USMLE® Step 1 style questions USMLE
A 40-year-old man presents to the emergency department with difficulty breathing over the past two days. His past medical history is significant for chronic liver disease secondary to chronic alcohol use disorder. His temperature is 36.6°C (97.8° F), pulse is 80/min, respirations are 21/min, and blood pressure is 125/80 mm Hg. Physical examination shows abdominal distention with shifting dullness. Serum creatinine concentration is 1.5 mg/dL, and serum urea nitrogen concentration is 20 mg/dL. The patient is started on furosemide, and his condition quickly improves. Three days later, repeated laboratory studies show the following:
|Fractional excretion of sodium (FENa)||<1%|
|Urine osmolality||600 mOsm/kg|
Which of the following is the most likely explanation for these laboratory findings?
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Tanner Marshall, MS
Acute kidney injury, or AKI, is when the kidney isn’t functioning at 100% and that decrease in function develops relatively quickly, typically over a few days. Actually, AKI used to be known as acute renal failure, or ARF, but AKI is a broader term that also includes subtle decreases in kidney function.
AKI can essentially be split into three types, prerenal AKI meaning the cause of kidney injury’s coming before the kidneys, postrenal AKI—meaning after the kidneys, or intrarenal AKI—meaning within the kidneys.
Now the kidney’s job is to regulate what’s in the blood, so they might remove waste, or make sure electrolyte levels are steady, or regulate the overall amount of water, and even make hormones - the kidneys do a lot of stuff!
Blood gets into the kidney through the renal artery, into tiny clumps of arterioles called glomeruli where it’s initially filtered, with the filtrate, the stuff filtered out, moving into the renal tubule.
Sometimes fluid or electrolytes can move back from the filtrate into the blood - called reabsorption, and sometimes more fluid or electrolytes can move from the blood to the fitrate - called secretion.
Along with fluid and electrolytes, though, waste-containing compounds are also filtered, like urea and creatinine, although some urea is actually reabsorbed back into the blood, whereas only a little bit of creatinine is reabsorbed. In fact, in the blood, the normal ratio of blood urea nitrogen, or BUN, to creatinine is between 5 and 20 to 1—meaning the blood carries 5 to 20 molecules of urea for every one molecule of creatinine, and this is a pretty good diagnostic for looking at kidney function!
Ultimately the filtrate is turned into urine and is excreted from the kidney through the ureter, into the bladder, and peed away. Meanwhile, the filtered blood drains into the renal vein.
Alright so prerenal kidney injury is due to a decreased blood flow into the kidneys.
So if you’ve got your body fluid, with fluid in circulating in the plasma as well as all the other intracellular and extracellular fluid. So a decreased blood flow could be due to an absolute loss of body fluid, where fluid actually leaves the body.
This could be due to major hemorrhage or blood loss, vomiting, diarrhea, or with severe burns where body fluid evaporates quickly without the protective skin. Decreased blood flow could also be due to a relative loss of fluid, where total body fluid stays the same, how can that happen though?
Well one example of this is distributive shock, which is where fluid moves from the blood vessels into the tissues, which keeps the total body fluid volume the same but you have a relative decrease in blood volume.
Prerenal azotemia is a form of azotemia in which the kidneys fail to adequately filter waste products from the blood, due to reduced renal perfusion. This can be caused by dehydration, excessive blood loss, heart failure, or any condition that decreases blood flow to the kidneys. Treatment of prerenal azotemia focuses on addressing the underlying cause, such as increasing fluid intake or treating the underlying condition.