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Kidney Week

Abstract: PO0282

The Answer Is in the Urine

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Patel, Kirtan, The Christ Hospital Physicians Spine, Cincinnati, Ohio, United States
  • Berger, Justin M., The Christ Hospital Physicians Spine, Cincinnati, Ohio, United States
  • Schwarz, Kyle, The Christ Hospital Physicians Spine, Cincinnati, Ohio, United States
  • Hergenrother, John, The Christ Hospital Physicians Spine, Cincinnati, Ohio, United States
Introduction

Ethylene glycol toxicity carries significant morbidity. Prompt recognition and treatment prevents mortality. Given time needed for confirmatory laboratory testing, high suspicion should be raised in cases of anion gap metabolic acidosis. Here we present a case of ethylene glycol toxicity diagnosed with simple urine microscopy.

Case Description

The patient is a 48-year-old male presented in an obtunded state. Laboratory evaluation was notable for a severe metabolic acidosis with a CO2 <5 mmol/L on basic metabolic panel. Anion gap was unable to be calculated but was at least 27. Serum labs were: Sodium 139 mmol/L, potassium 4.9 mmol/L, chloride 108 mmol/L. Glucose level 144 mg/dL Creatinine 1.14mg/dL and BUN 16 mg/dL, Lactic acid 7.63 mmol/L. ABG showed a pH of 7.14, pCO2 of 11 mmHg, pO2 of 114 mmHg, pHCO3 of 3.6 mmHg, and calculated base excess of -25.0. Measured serum osmolality was 321 mOsm/kg. Calculated serum osmolality was 292 mOsm/kg indicating an osmolar gap of 29 mOsm/kg. White blood cell count was 39.0 x103 /uL. Ethanol level was <10mg/dL. Volatile acid labs were sent. Unfortunately, these labs required send out to another facility to run which resulted in significant delay. Due to high suspicion of toxic volatile substance ingestion, Fomepizole was administered and a urine sample was viewed under the microscope. Needle shaped crystals were noted to be present. Patient underwent 1 session of hemodialysis and significantly improved clinically. Ethylene glycol level, drawn prior to hemodialysis, came back at 24.9 mg/dL. He received 4 additional doses of fomepizole. He also received high dose thiamine and pyridoxine to enhance the metabolism of ethylene glycol. Labs drawn the following morning resulted in an undetectable ethylene glycol level.

Discussion

Toxic ingestion needs to be considered in any obtunded patient. Workup should include careful assessment of acid-base status and osmolar gap. Prompt Treatment may need to be initiated prior to confirmatory lab results. Simple methods including urine microscopy and fluorescing the urine with Wood’s lamp can assist a prompt diagnosis . In our case, crystalluria was present. A teaching point is that the crystals need not be the classic “envelope shape” as a six-sided needle-like structure often occurs as noted in our patient. While labs may confirm the diagnosis, the answer can be found in the urine.