Case 57 Index
Vital Signs: T 36.7°C (98°F), Pulse 187 bpm, SpO2 95% (on 100% FiO2), MAP 35 mmHg, SBP 53 mmHg, DBP 27 mmHg; Weight 1300 g, 24-hr Fluid Balance +115.78 mL
General Appearance: Critically ill appearing, intubated on high-flow oscillatory ventilation, anasarca
HEENT: Facial and scalp edema, anterior fontanelle soft and full; periorbital edema; orally intubated
Cardiovascular: Oscillator sounds; unable to auscultate heart tones over ventilator, warm, brisk capillary refill
Abdominal: Soft, distended, silo in place and covered with gauze, unable to palpate kidneys, no umbilical line
Extremities: Pitting edema throughout, most notable in hands and feet, PICC line in right upper extremity and left lower extremity
Neurologic: Sedated, moves all 4 extremities
Skin: Warm, dry
Genitourinary: Significant scrotal edema, Foley in place draining pink urine
Initial serum laboratory values:
Based on the available information, what best describes this patient’s abnormal kidney function?
Chronic kidney disease
CKD is diagnosed after 3 months of abnormal kidney function; this baby is only 4 weeks old, so he technically does not meet this diagnosis (yet!)
Normal kidney function with elevated creatinine due to maternal creatinine
Immediately after birth, baby’s creatinine reflects maternal serum creatinine. In healthy infants, their creatinine should normalize within approximately 2 weeks
Acute kidney injury
After 4 weeks, one would expect the creatinine to no longer reflect maternal serum creatinine. Based on nmKDIGO staging, he has Stage 3 AKI
Based on the available information, what are your top 2 differential diagnoses?
Cardiorenal syndrome
While he has a large PDA, there is no evidence that there is cardiac dysfunction, which is a hallmark of this diagnosis
Sepsis secondary to a urinary tract infection
This is a consideration in a critically-ill neonate with a Foley and AKI, however the AKI appears to pre-date the Foley insertion
Congenital nephrotic syndrome
With anasarca and low albumin, this is a consideration. Further testing will be helpful here!
Protein losing enteropathy
While the albumin is low, there is no history of malabsorption to make this diagnosis as likely
Renal vein thrombosis
In premature neonates with gross hematuria, AKI, and palpable kidneys, this would be the leading diagnosis. This patient does not have palpable kidneys or umbilical lines, but it should still remain a consideration
Thrombotic microangiopathy
Hemolytic uremic syndrome (HUS) is a consideration in patients with AKI, microangiopathic anemia, and thrombocytopenia, though it is typically extremely rare in a neonate
Urethral obstruction/trauma
Trauma is a consideration in a patient with AKI and Foley insertion but would typically only cause AKI if there is complete obstruction
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Case 57 Index
Case 57 Introduction
