A Case Of Severe Acute Kidney Injury Due To Severe Dehydration Due To Traveler's Diarrhea While Taking Oral Angiotensin II Receptor Antagonist.

[Background] Renin-angiotensin (RA) system inhibitors such as angiotensin II receptor antagonists (ARBs) are frequently prescribed from the viewpoint of cardio- and renal-protective effects. The Japanese Society of Nephrology recommends that patients be advised to discontinue renin-angiotensin (RA) system inhibitors during sick days such as fever, diarrhea, vomiting, and decreased oral intake, as there is a risk of acute kidney injury (AKI). However, it is not well known. [Case] A man in his 70s. He has chronic kidney disease (CKD) G3A due to nephrosclerosis and was prescribed olmesartan and amlodipine. Although the patient went on a sightseeing trip to Cambodia and developed watery diarrhea about 8 times a day, he continued taking oral medications, including ARBs. After returning to Japan, he lost 7 kg in weight and felt nauseous, so he visited a local doctor, where his Cr level was found to be 9.8 mg/dL, and he was referred to our hospital. He was oliguric and his Cr rose to 13.4 mg/dL, but spontaneous urination improved with fluid replacement and ARB withdrawal. His renal function also improved to Cr2.9 mg/dL, and he was discharged home on the 9th hospital day. It was thought to be acute on chronic kidney disease due to dehydration from traveler's diarrhea and his ARB.

[Conclusion] It is important to discontinue his RA system inhibitors on sick days.

CLICK HERE TO GET NATURAL ORGANIC CISTANCHE EXTRACT WITH 25% ECHINACOSIDE AND 9% ACTEOSIDE FOR KIDNEY FUNCTION

Supportive Service Of Wecistanche-The largest cistanche exporter in the China:

Email:wallence.suen@wecistanche.com 

Whatsapp/Tel:+86 15292862950

Shop For More Specifications Details:

https://www.xjcistanche.com/cistanche-shop

Introduction

Renin-angiotensin (RA) system inhibitors, such as angiotensin II receptor blockers (ARBs), are frequently prescribed for chronic kidney disease, hypertension, heart disease, etc. It is desirable to stop taking RA system inhibitors when you are not feeling well, but this is not widely known. We report a case of severe renal failure due to severe dehydration due to traveler's diarrhea while prescribed ARB.

Symptom example

Example: A man in his 70s.

Chief complaints: diarrhea, weight loss, nausea.

[Current history]

Olmesartan 20 mg/day and amlodipine 5 mg/day had been prescribed by his local physician for chronic kidney disease (CKD) G3 a due to nephrosclerosis (his Cr 1.1 mg/dL at baseline). He was completely independent in activities of daily living.

He went on a 6-day sightseeing trip to Cambodia, and from the second day of the trip, he started having watery diarrhea about 8 times a day. The patient did not have a fever and was able to control his abdominal pain and was able to take oral medication, so he continued to take all prescribed medications orally. Blood pressure was not measured because the patient was traveling, but no subjective symptoms suggestive of hypotension or intravascular dehydration were observed, such as light-headedness or a feeling of darkness in front of the eyes when standing up.

After returning to Japan, he continued to have brown watery diarrhea 5 times a day, and when he weighed himself at home, he found that he had lost 7 kg (from 82 kg to 75 kg). He also developed nausea, so the day after he returned home (hereinafter referred to as Day 1), he visited his local doctor. Since the Cr level was as high as 9.5 mg/dL, the patient was referred to our hospital with a diagnosis of acute exacerbation of chronic kidney disease. In interviews with the person himself, it was revealed that the second half of the trip and

It was suggested that he was suffering from oliguria on Days 1 and 2 after returning to Japan (according to the patient, ``I went to the toilet frequently to defecate, but I feel like I hardly urinated.'') .

He asked for additional information regarding diarrhea caused by people traveling to Southeast Asia, but other than the fact that he drank pool water, he found no additional information of note.

【medical history】

Chronic kidney disease: Nephrosclerosis, Chronic Kidney Disease (CKD) G3 a, blood draw at previous doctor about 1 month ago showed Cr1.1 mg/dL.

Hypertension: This was noticed 5 to 6 years ago. No history of surgery including abdominal surgery.

【allergy】

nothing special.

[Oral medicine]

Amlodipine 5 mg tablet, 1 tablet once a day in the morning.

Olmesartan 20 mg tablet, 1 tablet once a day in the morning.

[Social history]

No alcohol. I quit smoking 10 years ago.

[Physical findings upon arrival]

Height: 165 cm, weight: 75 kg (BMI: 30.1 kg/m2). Clear consciousness. Glasgow Coma Scale (GCS) E4V5M6 (15 points), blood pressure 164/87 mmHg, pulse rate 98/min, body temperature 36.4°C, SpO2 96% (room air), respiratory rate 16/min.

There was no nuchal stiffness, the pupils were 3 mm/3 mm, and the light reflex was quick. There was no pallor in the palpebral conjunctiva, and no yellowing or hyperemia in the bulbar conjunctiva. There was no palpable lymphadenopathy in the neck, and there was no redness or white moss in the pharynx. The oral mucosa was markedly dry. In the chest, there was no left-right difference in respiratory sounds, neither rales nor stridor were heard, and no heart murmur was heard. In the abdomen, intestinal peristalsis sounds were slightly increased.

On palpation, it was soft and no tenderness or muscular guarding was observed. Rectal examination revealed neither bloody stool nor tenderness. Neurological examination revealed no notable local symptoms. The skin and joints of the whole body were observed, and no obvious redness or rash was observed. No lower leg edema was observed. The patient had a bowel movement in the emergency department, and the stool was brown and watery.

[Examination findings upon visit]

Blood test findings and urine test findings are summarized in Table 1. Severe renal impairment was observed with UN-102.9 mg/dL and Cr13.4 mg/dL, but serum K was within the normal range at 4.5 mEq/L. Qualitative urine analysis revealed 3+ protein in the urine, 3+ occult blood, and numerous red blood cells and urothelium in the urine sediment. No pathological casts were observed. Blood gas findings showed no increase in lactic acid levels, but metabolic acidosis due to anion gap expansion consistent with uremia and respiratory compensation were observed.

As shown in Table 2, tests for differential diagnosis of diarrhea in travelers to Southeast Asia were conducted, but all tests were negative.

[Image findings at visit]

A chest X-ray showed no notable abnormalities, and plain thoracoabdominal CT images showed no renal atrophy or urinary tract obstruction, and no other notable abnormalities. Ultrasound examination showed that left ventricular contractility was visually good (hyperdynamic), but intravascular dehydration was significant.

[Progress after hospitalization]

The patient was diagnosed with acute exacerbation of chronic renal dysfunction (AKI on CKD) due to severe dehydration due to traveler's diarrhea, and her clinical course suggested that her ARB may have been a factor in the exacerbation. After being admitted to the hospital, ARB was discontinued and AKI was managed with extracellular fluid replacement and a potassium-restricted diet. For traveler's diarrhea, an easily digestible diet was used, and after confirming that the specific infection evaluation (Table 2) was negative, antidiarrheal agents and lactic acid bacteria preparations were also administered.

The progress is summarized in Figure 1. One day after admission, she did not respond to extracellular fluid replacement and was oliguric (urine output 300 ml/day), and her Cr rose to a peak of 13.4 mg/dL, but it improved over time and her Cr2. It decreased to 9 mg/dL. His general condition improved and he was discharged home on the 9th hospital day. She is currently under follow-up as an outpatient, and her Cr level has improved to 1.6 mg/dL.