New Insight for Kidney Biopsy Series in Cases with COVID-19-related Acute Kidney Injury

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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Diagnostic utility of kidney biopsy in patients with sarcoidosis and acute kidney injury

International Journal of Nephrology and Renovascular Disease ◽

10.2147/ijnrd.s22549 ◽

2011 ◽

pp. 131 ◽

Cited By ~ 8

Author(s):

Ravish Shah ◽

Ravish Shah

Keyword(s):

Acute Kidney Injury ◽

Kidney Biopsy ◽

Kidney Injury ◽

Diagnostic Utility

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Tubulitis in a patient treated with nivolumab: Case report and literature review

Journal of Onco-Nephrology ◽

10.1177/2399369318812969 ◽

2018 ◽

Vol 2 (2-3) ◽

pp. 107-112

Author(s):

Viral Vakil ◽

Mark Birkenbach ◽

Katti Woerner ◽

Lihong Bu

Keyword(s):

Acute Kidney Injury ◽

Immune Checkpoint Inhibitors ◽

Kidney Biopsy ◽

Tubulointerstitial Nephritis ◽

Checkpoint Inhibitors ◽

Kidney Injury ◽

Programmed Death Ligand 1 ◽

Programmed Death ◽

Metastatic Urothelial Carcinoma ◽

Programmed Death 1

Kidney injury associated with use of immune checkpoint inhibitors that target the programmed death-1 molecule commonly manifests as acute tubulointerstitial nephritis on kidney biopsy. We present a case of a 66-year-old man who developed acute kidney injury at 6 months after initiation of treatment with anti-programmed death-1 antibody, nivolumab, for treatment of metastatic urothelial carcinoma. A renal biopsy showed focal moderate-to-severe lymphocytic tubulitis with minimal interstitial inflammation. Programmed death ligand-1 immunopositivity was detected only in tubules exhibiting lymphocytic tubulitis. The patient’s renal function improved to baseline with conservative management consisting of discontinuation of nivolumab followed by prednisone treatment.

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Acute Kidney Injury Associated with Minimal Change Nephrotic Syndrome in an Elderly Patient Successfully Treated with both Fluid Management and Specific Therapy Based on Kidney Biopsy Findings

Case Reports in Nephrology and Dialysis ◽

10.1159/000507426 ◽

2020 ◽

Vol 10 (1) ◽

pp. 42-50 ◽

Cited By ~ 2

Author(s):

Yuko Oyama ◽

Yoichi Iwafuchi ◽

Tetsuo Morioka ◽

Ichiei Narita

Keyword(s):

Elderly Patient ◽

Acute Kidney Injury ◽

Nephrotic Syndrome ◽

Kidney Biopsy ◽

Fluid Management ◽

Kidney Injury ◽

Oral Prednisolone ◽

Minimal Change Nephrotic Syndrome ◽

Minimal Change ◽

Fluid Removal

Oliguric acute kidney injury (AKI) with minimal change nephrotic syndrome (MCNS) has long been recognized. Several mechanisms such as hypovolemia due to hypoalbuminemia and the nephrosarca hypothesis have been proposed. However, the precise mechanism by which MCNS causes AKI has not been fully elucidated. Herein, we describe an elderly patient with AKI caused by MCNS who fully recovered after aggressive volume withdrawal by hemodialysis and administration of a glucocorticoid. A 75-year-old woman presented with diarrhea and oliguria, and laboratory examination revealed nephrotic syndrome (NS) and severe azotemia. Fluid administration had no effect on renal dysfunction, and hemodialysis was initiated. Her renal function improved upon aggressive fluid removal through hemodialysis. Renal pathological findings revealed minimal change disease with faint mesangial deposits of IgA. After administration of methylprednisolone pulse therapy followed by oral prednisolone, she achieved complete remission from NS. The clinical course of this case supports the nephrosarca hypothesis regarding the mechanism of AKI caused by MCNS. Furthermore, appropriate fluid management and kidney biopsy are also important in elderly patients with AKI caused by NS.

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Kidney Biopsy Findings in a Critically Ill COVID-19 Patient With Dialysis-Dependent Acute Kidney Injury: A Case Against “SARS-CoV-2 Nephropathy”

Kidney International Reports ◽

10.1016/j.ekir.2020.05.005 ◽

2020 ◽

Vol 5 (7) ◽

pp. 1100-1105 ◽

Cited By ~ 15

Author(s):

Giovanni Maria Rossi ◽

Marco Delsante ◽

Francesco Paolo Pilato ◽

Letizia Gnetti ◽

Liliana Gabrielli ◽

...

Keyword(s):

Acute Kidney Injury ◽

Critically Ill ◽

Kidney Biopsy ◽

Kidney Injury

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A Case of Chronic Ethylene Glycol Intoxication Presenting without Classic Metabolic Derangements

Case Reports in Nephrology ◽

10.1155/2014/128145 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3 ◽

Cited By ~ 1

Author(s):

Stephanie M. Toth-Manikowski ◽

Hanni Menn-Josephy ◽

Jasvinder Bhatia

Keyword(s):

Acute Kidney Injury ◽

Ethylene Glycol ◽

Kidney Biopsy ◽

Kidney Injury ◽

Altered Mental Status ◽

Chronic Ingestion ◽

Exposure History ◽

Ethylene Glycol Intoxication ◽

Physical Findings ◽

Osmolar Gap

Acute ethylene glycol ingestion classically presents with high anion gap acidosis, elevated osmolar gap, altered mental status, and acute renal failure. However, chronic ingestion of ethylene glycol is a challenging diagnosis that can present as acute kidney injury with subtle physical findings and without the classic metabolic derangements. We present a case of chronic ethylene glycol ingestion in a patient who presented with acute kidney injury and repeated denials of an exposure history. Kidney biopsy was critical to the elucidation of the cause of his worsening renal function.

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Acute Kidney Injury In Hospitalized Patients Who Underwent Percutaneous Kidney Biopsy

10.21203/rs.2.10344/v1 ◽

2019 ◽

Author(s):

Henrique Pinheiro Konigsfeld ◽

Thais Oliveira Claizoni Dos Santos ◽

Tatiana Garcia Viana ◽

Suzy Cristine Pereira ◽

Gianna Mastroianni Kirsztajn ◽

...

Keyword(s):

Acute Kidney Injury ◽

Kidney Disease ◽

Kidney Biopsy ◽

Density Lipoprotein ◽

Kidney Injury ◽

Tertiary Hospital ◽

Epidemiological Studies ◽

Hospitalized Patients ◽

Baseline Serum ◽

Primary Indication

Abstract Background Performing a kidney biopsy is necessary to accurately diagnose diseases such as glomerulonephritis and tubulointerstitial nephritis, among other such conditions. These conditions predispose patients to chronic kidney disease, as well as acute kidney injury (AKI). Notably, most epidemiological studies describing AKI have not investigated this patient population. Methods Included patients admitted to the nephrology ward of a tertiary hospital who underwent percutaneous kidney biopsy. AKI was diagnosed based on the Kidney Disease: Improving Global Outcomes criteria. Results Of the 223 patients investigated, 140 (62.8%) showed AKI. Of these, 91 (65%), 19 (13.6%), and 30 (21.4%) presented with AKI classified as stages 1, 2, and 3, respectively. The primary indication for performing biopsy was nephrotic syndrome or nephrotic proteinuria (73 [52.1%] in the AKI vs. 51 [61.4%] in the non-AKI group, p=0.048). Focal segmental glomerulosclerosis was the most prevalent primary disease (24 [17.1%] in the AKI vs. 15 [18.0%] in the non-AKI group, p=0.150). Multivariate analysis of risk factors associated with AKI showed hemoglobin levels (odds ratio [OR] 0.805, 95% confidence interval [CI] 0.681–0.951, p=0.011), serum high-density lipoprotein cholesterol levels (HDL-c, OR 0.970, 95% CI 0.949–0.992, p=0.008), and baseline serum creatinine levels (OR 2.703, 95% CI 1.471–4.968, p=0.001) were significantly associated with AKI. Conclusions We observed a high incidence of AKI in hospitalized patients who underwent kidney biopsy to investigate their renal disease, particularly glomerulonephritis. Higher levels of hemoglobin and serum HDL-c were associated with a lower risk of AKI.

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MO378WHAT LIES BENEATH ANTICOAGULATION-RELATED ACUTE KIDNEY INJURY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab082.0032 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Hernando Trujillo ◽

Justo Sandino Pérez ◽

Teresa Cavero Escribano ◽

Eduardo Gutierrez ◽

Angel Sevillano ◽

...

Keyword(s):

Acute Kidney Injury ◽

Kidney Disease ◽

Iga Nephropathy ◽

Kidney Biopsy ◽

Vitamin K Antagonists ◽

Immunosuppressive Treatment ◽

Kidney Injury ◽

Secondary Outcome ◽

Biopsy Specimens

Abstract Background and Aims Acute kidney injury (AKI) secondary to glomerular hemorrhage in the context of overanticoagulation, commonly known as anticoagulant-related nephropathy (ARN), is a relatively novel recognized entity. Preexisting or underlying kidney disease seems to be a predisposing factor; however, few studies have described histologic findings in patients with ARN. We aimed to examine underlying kidney pathology in patients on oral anticoagulation who presented an episode of AKI with hematuria in whom a kidney biopsy was performed. Method Spanish retrospective observational multicenter case study in patients treated with oral anticoagulants who developed macroscopic or intense hematuria followed by AKI. Only patients with available kidney biopsy specimens were included. Histologic findings and clinical data throughout follow-up were analyzed. The main outcome was to describe pathologic findings in kidney biopsy specimens of patients with clinical suspicion of ARN. The secondary outcome was to assess kidney outcomes during follow-up. Results Twenty-four patients were included with a median age of 76 years (interquartile range [IQR] 64-81) and a follow-up period of 10.1 (IQR 1.3-41.1) months. 79% were male, 22 (91%) had hypertension and 9 (37%) were diabetic. Most cases (91%) were on anticoagulation with vitamin K antagonists. At admission, 87% of cases presented gross hematuria with a median serum creatinine (SCr) of 4.2 mg/dl and a median INR of 2.3. During follow-up, median highest (peak) SCr was 6.3 mg/dl and 11 (45%) patients required acute dialysis. Kidney biopsy showed that all patients except one had an underlying nephropathy (confirmed IgA nephropathy in 16 [66.7%], probable IgA nephropathy in 2, diabetic nephropathy in 3, nephrosclerosis in 1, and idiopathic nodular glomerulosclerosis in 1). Tubules filled with red cells and red cell casts were observed in 66.7% of the cases and acute tubular necrosis in 70.8%. Management included anticoagulation withdrawal in 14 cases (58.3%) and immunosuppressive treatment with corticosteroids (n = 17 [70.8%]) and mycophenolic acid (n = 5 [20.8%]). At 12 weeks after discharge, 11 patients had >50% decrease in SCr (with respect to peak SCr), 6 had <50% decrease and 5 were on chronic dialysis. Conclusion IgA nephropathy was the most common underlying kidney disease in our biopsy-proven series of ARN, in which a significant percentage of patients did not achieve kidney function recovery.

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