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Case Report: Metabolic Disorder and Functional Acute Renal Failure in a 63-Year-Old Male

A 63-year-old American male with a history of type 2 diabetes and colon cancer presents with vomiting and diarrhea, leading to acute renal failure and metabolic acidosis. Physical examination reveals asthenia, but normal consciousness and vital signs. Diagnostic imaging shows normal organ sizes with no significant abnormalities. Lab results indicate elevated creatinine levels and a pH of 7.24, confirming metabolic acidosis with an increased anion gap. The likely cause of acute renal failure is dehydration, exacerbated by Metformin treatment. Analysis and management strategies are discussed.

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Case Report: Metabolic Disorder and Functional Acute Renal Failure in a 63-Year-Old Male

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  1. Case report n°2Metabolic disorder A&E medical meeting 22/02/2012

  2. Presentation: American male 63 years • Past medical history: diabetes type 2 treated by Metformin 200mg x 2 • Past surgical history: Colon cancer operated 1 year ago followed by chemiotherapy • Current history: vomiting (2-3/day) and diarrhea (9/day) for 6 days, no fever.

  3. Physical examination • General status: asthenia ++, but normal consciousness, no neurodeficit  • Cardio. exam:regular, no abnormal murmur, no sign of cardiac failure   • Pulmo. exam: clear , no rale, no evident dyspnea, no crackles at the bases • Abdo. exam: soft , no local pain , no organomegaly , B.sound increasing +++ • Dehydration +/- • Legs: no edema.

  4. Diagnosis hypothesis ? • What kind of acido-basic disorder is-it? • What is the origin of this acido-basic disorder? • Which biologic test (or calculation) could you ask to have a more accurate analysis? • What are the possible origins of this severe renal failure? • What is in favor of acute/chronic renal failure?

  5. Abdominal ultrasound • The liver is normal in size. Its borders are regular. Its structure is hyperechoic. No focal lesion seen.  • The gallbladder is anechoic. Its wall is not thickened. The bile ducts are not dilated.  • Normal portal flow.  • The spleen, the pancreas demonstrate no abnormality.  • The kidneys are normal in size (right=110x51x74mm, left = 120x52x57mm). No renal stone detected. No hydronephrosis noted.  • Absence of ascites. No pleural effusion.  • No suspicious lymphadenopathy.  • The urinary bladder is anechoic with regular borders • The prostate measures 35x48x35mm=30.5ml (normal < 30ml).

  6. Renal failure analysis • Creat about 600micmol/l > Clearence 16ml/min (Cokroft formula) • Kidneys normal size • No anemia (Hb 12.4g) • No hypercalcemia (1.98mmol/l) Conclusion: Fonctional Acute Renal failure due to dehydration (vomiting & diarrhea) + Metformin treatment

  7. Acido-basic disorder • pH 7.24 with pCO2 25mmHg & Bicar 11mmol/l • Metabolic acidosis (Bicar ↓ & pCO2 ↓) • Anion gap: The term anion gap represents the concentration of all the unmeasured anions in the plasma (ex: Lactates, ketonic, ethanol etc…) Anion Gap* = Na – (Cl + HCO3) * Normal 12+/-2 mmol/l

  8. Different kind of lactic acidosis

  9. Anion gap calculation • Anion Gap = Na –(Cl + HCO3) • Anion Gap = 131 – (101 +11) = 19mmol/l Anion Gap slightly increased 19mmol/l(normal 12 +/-2mmol/l) Lactate dosage: 0.96mmol/l (normal 0.63 – 2.44mmol/l) This is not a lactic acidosis under Metformin…

  10. Anion Gap increased AnionGap normal

  11. How to analyze a metabolic acidosis • Recognize the metabolic acidosis (pH<7.35 with HCO3 ↓) • Calculate the “Anion Gap” to know if this acidosis is due to accumulation of acid (Anion Gap increased) or a loss of base (Anion Gap normal) • Look for the origin of the disorder (see table before)

  12. Evolution in ICU

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