CURRENT Essentials of Critical Care.pdf

212 Current Essentials of Critical Care■■■Pulmonary-Renal SyndromesEssentials of Diagnosis• Vasculitic syndromes that involve both lungs and kidneys• Cough, dyspnea, hemoptysis, alveolar hemorrhage; may haverash, upper respiratory tract involvement depending on disorder• Microscopic hematuria often precedes fulminant renal failure• Radiographically diffuse alveolar infiltrates; occasionally cavitarylesions• Bronchoalveolar lavage with 20% hemosiderin-laden macrophagesindicates alveolar hemorrhage; nonspecific• Need to exclude correlated pulmonary and renal disorders: CHFwith excessive diuresis, renal failure complicated by pulmonaryedema, disseminated infection• Drug/toxin exposure history helpful: penicillamine in Goodpasturesyndrome, SLE; leukotriene inhibitors in Churg-Strausssyndrome; hydrocarbon in Goodpasture disease; hydralazine,procainamide, quinidine in SLE• Serological markers: ANCA, anti-GBM, ANA, anti-dsDNA• Definitive diagnosis often with renal biopsy with immunofluorescentstainingDifferential Diagnosis• Wegener granulomatosis • Goodpasture syndrome• Microscopic polyangiitis • Churg-Strauss syndrome• Systemic lupus erythematosus (SLE)Treatment• Maintain adequate airway in massive hemoptysis• Hemodialysis may be indicated in acute renal failure• Immunosuppressive agents: corticosteroids, cyclophosphamide• Plasmapheresis in Goodpasture syndrome• Adjunctive trimethoprim-sulfamethoxazole may be consideredin Wegener granulomatosis• Renal histopathology in SLE often determines treatment■ PearlThough first believed that leukotriene inhibitors can trigger developmentof Churg-Strauss syndrome, it is more likely that the use of thesemedications in steroid-dependent asthmatics unmasks clinical manifestationsof a previously suppressed eosinophilic syndrome.ReferenceRodriguez W et al: Pulmonary-renal syndromes in the intensive care unit. CritCare Clin 2002;18:881. [PMID: 12418445]