Diffuse bilateral cortical necrosis; a longitudinal study of the functional characteristics of residual nephrons

Purtscher's retinopathy and renal cortical necrosis: two rare vaso-occlusive complications in a patient with acute pancreatitis: a case report

BACKGROUND

Purtscher's retinopathy and renal cortical necrosis are two rare vaso-occlusive complications of acute pancreatitis. Purtscher's retinopathy causes sudden impairment of vision, which was first reported in a patient with head trauma. Subsequently, it was also reported as a complication of acute pancreatitis and few other clinical conditions. Acute pancreatitis also rarely causes renal cortical necrosis leading to acute kidney injury. However, the simultaneous presence of both complications is rarely reported.

CASE PRESENTATION

A 20-year-old Bengali man presented to our hospital with a history of acute upper abdominal pain, vomiting, anuria, and disorientation. He was ultimately found to have bilateral complete blindness due to Purtscher's retinopathy and acute kidney injury due to renal cortical necrosis, as sequelae of acute pancreatitis. He became dialysis-dependent, his vision did not recover, and he died 16 months after diagnosis.

CONCLUSIONS

This case highlights Purtscher's retinopathy and renal cortical necrosis might be considered as a recognized pair complication of acute pancreatitis.

Changing picture of renal cortical necrosis in acute kidney injury in developing country

Renal cortical necrosis (RCN) is characterized by patchy or diffuse ischemic destruction of all the elements of renal cortex resulting from significantly diminished renal arterial perfusion due to vascular spasm and microvascular injury. In addition, direct endothelial injury particularly in setting of sepsis, eclampsia, haemolytic uremic syndrome (HUS) and snake bite may lead to endovascular thrombosis with subsequent renal ischemia. Progression to end stage renal disease is a rule in diffuse cortical necrosis. It is a rare cause of acute kidney injury (AKI) in developed countries with frequency of 1.9%-2% of all patients with AKI. In contrast, RCN incidence is higher in developing countries ranging between 6%-7% of all causes of AKI. Obstetric complications (septic abortion, puerperal sepsis, abruptio placentae, postpartum haemorrhage and eclampsia) are the main (60%-70%) causes of RCN in developing countries. The remaining 30%-40% cases of RCN are caused by non-obstetrical causes, mostly due to sepsis and HUS. The incidence of RCN ranges from 10% to 30% of all cases of obstetric AKI compared with only 5% in non-gravid patients. In the developed countries, RCN accounts for 2% of all cases of AKI in adults and more than 20% of AKI during the third trimester of pregnancy. The reported incidence of RCN in obstetrical AKI varies between 18%-42.8% in different Indian studies. However, the overall incidence of RCN in pregnancy related AKI has decreased from 20%-30% to 5% in the past two decades in India. Currently RCN accounts for 3% of all causes of AKI. The incidence of RCN in obstetrical AKI was 1.44% in our recent study. HUS is most common cause of RCN in non-obstetrical group, while puerperal sepsis is leading cause of RCN in obstetric group. Because of the catastrophic sequelae of RCN, its prevention and aggressive management should always be important for the better renal outcome and prognosis of the patients.

Bilateral traumatic renal artery occlusion with survival after late reconstitution of arterial flow

Survival after bilateral traumatic renal artery occlusion is uncommon. A patient is described who recovered useful renal function despite a 12-hour delay in reconstitution of arterial flow. Postoperative oliguria latest 45 days, necessitating prolonged haemodialysis.

Renal function following acute renal failure in childhood: a long term follow-up study

We measured glomerular and tubular function in 10 children, aged 7 to 19 years, 7 to 12 years after apparent recovery from their episodes of acute renal failure. Although glomerular filtration rate was normal in all, filtration fraction (inulin clearance/PAH clearance) was elevated in six of eight patients. Segmental tubular sodium transport was assessed using clearance techniques during hypotonic saline diuresis; both proximal and distal sodium reabsorption were normal when compared with age-appropriate normal standards. Tubular reabsorption of phosphate, glucose and amino acids were also normal, as were urinary concentrating and diluting capacity and distal tubular hydrogen ion secretion. We conclude that, despite normal glomerular filtration rate, glomerular function is abnormal in a significant number of children who have apparently recovered completely from ARF, probably due to destruction of a proportion of the total nephron population, predominantly those located in the superficial layers of the cortex.

Spectrum of acute cortical necrosis in Indian patients

Forty-nine out of 662 patients (7.4%) dialysed for acute renal failure were found to have bilateral renal cortical necrosis. Amongst 6061 autopsies carried out in our centre during the same period, the incidence of cortical necrosis was 0.7%. Obstetric causes were responsible for the renal lesion in 35 (71%) and non-obstetrical causes in 14 patients. In the obstetric group, cortical necrosis was observed in association with spontaneous or induced abortion in 39% and as a complication of late pregnancy in 33%. The non-obstetric causes included snake bite in 26 (12%), acute gastro-enteritis in 5 (10%), haemolytic uremic syndrome in 2 (4%) and G6PD deficiency with intravascular haemolysis in one patient (2%). Thirty-nine (80%) patients were anuric or severely oliguric throughout their illness but a steady rise in urinary output following a protracted phase of oligo-anuria was observed in ten patients. Forty-two (86%) patients died and seven survived. None of the survivors, however, achieved a normal renal function (Ccr 8 ml to 28 ml/min). The diagnosis of renal lesion was confirmed during life in 8 and after death in 41 patients. Morphological lesions were consistent with bilateral diffuse cortical necrosis in 39 (80%) and patchy lesions in 10 patients. Factors responsible for the high incidence of cortical necrosis amongst Indian patients have been high-lighted.

Prolonged oliguria with survival in acute bilateral cortical necrosis

Survival is uncommon in cases of acute bilateral cortical necrosis. Three cases admitted to the renal unit at Newcastle have regained useful renal function after oliguric phases of 38, 46, and 120 days.Prolonged periods of intermittent dialysis are justified in patients in whom a firm diagnosis of acute cortical necrosis is made.