Tuesday, May 21, 2013

Renal Fellow Network: Does she drink tea?

Renal Fellow Network: Does she drink tea?: I was quickly moving along through my busy university clinic, seeing another CKD patient when the nurse came to inform me that the patien...

Wednesday, May 1, 2013

41 yo women 30 weeks pregnant (IVF twins) admitted to labor and delivery for possible preterm labor.  She has a history of liver transplant 20 years ago for "autoimmune hepatitis" managed with tacrolimus; levels throughout pregnancy have been 3-5.  She has had a mild transaminitis for the last several months (AST/ALT in the 125-200 range), mild hyperbilirubinemia (TB 2.5), mild hypoalbuminemia (alb 3.0), and normal INR.  She has had chronic intermittent nausea/vomiting throughout pregnancy.  In addition to prograf, her outpatient medication regimen includes lasix 40mg daily, which she has been on for "years" and has been continued during pregnancy.

On evaluation in labor and delivery, she is normotensive (105/75), with 1+ bilateral lower extremity edema.  Over the next 36 hours, her renal function progressively declines: Cr 1.0 on admission, up to 1.3 then - despite 100ml/h normal saline for 8 hours - 1.6 mg/dl.  No new meds, no contrast exposure, no NSAIDs.  Prograf level 5 days ago was 5.0, and dosage was increased from 1.5mg bid to 2 mg bid.  Repeat prograf level is pending.  Ob/gyn says she is not in labor, and the fetuses are appropriate for gestational age.

Any ideas?