Today, I review, link to, embed, and excerpt from MetroHealth Emergency Ultrasound‘s POCUS in Acute Kidney Injury.
All that follows is from the above resource.
Jun 17, 2021This discussion is part of our weekly ultrasound education series. Here we have a guest speaker. Dr. Abhilash Koratala is talking about the use of ultrasound to evaluate patients with acute kidney injury. Follow us on Social Media:
Twitter:
/ mh_emultrasound
Instagram:
/ mh_emultras. .
0:02
0:26
2:06
3:57
5:03 Left figure is normal. Right figure is hydronephrosis.
5:56
6:49
7:30 She had a B-cell lymphoma causing the hydronephrosis.
7:48
7:59
8:36
9:20
9:47
10:05
11:18
11:52
12:10
13:27
14:14
14:50
15:43
16:23
16:36
19:00 Normal cortical echogenicity is less than that of the liver.
20:30
20:56
21:30 Increased cortical echogenicity.
22:14 The correct answer is acute kidney injury (the cortex is hyperechoic to the liver).
23:08 Below is hypoechoic (less than the liver)
23:23 Hyperechoic (greater than liver echogenicity) below.
23:30
I suspect the two primary differentials would beeither it’s a deposition disease that’s common thing uh that elderly patients present to nephrology clinic with
unexplained aka and found to have multiple myeloma or I think it is AIN (acute interstitial nephritis).
24:24
so it turns out that the biopsy showed this. So what you see here is firstyou see a lot of blue things here so blue things are cells so that means there is a lot of uh cellular infiltrate in the
interstitium that’s one thing so my prediction about having interstitial nephritis is correct and on top of that
you see something more interesting that these arrows point to here so you notice this glassy structure is better
seen on this polarized microscopy here so they light up here so these are calcium oxalate crystals
and remember i mentioned he was taking vitamin c and d for covid19 prophylaxis poor guy because somebody said
they can boost the immune system so what happened is oxalate nephropathy is seen as a complication of
too much vitamin c and ascorbic acid gets converted into oxalate and that can get deposited in the kidney
and cause oxalate nephropathy. This a is very unfortunate situation and simultaneously if you’re taking vitamin d
and you don’t have vitamin deficiency it can it causes uh hypercalceuria and that calcium and
oxalate passing through the kidney um probably led to all this calcium oxalate
25:31formation this is very unfortunate scenario because uh this anecdotally has you know poor prognosis and this patientum like i mean i started him on steroids for the inflammation component but didn’t really respond and ended up in
hospital we initiated him on dialysis i hope he recovers but but that’s a bad thing
so you need to be aware of this thing like i mean especially in er setting or even in the icu setting there are case
reports where in some icos patients received iv vitamin c and patients developed
oxalate nephropathy okay so based on my experience i would just
say in in general in clinic if you are seeing a patient with relatively preserved parenchymal
thickness and hyperechoic kidneys the first differential would be aan acute interstitial nephritis
most likely from some over the counter medications or paraprotanemia then some kind of
glomerulonephritis or you would also want to rule out hiv because hiv induced nephropathy can have big hyperechoic kidneys. We
don’t see that often these days because patients present early and we have better treatments but
that used to be like a very common differential previously. And if you are seeing impatient with similar picture with big
hyperechoic kidneys most of the time it’s ATN and the second differential would be AIN
27:11 The patient below:
This is a young female with right flank pain and no known comorbidities. Just had severe flank pain and came to the ER.
Is there anything suspicious forintrinsic cause? The urinalysis was really unremarkable meaning
there there was no blood in the urine, no white cells in the urine.
She did have some subjective fever but there was no measured fever or elevated temperature so
it looks pretty normal and there is no obstruction there are no obvious stones maybe there is
some hypoechoic area in this [upper pole] region maybe it gives little bit of heterogeneous appearance to the
parenchyma but nothing really [stands out] so what’s the next step you do?
Kidney ultrasound again is never complete without bladder ultrasound and also never complete without
you doing one at least one color doppler image so the color doppler image shows
this spectacular pattern where the there was blood flow only to one part of the kidney and the the top portion of the kidney is
completely bloodless so and the ct scan eventually showed a massive renal infarction
i mean it’s it’s strange that like we couldn’t find any cause of renal infection despite doing uh
angiogram and all the hypercoagulable workup and all this all that stuff and it is said that about 30 percent of
the patients can have idiopathic renal infarction. So this is one important thing i think especially for in the ed setting.
Never finish without a color doppler [or power doppler] image okay.
and then the hemodynamic causes so hemodynamic causes forward flow and um you know venous congestion c
