Acute Kidney Injury, Recurrent Seizures, and Thrombocytopenia in a Young Patient with Lupus Nephritis: A Diagnostic Dilemma

Introduction. Posterior reversible encephalopathy syndrome (PRES) is a constellation of clinical and radiologic findings. Fluctuations in blood pressure, seizures, and reversible brain MRI findings mainly in posterior cerebral white matter are the main manifestations. PRES has been associated with multiple conditions such as autoimmune disorders, pregnancy, organ transplant, and thrombotic microangiopathy (TMA). Case Presentation. A 22-year-old woman with history of Systemic Lupus Erythematous complicated with chronic kidney disease secondary to lupus nephritis class IV presented with recurrent seizures and uncontrolled hypertension. She was found to have acute kidney injury and thrombocytopenia. Repeat kidney biopsy showed diffuse endocapillary and extracapillary proliferative and membranous lupus nephritis (ISN-RPS class IV-G+V) and endothelial swelling secondary to severe hypertension but no evidence of TMA. Brain MRI showed reversible left frontal and parietal lesions that resolved after controlling the blood pressure, making PRES the diagnosis. Conclusion. PRES is an important entity that must be recognized and treated early due to the potential reversibility in the early stages. Physicians must have high suspicion for these unusual presentations. We present a case where performing kidney biopsy clinched the diagnosis in our patient with multiple confounding factors.

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Relationship between acute kidney injury and brain MRI findings in asphyxiated newborns after therapeutic hypothermia

Pediatric Research ◽

10.1038/pr.2013.230 ◽

2013 ◽

Vol 75 (3) ◽

pp. 431-435 ◽

Cited By ~ 42

Author(s):

Subrata Sarkar ◽

David J. Askenazi ◽

Brian K. Jordan ◽

Indira Bhagat ◽

J.R. Bapuraj ◽

...

Keyword(s):

Acute Kidney Injury ◽

Therapeutic Hypothermia ◽

Brain Mri ◽

Kidney Injury ◽

Mri Findings

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334 Relationship Between Acute Kidney Injury (AKI) using AKI Network Criteria and Brain MRI Findings in Asphyxiated Newborns after Therapeutic Hypothermia

Archives of Disease in Childhood ◽

10.1136/archdischild-2012-302724.0334 ◽

2012 ◽

Vol 97 (Suppl 2) ◽

pp. A98-A98

Author(s):

S. Sarkar ◽

B. Jordan ◽

I. Bhagat ◽

J. Bapuraj ◽

R. Dechert ◽

...

Keyword(s):

Acute Kidney Injury ◽

Therapeutic Hypothermia ◽

Brain Mri ◽

Kidney Injury ◽

Mri Findings

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Uncontrolled hypertension and elevated NT-proBNP predict acute kidney injury and cardiac death in all-comer patients 1 year after acute coronary syndromes

European Heart Journal ◽

10.1093/ehjci/ehaa946.1655 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Denegri ◽

L Raeber ◽

S Windecker ◽

B Gencer ◽

F Mach ◽

...

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Cardiac Death ◽

Acute Coronary Syndromes ◽

Kidney Injury ◽

Composite Endpoint ◽

Uncontrolled Hypertension ◽

Increased Risk ◽

Coronary Syndromes ◽

One Year

Abstract Background Hypertension is a recognized cardiovascular (CV) risk factor and, although many highly effective antihypertensive drugs have been developed, most patients fail to achieve recommended blood pressure target levels. This may increase major adverse CV events after acute coronary syndromes (ACS) such as acute kidney injury (AKI) and cardiac death (CD). Purpose We assessed the prognostic value of uncontrolled hypertension (UH) and elevated NT-proBNP among 2,168 all-comer patients admitted to 4 Swiss University Hospitals for acute coronary syndromes (ACS) enrolled in the prospective multicenter SPUM registry. Methods Patients with UH defined as a systolic blood pressure≥140 mmHg, and a NT-proBNP>900 ng/l were considered for the analysis. The composite primary endpoint was AKI and CD. Adjusted Cox proportional hazards regression models were implemented to determine risk prediction for UH and elevated NT-proBNP levels. Results Out of 2,168 ACS patients, 235 patients (10.8%) showed UH and NT-proBNP>900 ng/l (Fig. 1A). Compared to the general ACS population, those with UH and elevated NT-proBNP were more likely to be older (41.7% vs 20.0%, p<0.001), of female sex (36.2% vs 19.7%, p<0.001) and with a more complex history of CV disease, such as hypertension (77.0% vs 56.2%, p<0.001), diabetes (24.7% vs 17.5%, p=0.006), peripheral artery disease (9.4% vs 5.2%, p=0.011), cerebrovascular disease (6.8% vs 3.4%, p=0.013), chronic heart failure (3.4% vs 1.3%, p=0.025), dialysis (2.1% vs 0.3%, p=0.004) as well as prior CABG (9.4% vs 5.2%, p=0.010) and more often admitted as NSTEMIs (59.6% vs 40.9%, p<0.001). Although these patients were on a more aggressive antihypertensive therapy at admission (all p<0.05 for ACEi, ARB, Beta-blockers, calcium antagonists, nitrates and diuretics), there was a higher rate of death (OR 1.83, 95% CI 1.07–3.14, p=0.027), CD (OR 2.13, 95% CI 1.19–3.81, p=0.009), AKI (OR 2.83, 95% CI 1.41–5.67, p=0.002) and composite endpoint AKI+CD (OR 2.46, 95% CI 1.56–3.90, p<0.001) at one year. This combined risk persisted after adjustment for baseline differences, with a 71% (Adj. HR 1.71, 95% CI 1.44–1.84, p=0.003) increase for the composite endpoint (Fig. 1B). Conclusions Among a real-world cohort of ACS patients, coexistence of UH with elevated levels of NT-proBNP confers increased risk for AKI and CD up to one year after ACS. These observations might help clinicians to identify ACS patients at risk using simple clinical parameters and biomarkers and to target them for more intense preventive therapies. Figure 1. A: GRADE1 = 140–159 mmHg and/or 90–99 mmHg; GRADE2 = 160–179 mmHg and/or 100–109 mmHg; GRADE3 = ≥180 mmHg and/or ≥110 mmHg; ISH (isolate systolic hypertension) = ≥140 mmHg and <90 mmHg; NT-proBNP = N-terminal-pro B-type natriuretic peptide. B: UH = uncontrolled hypertension; AKI = acute kidney injury; CD = cardiac death. Funding Acknowledgement Type of funding source: None

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Faculty Opinions recommendation of Changes in blood pressure before the development of nosocomial acute kidney injury.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1147523.604713 ◽

2009 ◽

Author(s):

Andrew Davenport

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Kidney Injury

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Granulomatous interstitial nephritis in a patient with SARS-CoV-2 infection

BMC Nephrology ◽

10.1186/s12882-020-02213-w ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Katarzyna Szajek ◽

Marie-Elisabeth Kajdi ◽

Valerie A. Luyckx ◽

Thomas Hans Fehr ◽

Ariana Gaspert ◽

...

Keyword(s):

Acute Kidney Injury ◽

Interstitial Nephritis ◽

Kidney Biopsy ◽

Kidney Diseases ◽

Case Reports ◽

Kidney Injury ◽

Maculopapular Rash ◽

Tubular Injury ◽

Granulomatous Interstitial Nephritis ◽

First Case

Abstract Background Acute kidney injury (AKI) associated with severe coronavirus disease 19 (COVID-19) is common and is a significant predictor of morbidity and mortality, especially when dialysis is required. Case reports and autopsy series have revealed that most patients with COVID-19 – associated acute kidney injury have evidence of acute tubular injury and necrosis - not unexpected in critically ill patients. Others have been found to have collapsing glomerulopathy, thrombotic microangiopathy and diverse underlying kidney diseases. A primary kidney pathology related to COVID-19 has not yet emerged. Thus far direct infection of the kidney, or its impact on clinical disease remains controversial. The management of AKI is currently supportive. Case Presentation The patient presented here was positive for SARS-CoV-2, had severe acute respiratory distress syndrome and multi-organ failure. Within days of admission to the intensive care unit he developed oliguric acute kidney failure requiring dialysis. Acute kidney injury developed in the setting of hemodynamic instability, sepsis and a maculopapular rash. Over the ensuing days the patient also developed transfusion-requiring severe hemolysis which was Coombs negative. Schistocytes were present on the peripheral smear. Given the broad differential diagnoses for acute kidney injury, a kidney biopsy was performed and revealed granulomatous tubulo-interstitial nephritis with some acute tubular injury. Based on the biopsy findings, a decision was taken to adjust medications and initiate corticosteroids for presumed medication-induced interstitial nephritis, hemolysis and maculo-papular rash. The kidney function and hemolysis improved over the subsequent days and the patient was discharged to a rehabilitation facility, no-longer required dialysis. Conclusions Acute kidney injury in patients with severe COVID-19 may have multiple causes. We present the first case of granulomatous interstitial nephritis in a patient with COVID-19. Drug-reactions may be more frequent than currently recognized in COVID-19 and are potentially reversible. The kidney biopsy findings in this case led to a change in therapy, which was associated with subsequent patient improvement. Kidney biopsy may therefore have significant value in pulling together a clinical diagnosis, and may impact outcome if a treatable cause is identified.

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Immunotherapy‐related acute kidney injury: Kidney biopsy or not?

Nephrology ◽

10.1111/nep.13687 ◽

2020 ◽

Vol 26 (1) ◽

pp. 89-90 ◽

Cited By ~ 1

Author(s):

Sophie Chatterton ◽

Sarah Williams ◽

Kazi Nahar ◽

Alexander M. Menzies ◽

Muh G. Wong

Keyword(s):

Acute Kidney Injury ◽

Kidney Biopsy ◽

Kidney Injury

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A rare case of posterior reversible encephalopathy syndrome in a patient with severe leptospirosis complicated with rhabdomyolysis and acute kidney injury; a case report

BMC Infectious Diseases ◽

10.1186/s12879-021-06240-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jayawardane Pathiranage Roneesha Lakmali ◽

Kanapathipillei Thirumavalavan ◽

Danapala Dissanayake

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Blood Pressure Control ◽

Posterior Reversible Encephalopathy Syndrome ◽

Vision Loss ◽

Kidney Injury ◽

Pressure Control ◽

Posterior Reversible Encephalopathy ◽

Peripheral Nerve Involvement ◽

Reversible Encephalopathy

Abstract Background Leptospirosis is a zoonotic spirochetal disease caused by Leptospira interrogans. The clinical presentation ranges from an asymptomatic state to a fatal multiorgan dysfunction. Neurological manifestations including aseptic meningitis, spinal cord and peripheral nerve involvement, cranial neuropathies and cerebellar syndrome are well recognized with varying frequencies among patients with this disease. Posterior reversible encephalopathy syndrome is a very rare occurrence in leptospirosis and only two cases are reported in the medical literature up to now. We report a case of posterior reversible encephalopathy syndrome in a patient with leptospirosis with rhabdomyolysis and acute kidney injury. Case presentation A 21 year-old male presented with fever and oliguric acute kidney injury with rhabdomyolysis. A diagnosis of leptospirosis was made and he was being managed according to the standard practice together with regular hemodialysis. The clinical condition was improving gradually. On day 8 of the illness, he developed headache and sudden painless complete bilateral vision loss followed by several brief generalized tonic clonic seizure attacks. Examination was significant for a Glasgow Coma Scale of 14/15, blood pressure of 150/90 mmHg and complete bilateral blindness. The findings of magnetic resonance imaging of the brain were compatible with posterior reversible encephalopathy syndrome. He was managed with blood pressure control and antiepileptics with supportive measures and standard treatment for leptospirosis and made a complete recovery. Conclusion Posterior reversible encephalopathy syndrome, though very rare with leptospirosis, should be considered as a differential diagnosis in a patient with new onset visual symptoms and seizures, especially during the immune phase. Optimal supportive care together with careful blood pressure control and seizure management would yield a favourable outcome in this reversible entity.

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Pregnancy-related acute kidney injury at high altitude: a retrospective observational study in a single center

BMC Nephrology ◽

10.1186/s12882-021-02418-7 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Xin Li ◽

Xiaojing Wu ◽

Muyin Zhang ◽

Lili Xu ◽

Guohui Li ◽

...

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

High Altitude ◽

Kidney Injury ◽

Hypertensive Disorders Of Pregnancy ◽

Fetal Outcomes ◽

Uncontrolled Blood Pressure ◽

Logistic Regression Models ◽

Hypertensive Disorders ◽

Term Delivery

Abstract Background Pregnancy-related acute kidney injury (Pr-AKI) is associated with maternal and fetal morbidity and mortality. There are few studies focusing on Pr-AKI at high altitude in the literature. Objectives to investigate the incidence, etiology, clinical features and maternal-fetal outcomes of Pr-AKI in women living at high altitude. Methods 6,512 pregnant women attending the Department of Obstetrics & Gynecology at local hospital from January 2015 to December 2018 were screened for Pr-AKI. Patients with serum creatinine above normal range(> 70umol/L) then underwent assessment to confirm the diagnosis of Pr-AKI. AKI was diagnosed and staged based on Kidney Disease Improving Global Outcomes(KDIGO) guideline. Individuals meeting the Pr-AKI criteria were recruited. Their clinical data were recorded and retrospectively analyzed. Results Pr-AKI was identified in 136/6512(2.09 %) patients. Hypertensive disorders of pregnancy(HDP) was the leading cause of Pr-AKI(35.3 %). 4(2.9 %) women died and the majority(86.1 %) had recovered renal function before discharge. Fetal outcomes were confirmed in 109 deliveries with gestational age ≥ 20 weeks. Pre-term delivery occurred in 30(27.3 %) cases and perinatal deaths in 17(15.5 %). The rate of low birth weight infant(LBWI) and intrauterine growth restriction(IUGR) was 22.0 and 10.9 % respectively. 16(14.5 %) infants were admitted to NICU after birth. Patients with HDP had a higher cesarean rate(56.3 %). More IUGR(25.0 %) and LBWI(37.8 %) were observed in their infants with a higher risk of admission to NICU(22.0 %). High altitude might have an adverse impact on HDP-related Pr-AKI patients with earlier terminated pregnancy and more stillbirth/neonatal death. Logistic regression models indicated that uncontrolled blood pressure, high altitude and advanced AKI were associated with adverse fetal outcomes in HDP-related Pr-AKI patients. Conclusions Pr-AKI was not rare in high-altitude regions and caused severe fetal morbidities and mortalities. Uncontrolled blood pressure, high altitude and advanced AKI were all risk factors for adverse fetal outcomes in Pr-AKI patients, especially for those with hypertensive disorders of pregnancy.

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