education | vision    about | home

Prolonged Anuric ARF Submitted by Alfredo Zannier, MD, MSC.

To View Original Image Click on Thumbnail

Dear Nephrolnauts,

A 61 y.o. male was admitted in ICU for anuric ARF and pulmonary edema. Ten days before he had presented with hiccups, asthenia, anorexia and nausea and refused admission. No history of meds, alcohol, tobacco or drugs.

At admission he was disoriented, agitated. Questioning was unfeasible. Thin, BP 130/80, 37°C, tachypnea, lower limbs edema, creps and ronchus in both lungs. No gallop.

Creatinine 3684 mcmol/l (42 mg/dl), urea 97.18 mmol/l (272 mg/dl), Na 133, K 7.1, Cl 85, pH 7.43, pCO2 19, pO2 65.7, HCO3 12.5, BE –9.2, Ca 2.29, phosphate 7.32, protides 74 g/l, glucose 7.44 mmol/l, Hb 13.2 g/dl, WBC 22690. Myoglobin 1009 mcg/l, CPK 1175 UI/l, LDH 477 UI/l, lipase 356 UI/l. Methanol and ethylene glycol negatives. No urine avilable for tests.

Heart U/S: LV without dilatation, EF 25-30 %. Urologic U/S: no obstruction, kidneys “normal”. Chest X-ray showed diffuse pulmonary edema.

Initial impression: Anuria with unusual creatinine and BUN levels. Compensated metabolic acidosis and high (42.6) anion gap without a source of it identified - other than renal failure per se or fasting. Neither anemia nor hypocalcemia, favoring a recent renal failure occurrence. The mild rhabdomyolysis seems not to play a significant role here. ARF due to ATN or RPGN.

He was put on mechanical ventilation and hemodialyzed daily during the first week, thrice weekly afterwards. Myoglobin and altered enzymes normalized rapidly.

Further results: Hyperthyroidism, PTH twice normal, anemia (established days later). Immune panel, bone marrow aspirate, protein electrophoresis, and tumor markers were normal / negative. Urine: 10 ml, no sediment feasible, Na 141, EFNa 65%, favoring ATN.

Bronchoalveolar lavage showed Serratia marcescens and Klebsiella oxitoca. He was given Ceftriaxone. Mechanical ventilation was discontinued at day (D) 5. Repeated questionings were negative for a putative cause of the ARF. Renal biopsy performed at D 21.

Phone Bx report stated ATN and infiltrates so he was given 3 courses of 500 mg of Methylprednisolone. It was discontinued when definitive report showed infiltrate was focal and sparse.

Here are the Bx micrographs. There is an ATN and a focal mononuclear cell infiltrate as described in the report. However, they also show eosinophils contributing to the infiltrate as well as a few epithelial cells in Bowman’s capsule (.vl2 and .vl3).

At D 51 he remains anuric. No etiology has been identified to date. My questions:

Could it be the infiltrate is a superimposed phenomenon, i.e., acute TIN due to Ceftriaxone going unperceived, contributing to the long lasting anuria? (I’d think it is possible).
Do you think this infiltrate could explain the anuria? (I don’t).
Could those few epithelial cells be considered as incipient crescents?
Do you biopsy him again? (I’d say yes).

Thanks for you comments.

Alfredo

A. Zannier, MD, MSc
 

          Back