A 70-year-old male presents to the ED with a 2-week history of increasing dyspnoea, cough with altered sputum and fever. Past history includes chronic obstructive airways disease (COPD), lung cancer seven years ago treated with chemotherapy and radiation therapy with no sign of recurrence since.
Examination findings included RR 30 breaths/min, BP 110/70mmHg, HR 145 bpm, Temp 37.4ºC, anxious and distress but tired and peripherally cold and cyanosed.
CXR shows findings consistent with COPD and right lower lobe infiltrate.
The following arterial blood gas is taken one hour after receiving 2 litres of fluid resuscitation, antibiotics and bi-level non-invasive ventilation (NIV), at FiO2 = 1.0.
(This blood gas is discussed in Question 23.1 )
Parameter
Patient Value
Normal Adult Range
FiO2
1.0
pH
7.16*
7.35
– 7.45
PCO2
33 mmHg* (4.3 kPa)*
35
–
45 (4.6 – 6.0)
PO2
272 mmHg (38.5 kPa)
Bicarbonate
11 mmol/L*
22
–
30
Base Excess
-17 mmol/L*
-3 – +3
Sodium
138 mmol/L
135 – 145
Potassium
4.3 mmol/L
3.5 – 5.0
Chloride
121 mmol/L*
95
–
110
Glucose
13.1 mmol/L*
3.5 – 7.8
Lactate
6.4 mmol/L*
0.6 – 2.4
Haemoglobin
131 g/L*
135 – 175
Creatinine
150 micromol/L*
70
–
120
Six hours later the patient remains on NIV, is conscious, reports feeling slightly better, feet remain cyanosed, BP 105/72 mmHg, HR 108 bpm, RR 30 breaths/min, urine output 10 – 20 mL/hr and the following biochemistry profile is obtained:
Parameter |
Patient Value |
Normal Adult Range |
||||
Sodium |
139 mmol/L |
135 – 145 |
||||
Potassium |
5.5 mmol/L* |
3.5 – 5.2 |
||||
Chloride |
110 mmol/L |
95 |
– 110 |
|||
Bicarbonate |
12 mmol/L* |
22 |
– 32 |
|||
Urea |
20.0 mmol/L* |
2.7 – 7.8 |
||||
Creatinine |
220 μmol/L* |
70 |
– 120 |
|||
Estimated glomerular filtration rate (eGFR) |
25 mL/min/1.73 m2* |
> 90 |
||||
Anion gap |
22 mmol/L* |
8 – 18 |
||||
Total protein |
57 g/L* |
60 |
– 80 |
|||
Albumin |
27 g/L* |
35 |
– 50 |
|||
Total bilirubin |
24.9 μmol/L |
< 25 |
||||
Alkaline phosphatase (ALP) |
81 IU/L |
30 |
– 110 |
|||
Alanine transaminase (ALT) |
6138 IU/L* |
< 65 |
||||
Aspartate transaminase (AST) |
10122 IU/L* |
< 50 |
||||
g-Glutamyl transferase (GGT) |
88 IU/L |
< 90 |
||||
C-reactive protein (CRP) |
22.5 mg/L* |
< 8 |
b) Give your interpretation of these findings. Include likely aetiologies. (40% marks)
Increasing anion gap due to worsening renal impairment and possibly increasing lactate.
LFTs deranged with predominant finding of transaminitis. (This is likely to be associated with an increase in lactate).
Aetiologies
The following biochemical abnormalities are present in the second set of results:
The raised transaminases are described as a "transaminitis" by the college, a term which has been in use since 1977, in spite of some authors referring to it as "made up and improper" (Stellpflug, 2011). The previous set of results from Question 23.1 demonstrated a raised lactate and severe acidaemia wioth a normal glucose and normal haemoglobin. From the list of causes of elevated transaminases, the following are relevant diferentials, and parenthesised comments as to why they are relevant:
And then those things which this is not:
Stellpflug, Samuel J. "Transaminitis: The Lab Test That Has Inflammation…." Journal of Medical Toxicology 7.3 (2011): 252-253.
Johnston, David E. "Special considerations in interpreting liver function tests." American family physician 59 (1999): 2223-2232.
Limdi, J. K., and G. M. Hyde. "Evaluation of abnormal liver function tests." Postgraduate medical journal 79.932 (2003): 307-312.
Hoekstra, Lisette T., et al. "Physiological and biochemical basis of clinical liver function tests: a review." Annals of surgery 257.1 (2013): 27-36.