Perioperative fluid management in a patient with Fanconi syndrome and renal tubular acidosis undergoing major orthopaedic surgery: A case report

Abstract

Fanconi syndrome (FS) due to tenofovir disoproxil fumarate (TDF) can lead to proximal renal tubular acidosis (type 2 RTA), bone fragility and pathological fractures. Perioperative fluid and acid-base management in this setting is complex and not well described. To outline the perioperative fluid approach, acid-base management and early outcome in a young woman with TDF-related FS and type 2 RTA undergoing major orthopaedic surgery. Case report of a 29-year-old human immunodeficiency virus-positive woman with kyphoscoliosis and bilateral subtrochanteric fractures who underwent bilateral femur osteotomies and cephalomedullary nail fixation. Perioperative care included multidisciplinary optimisation, adjustment of antiretroviral therapy, avoidance of nephrotoxins, correction of electrolytes, preference for balanced crystalloids, titrated bicarbonate therapy and close monitoring with serial blood gases and fluid balance in the intensive care unit (ICU). The patient was admitted to the ICU with severe non-anion gap metabolic acidosis (pH 7.22; base excess –11.3). With balanced crystalloids and bicarbonate therapy, acid-base status normalised within 72 h (Day 3: pH 7.39; HCO₃ 26.4 mmol/L), lactate resolved, haemodynamics stabilised and electrolytes corrected. Renal function remained stable, and she was discharged from the ICU with normal acid-base status for further orthopaedic rehabilitation.
Contribution: In patients with TDF-associated FS and proximal RTA, a tailored physiology-based perioperative strategy emphasising balanced crystalloids, electrolyte correction and guided bicarbonate therapy can restore acid-base balance and allow safe recovery after major surgery. This case highlights practical considerations for fluid management in a high-risk group.