Of course, this isn’t always the case. Lots of people go into renal failure in the hospital for lots of reasons. They get dialysis and do fine in the end. Some don’t even stay on dialysis. So, this isn’t a hard-and-fast rule. But when a patient suddenly stops making urine and their kidneys are shutting down…frequently the story won’t have a happy ending.
I’m finished with my rural rotation and have been dropped – with a dull plunk – back into the hospital.
Hospital medicine is tough. Described at least once as a process of “herding cats”, inpatient medicine demands constant attention to seemingly endless, often easily-forgotten details.
Aside from the sheer mental effort generally required to manage complicated hospital patients, drastic outcomes are more common too. If a guy comes into clinic and says, “Hey doc, this hurts.” The doctor often shrug and tell them not to do “that”, and to let them know if the pain doesn’t go away. But in the hospital, what appears to be a vague ache or pain can be life-ending.
One of my first patients today came in with so many problems I felt sick just reading her history. Renal stones, chronic pancreatitis (if you’re wondering what real pain is like, try that one), severe carotid stenosis (almost no blood gets to the brain), strokes, heart attacks, bowel obstructions. Yuck, yuck, yuck.
Today, I noticed that two of the best indicators of renal function – BUN and Creatinine – were just barely worse than yesterday. In talking the problem over with my attending, our assesment was that she probably had some decrease in her renal function because she recently had a CT with contrast (NOT a nice test…contrast is the destroyer of kidneys). So, some elevation was to be expected. Besides, the lady was peeing. This is a big deal.
I once was asked by a prestigious nephrologist, rhetorically, what was the best way to identify severe renal failure. I futzed and bumbled around, throwing out dimwitted answers about excreted urine sodium compared to plasma sodium and potassium. After watching me wriggle around uncomfortably for awhile, the gleeful specialist exclaimed, “They’re makin’ PEE! HAHAHAHA!”
By that, he meant that the patient was generating at least 30cc of urine per hour. Something around that much and you don’t have too much to worry about.
And this morning, that patient was making almost 50 cc/hour. I re-checked her urine bag myself because I was surprised that someone so sick could be producing urine so “well”. Satisfied, I figured she would be improving in short order and soon we would be calling for the wheelchair and home-care nurses.
Instead, I got a page this afternoon notifying me that the patient had produced less than 20cc of urine over the previous 2 hours. And she was having difficulty breathing not long after that. And every limb was suddenly swollen and puffy. And her pain was immense. And she was febrile and what about that white count that never really came down, doctor?
After checking on her, it became clear that for reasons unclear to us, the woman’s kidney’s were headed for total collapse. In a younger patient with fewer medical problems, simple dialysis would probably solve the problems. But this patient is infinitely more complicated. Her kidneys are shutting down because her body is shutting down. She can’t breathe because the fluid that she’s supposed to pee out is backing up into her lungs. And limbs, which causes the swelling. I can’t explain the pain, but the white cell count is elevated because she likely has disseminated infection that is attacking other organ systems.
In the hospital, things can go from promising to dire in the space of 2 hours, or less. Some of the more dramatic turns for the worse have occurred when the kidneys throw in the towel. Although most of us don’t think much about urinating throughout our day, the truth is that when the peeing stops, many times the rest of the body is soon to stop as well. I don’t know if my patient will make it through this, but I sure had more hope for her this morning – when she was happily peeing – than I do now.
Nice first day back…