Take a look at some preliminary testing!
Choose the highest yield tests below (more than one choice may be correct)!
BK virus serum PCR level
Good thought! Transplant recipients are at risk for opportunistic infections, and BK virus can cause BK nephropathy resulting in AKI. This patient’s BK virus serum PCR is undetectable.
Excellent idea. Given this patient’s hyperkalemia, we should look for any ECG abnormalities that may require more urgent hyperkalemia treatment. ECG shows normal sinus rhythm with no peaked T waves or QRS prolongation.
Great thinking, especially in the setting of an AKI with a low serum bicarbonate. Acidosis can induce elevated serum potassium due to cell shift as well as increased activity of the hydrogen/potassium exchanger in the collecting duct. While either a venous or arterial blood gas (ABG) would be sufficient here, here’s the ABG: 7.40/35/95 (pH/PCO2/pO2)
Though this may be reasonable later depending on further work up to look for rejection or glomerular disease if the AKI does not improve, noninvasive tests may be able to help us a bit more first.
You nailed it! Tacrolimus can certainly cause hyperkalemia, especially since this patient has poor oral intake and AKI. Her trough tacrolimus level is 20 ng/mL.
This patient’s history and urinalysis are not suggestive of a urinary tract infection. Pick again!
Mycophenolate mofetil level
Unfortunately, mycophenolate levels do not correlate with adverse effects related to the drug. In addition, while diarrhea is a common adverse effect, this patient’s AKI and hyperkalemia are likely from another cause.
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What’s on your differential diagnosis for acute kidney injury (AKI) in this patient? Pick your top 3!
Non-steroidal anti-inflammatory drug (NSAID) induced injury
Calcium channel blocker toxicity
Calcineurin inhibitor toxicity
Transplant renal artery stenosis (TRAS)
Kidney Transplant Pyelonephritis
Rejection of pancreas allograft
Rejection of kidney allograft