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Author Topic: AKI in a renal transplant recipient
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Post AKI in a renal transplant recipient
on: December 3, 2012, 10:27
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Patient with renal transplant who has significant proteinuria on ACEI, comes in with AKI thought to be pre-renal. Would you hold ACEI? My tho0ughts are no to hold due to significant proteinuria and etiology of AKI is thought pre-renal. Although if worsens after hydration would then hold. Thanks

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Post Re: AKI in a renal transplant recipient
on: December 3, 2012, 10:31
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Before I can answer this question, I will need to know why the patient has high proteinuria? Is the AKI truly due to a pre-renal condition, or is it an indication of a worsening of the underlying proteinuric state?

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Post Re: AKI in a renal transplant recipient
on: December 3, 2012, 10:35
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Patient over the last year has been having slowly increasing creatinine. with a gram proteinuria. recently had decreased PO intake, fever,chills and burning when she urinates, polyuria >10 times daily cultures taken and placed on broad spectrum abx. on exam MM were dry and labs show increase cr from 1.69 to 2.37.UA with >3g proteinuria with hematuria and pyuria but then she is menstruation so degree of proteinuria might have been exaggerated.

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Post Re: AKI in a renal transplant recipient
on: December 3, 2012, 10:40
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great. thanks for the extra info. The rise in proteinuria is likely tubular in nature because of the AKI and, more likely, the underlying UTI. Indeed the proteinuria is not accurate in this clinical condition because it is partly tubular, partly tissue in origin (as opposed to glomerular in origin). Given the clinical history, it is reasonable to assume she is hypovolemic, especially if she has borderline or frank orthostatic hypotension.

However, there is no benefit in maintaining the ACEi at this time. The anti-proteinuric effects of ACE inhibition (or RAAS blockade in general) are not immediate. In one study, it took *weeks* for the antiproteinuric effects of ACEi to be realized (http://www.ncbi.nlm.nih.gov/pubmed/2550696).

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