ray shows cardiomegaly and bilateral small pleural effusions. An EKG shows sinus tachycardia with left atrial enlargement and left ventricular hypertrophy. His laboratory tests are as follows: troponin negative, hemoglobin 9.1 g/dL, WBC count and platelets normal, Na 136 meq/L, K 4.4 meq/L, Cl 96 meq/L, HCO3 19 meq/L, BUN 108 mg/dL, Cr 11.9 mg/dL, glucose 104 mg/dL, calcium 7.8 mg/dL, albumin 4.0 g/dL.

1		Which of the following is the most appropriate next step?
			A)	Prescribe levofloxacin and discharge patient with follow-up the next day.
			B)	Prescribe furosemide and discharge patient with follow-up the next day.
			C)	Administer a bolus of normal saline intravenously and admit the patient.
			D)	Administer furosemide intravenously and admit the patient.
			E)	Perform thoracentesis for diagnostic purposes.
2		How should the low calcium be approached in the emergency department?
			A)	Administer calcium gluconate intravenously.
			B)	Obtain a serum parathyroid hormone level.
			C)	Monitor for signs and symptoms of hypocalcemia.
			D)	Obtain an ionized calcium level.

Your patient is admitted. Initially, his urine output increases slightly with loop diuretics, but then he becomes oliguric. You ask for a nephrology consult to assist in management of this case. The nephrologist plans to place an IV catheter for dialysis and is considering a renal biopsy. If the patient develops bleeding with these procedures, he may have difficulty achieving hemostasis.

3		Which of the following treatments is LEAST likely to reduce the risk of bleeding in this patient?
			A)	Hemodialysis.
			B)	DDAVP.
			C)	Cryoprecipitate.
			D)	Platelet transfusion.
4		In order to reduce the risk of renal osteodystrophy (elevated serum parathyroid hormone with mobilization of calcium from bone), which of the following medications will you prescribe initially?
			A)	Calcium carbonate.
			B)	Aluminum hydroxide.
			C)	Magnesium hydroxide.
			D)	Calcium citrate.
			E)	Vitamin D.