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Case (2008-09-05) TACE 시술 후 발생한 Acute Renal Failure 소화기내과 R2 진상욱.

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Presentation on theme: "Case (2008-09-05) TACE 시술 후 발생한 Acute Renal Failure 소화기내과 R2 진상욱."— Presentation transcript:

1 Case (2008-09-05) TACE 시술 후 발생한 Acute Renal Failure 소화기내과 R2 진상욱

2 Chief Complaint for TACE Present Illness 1988 년 Alcoholic LC, 1996 년 HCC 진단받고 hot saline injection #2, TACE #2 시행 후 본원 소화기내과 외래 F/U (prof. 김병호 ) 중인 환자로 2008 년 6 월 F/U CT 에서 dysplastic nodule in Lt. lateral segment 증 가 소견 (4cm) 보였으며 이후 시행한 liver MRI 에서 HCC recur 소견 있 어 TACE 시행 위해 내원

3 Past Medical History HTN (+) / DM (-) / Hepatitis (-) / Tb (-) Op Hx ( + ) : hernia op 25 년 전 Personal History Alcohol (-) : 5 년 전 ( 중단 이전에는 매일 소주 2-3 병 씩 25 년 ) Smoking (-) : ex-smoker 15 pack-years Drug History none

4 General Fatigue(-) Febrile sensation (-) Chill (-) Skin Rash(-) Pigmentation(-) Itching (-) jaundice (-) H&N Headache (-) Dizziness (-) Stiffness (-) Respiratory Dyspnea (-) Cough (-) Sputum (-) Cardiac Chest pain (-) Orthopnea (-) Palpitation (-) GI Anorexia (-) Nausea (-) Vomiting (-) Abd. Pain (-) Abd distension (-) Melena (-) Hematochezia (-) Renal Dysuria(-) Urgency(-) Frequency (-) Hematuria(-) B/Ext. Lt. back pain (-) Both knee pain (-) Weakness (-) Review of Systems

5 V/S 130/80mmHg– 88/min – 20/min - 36.4°C General Appearance alert mental status chronically ill-looking appearance Head & Neck No cervical LN enlargement No neck vein engorgement No thyroid enlargement Skin rash(-) pigmentation(-) skin turgor : intact jaundice (-) Physical Examination

6 E & ENT isocoric pupil with PLR (+/+) pink conjunctiva with icteric sclera Chest clear breathing sound without crackle or wheezing regular heart beat without murmur Abdomen soft abdomen normoactive bowel sound abdominal Td/RT (-/-) hepatosplenomegaly (-) shifting dullness (-) Back & Extremities CVA tenderness (-/-) pretibial pitting edema (+/+)

7 CBC/DC 7460/mm 3 – 12.4g/dL – 36.7 % - 139K/mm 3 (seg. 63.8%) (aPTT : 40.1 INR 1.33) Chemistry TB/DB 0.68/0.27mg/dL Prot/Alb 5.2/2.7 g/dL AST/ALT 29/12 U/L ALP/GGT 82/89U/L BUN/Cr 29/2.4 mg/dL Na/K/Cl 142/4.1/117 mmol/L (GFR 29ml/min/1.73m2, stage 4 CKD) Ca/P 6.9/2.4 mg/dL Mg 1.8mg/dL CRP < 0.5 mg/dL U/A RBC 0-1 / WBC 2-4 / occult blood (-) / Protein (++) Initial Lab Findings

8 Liver CT on 08-06-11

9 Liver MRI on 08-06-25

10 Abdominal USG on 08-07-07

11  Initial Assessment 1. HCC s/p TACE #2 hotsaline injection #2 2. ALC (child B) with gastric varix 3. unknown origin of CKD  Plan 1. TACE #3 2. hydration - acetylcystein (ACEC) 6/30 ACEC 600mg po 7/1 before TACE : 150mg/kg of ACEC for 30 mins after TACE : 50mg/kg of ACEC for 4 hours - check F/U BUN/Cr after TACE Initial Assessment and Plans

12 TACE on 08-07-01

13 6/307/37/77/107/117/127/15 BUN29386492105104119 Cr2.44.05.46.58.18.69.0 Ammonia313210243290403534 TB0.681.451.481.31.181.061.52 Albumin2.73.02.83.02.8 3.1 LFT29/12227/7810/1917/1026/1027/1026/11 I/O2270/ 1901 3150/ 800 1440/ 1025 2600/ 1200 3150/ 2310 2700/ 2400 HD

14 7/15 - hemodialysis started 7/17 - DIC and septic shock due to pneumonia 7/21 – MRSA at blood culture 7/23 - expired Clinical Course

15  HCC s/p TACE #3 hot saline injection #2  ALC child B with gastric varix  ARF on CRF  unknown origin CKD (stage 4)  pneumonia sepsis  DIC  hepatic encephalopathy Final Diagnosis


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