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

Tranexamic acid-induced acute bilateral renal cortical necrosis in a young trauma patient: a case report and literature review

BACKGROUND

Tranexamic acid is an anti-fibrinolytic drug recommended in the setting of post-partum hemorrhage and non-obstetrical massive bleeding. Its putative role in the pathogenesis of renal cortical necrosis is unclear and has been rarely reported.

CASE PRESENTATION

We report the case of a young woman who developed anuric acute kidney injury upon administration of tranexamic acid in the setting of mild traumatic hemorrhage. Early contrast-enhanced computed tomography revealed diffuse defects of cortical enhancement in both kidneys, consistent with the diagnosis of acute bilateral renal cortical necrosis. Biological tests did not detect hallmarks of thrombotic microangiopathy or disseminated intravascular coagulation and testing for acquired thrombophilic disorders were negative. The patient remained dialysis-dependent for two months and then partially recovered renal function to an estimated glomerular filtration rate of 40 ml/min/1.73 m2.

CONCLUSIONS

This case illustrates the potential prothrombotic effect of tranexamic acid administered in the context of non-obstetric acute bleeding and the importance of re-considering its prescription in the presence of concomitant estrogenic impregnation in order to alleviate the risk of occurrence of renal cortical necrosis. It also addresses the predictive value of kidney imaging for the severity of renal cortical necrosis and subsequent renal recovery.

Snakebite-associated acute kidney injury in South Asia: narrative review on epidemiology, pathogenesis and management

Snakebite-associated acute kidney injury (AKI) poses a significant health burden in the South Asia region, resulting in considerable morbidity and mortality. Multiple factors contribute to the pathogenesis of AKI following snakebites, including hypotension, intravascular haemolysis, disseminated intravascular coagulation, rhabdomyolysis, thrombotic microangiopathy (TMA) and direct nephrotoxicity. Clinical features manifest as anuria, oliguria, haematuria, abdominal pain and hypertension. Diagnosis is supported by elevated serum creatinine levels and urine output monitoring. Renal histology studies revealed a spectrum of lesions, including acute tubular necrosis, renal cortical necrosis, glomerulonephritis and TMA. Management strategies centre around timely administration of antivenom, fluid and electrolyte balance and dialysis to improve renal outcomes. While dialysis has demonstrated efficacy in reducing AKI-related mortality rates, the use of fresh frozen plasma and therapeutic plasma exchange may be the subject of some controversy. Understanding the pathophysiological link between coagulopathy, TMA and AKI is important for tailoring effective treatment approaches. Species-specific randomized controlled trials are imperative to evaluate targeted interventions. In tackling the complexities of snakebite-associated AKI and chronic kidney disease, a multidisciplinary approach integrating clinical management with rigorous research efforts is essential. This collaborative endeavour aims to confront the challenges posed by these conditions and improve patient outcomes in the affected regions.

ACUTE KIDNEY INJURY PRECIPITATED BY HAFF DISEASE IN A 28-YEAR-OLD NIGERIAN MALE "CASE REPORT"

Haff disease is defined as unexplained rhabdomyolysis following ingestion of some sea fish and crayfish. First reported in 1926 from the Baltic region, its pathophysiologic mechanism is largely unknown, but toxins release have been implicated. Common features include generalized myalgia, brown/ dark urine, elevated serum creatine kinase and creatinine, kidney dysfunction can be severe enough to cause acute kidney injury (AKI). We present the case of a 28-year-old man who ate cooked freshwater fish and initially presented with diffuse myalgia, headache and brown-colored urine, and later fever and diarrhea. He had severely elevated serum creatine kinase and creatinine, and was managed as a case of Haff disease related AKI (HDRAKI) complicated by sepsis. He had haemodialysis and antibiotics, and recovered kidney function. A detailed history of recent diet and occupational exposure is essential in the diagnosis and management of HDR-AKI. Dialysis could be life-saving.

Unilateral renal cortical necrosis

A 51-year-old woman presented to her local emergency department with acute onset right-sided flank pain and nausea. Her blood results on admission were largely unremarkable aside from leucocytosis and neutrophilia. Two days after admission, she developed the following: stage 3 AKI with oliguria, anaemia, thrombocytopenia, and acute derangement of liver function tests. A computed tomography of the kidney ureter bladder demonstrated a right-sided 4 mm obstructing vesicoureteric junction stone with associated hydronephrosis and hydroureter. She was transferred to a tertiary care centre; gram negative sepsis was confirmed with a Proteus on blood culture and laboratory findings were in keeping with DIC. She was treated with Tazobactam/Piperacillin and intravenous fluids. In addition, further imaging showed improving right-sided hydronephrosis and left renal cortical necrosis. The aetiology of this presentation was sepsis complicated by disseminated intravascular coagulation. The coagulopathy likely contributed to the unilateral renal cortical necrosis. Cortical necrosis usually affects both kidneys, and is typically a complication of sepsis, shock, or obstetrical trauma. To our knowledge, there are only 2 reported cases of unilateral renal cortical necrosis and contralateral hydronephrosis with renal colic and septic shock. Potential pathogenetic mechanisms are discussed.

Renal cortical necrosis - a rare manifestation of dengue fever: A case report

RATIONALE

Dengue fever is a widespread mosquito-borne viral disease, most prevalent in the tropical and subtropical areas of the world. There has been a significant rise in the incidence and number of outbreaks of dengue in recent years, which has made it a matter of global concern. It may be associated with a number of renal complications, ranging from hematuria, proteinuria, glomerulonephritis, and acute tubular necrosis. However, renal cortical necrosis (RCN) is a rare renal complication of this disease.

PATIENTS CONCERNS

We report the case of a young gentleman who presented with fever, vomiting, and anuria. On workup, he was found to be having complicated Dengue fever with RCN resulting in acute renal failure.

DIAGNOSIS

To the best of our knowledge, RCN is not a reported renal complication of dengue fever.

INTERVENTIONS AND OUTCOMES

Our report highlights the importance of early consideration of renal cortical necrosis in patients with dengue fever and persistent anuria.

LESSON

This would allow for better disease prognostication while enabling physicians to develop more effective treatment strategies.

Hidden in Plain Sight: Does Medullary Red Blood Cell Congestion Provide the Explanation for Ischemic Acute Kidney Injury?

Acute kidney injury (AKI) represents a sudden reduction in renal function and is a major clinical problem with a high mortality rate. Despite decades of research, there are currently no direct therapies for AKI. The failure of therapeutic approaches identified in rodents to translate to human beings has led to questions regarding the appropriateness of these models. Our recent data indicate that there are two distinct processes driving tubular injury in the commonly used rat model of warm bilateral renal ischemia reperfusion injury, which often is used to mimic ischemic AKI. One results from the period of warm ischemia, manifesting as sublethal injury and coagulative necrosis of the proximal tubules in the renal cortex. This is the predominate type of injury observed 24 hours after reperfusion and the most well studied. The other results from red blood cell congestion of the outer medullary vasculature. This type of injury manifests as cell sloughing, along with the later formation of heme casts that fill distal nephron segments. Cell sloughing from congestion is most prominent in the early hours after reperfusion and often is masked by regeneration of the tubular epithelium by 24 hours postischemia. In this review, we argue that injury from outer medullary red blood cell congestion reflects the pathology observed in human kidneys and likely is representative of injury in most cases of ischemic AKI after shock. Greater focus on this congestive injury is likely to lead to improved translation in AKI.

Bilateral renal cortical necrosis in a child with acute pancreatitis

Bilateral renal cortical necrosis (RCN) as a cause of acute kidney injury is very rare in the pediatric population. Progression to end-stage renal disease is seen virtually in every patient with RCN. There are many causes for the occurrence of cortical necrosis in children, with severe pancreatitis being a rarity. In this report, we describe a child with severe acute pancreatitis complicated by bilateral RCN.

Acute Renal Failure after Abdominal Trauma: Renal Artery Spasm Hypothesis in Ischemic Infarction in a 12-Year-Old Girl

Posttraumatic renal failure is often due to postischemic renal infarction, caused by identified vascular lesions. In our patient, a 12-year-old girl with acute anuric renal failure requiring hemodialysis after severe abdominal trauma, no vascular lesion or thrombosis was identified. Nevertheless, CT-scan and renal biopsy showed typical lesions of diffuse bilateral renal ischemic necrosis. The main hypothesis is a severe bilateral arterial vasospasm after a blunt abdominal trauma. The patient recovered only partially with persisting chronic renal failure.

Clinical assessment and pathophysiology of Bothrops venom-related acute kidney injury: a scoping review

Bothrops are one of the most common medically important snakes found in Latin America. Its venom is predominantly hemotoxic and proteolytic, which means that local lesion (edema and redness) and hemorrhagic symptoms are recurrent in envenoming by this snake. Although hemorrhage is usually the major cause of death, snakebite-related acute kidney injury is another potentially fatal clinical complication that may lead to chronic kidney disease. The present review highlights the main studies on Bothrops venom-related acute kidney injury, including observational, cross-sectional, case-control and cohort human studies available up to December 2019. The following descriptors were used according to Medical Subject Headings (MeSH): on Medline/Pubmed and Google Scholar "acute kidney injury" or "kidney disease" and "Bothrops"; on Lilacs and SciELO "kidney disease" or "acute kidney injury" and "Bothrops". Newcastle-Ottawa quality assessment scale was used to appraise the quality of the cross-sectional and cohort studies included. The selection of more severe patients who looked for health care units and tertiary centers is a risk of bias. Due to the methodological heterogeneity of the studies, a critical analysis of the results was performed based on the hypothesis that the design of the included studies influences the incidence of acute kidney injury. Fifteen human studies (total participants 4624) were included according to stablished criteria. The coagulation abnormalities (hemorrhagic symptoms, abnormal fibrinogen and activated partial thromboplastin time) were associated with acute kidney injury in the most recent studies reported. The findings observed in this review provide up-to-date evidence about the acute kidney injury pathogenesis following Bothrops syndrome. Studies pointed out that coagulation abnormalities comprise the major pathway for acute kidney injury development. This review may improve patient management by primary healthcare providers, allowing earlier diagnosis and treatment of Bothrops venom-related acute kidney injury.

Renal Cortical Necrosis; Five Consecutive Cases within Short Span of Time

Renal cortical necrosis (RCN) is characterized by patchy or diffuse destruction of all the elements of renal cortex resulting from significantly diminished renal arterial perfusion due to vascular spasm and microvascular injury. It is a rare cause of acute kidney injury (AKI) in developed countries with frequency of 1.9%-2% of all patients of AKI. In contrast, the incidence of RCN is higher in developing countries ranging from 6%-7%. Obstetric complication is the main cause of RCN, earlier it was about 20%-30% which has been declining to 5% in the Indian subcontinent during the past two decades. The aim of this study is to review five consecutive cases of RCN diagnosed within very short span of time. Histopathologically, diagnosed five cases of RCN during one-month span in September 2016 at Armed Forces Institute of Pathology, Dhaka were included in this study. All the cases were referred cases from a tertiary level obstetric center of Dhaka city; the mean age was 24.2 ± 3.4 years. All the cases had the history of postpartum hemorrhage followed by septicemia. They all presented with acute renal failure dependent on hemodialysis for >21 days. On histological examination, three (60%) had patchy RCN and two (40%) had diffuse RCN. Two (40%) showed coagulative necrosis of all the glomeruli, two (40%) showed coagulative necrosis of >50% of glomeruli, and in one (20%) case necrosis of about 25% of glomeruli. One of the glomeruli showed global sclerotic change of most of the glomeruli. In all the cases, interstitium showed moderate focal lymphocytic infiltration and mild edema. Among all, one (20%) was found with immunoglobulin A nephropathy as an associated diagnosis. RCN is still encountered as an obstetric complication in our setting and this type of grave consequences should be prevented by better monitoring of pregnancies.

Partially Reversible Acute Renal Cortical Necrosis Secondary to Hyperhomocysteinemia - A Case Report and Literature Review

Acute renal cortical necrosis (ACN) is a potentially fatal renal condition. Our objective is to report a case of ACN in a young man who had developed premature atherosclerotic vascular disease and required intermittent hemodialysis support. His renal biopsy showed diffuse cortical necrosis. Subsequently, 2 weeks after the renal insult, he developed a cardioembolic stroke and was anticoagulated with low-molecular-weight heparin. Thrombophilia screen revealed elevated serum homocystein and he was treated with folate supplement and vitamin B12 injection. With these treatments, he had partial renal recovery and became dialysis independent. In conclusion, this is a rare case of ACN, which may have occurred as a complication of hyperhomocysteinemia.

Cell Death in the Kidney

Apoptotic cell death is usually a response to the cell's microenvironment. In the kidney, apoptosis contributes to parenchymal cell loss in the course of acute and chronic renal injury, but does not trigger an inflammatory response. What distinguishes necrosis from apoptosis is the rupture of the plasma membrane, so necrotic cell death is accompanied by the release of unprocessed intracellular content, including cellular organelles, which are highly immunogenic proteins. The relative contribution of apoptosis and necrosis to injury varies, depending on the severity of the insult. Regulated cell death may result from immunologically silent apoptosis or from immunogenic necrosis. Recent advances have enhanced the most revolutionary concept of regulated necrosis. Several modalities of regulated necrosis have been described, such as necroptosis, ferroptosis, pyroptosis, and mitochondrial permeability transition-dependent regulated necrosis. We review the different modalities of apoptosis, necrosis, and regulated necrosis in kidney injury, focusing particularly on evidence implicating cell death in ectopic renal calcification. We also review the evidence for the role of cell death in kidney injury, which may pave the way for new therapeutic opportunities.

Characteristics and Outcome of Obstetric Acute Kidney Injury in Pakistan: A Single-center Prospective Observational Study

Introduction

Acute kidney injury (AKI) continues to be a cause of increased morbidity and mortality in pregnant women. While studies have been conducted on the incidence and etiology of this complication, the outcomes of obstetric AKI have not been extensively investigated. The primary focus of this prospective observational study was to analyze the risk factors, etiologies as well as maternal and fetal outcomes of AKI in pregnant females in Pakistan.

Methods

A total of 56 patients with obstetric AKI were recruited. Patients were followed for a period of three months postpartum. The diagnosis and staging of AKI were based on the classification of the Acute Kidney Injury Network (AKIN).

Results

Fifteen patients were lost to follow-up and were excluded from the study. The mean age of the remaining 41 patients was 26±6 years. Twenty-two (54%) patients were multigravida, and 19 (46%) were primigravida. Twenty (48%) patients did not receive any antenatal care, 13 (31%) were visited by a traditional birth attendant, and only eight (19%) had adequate antenatal care by a gynecologist. Out of 41 patients, seven (17%) presented before 28 weeks, and 34 (83%) patients presented after 28 weeks of gestation. Four (10%) patients were found to be in stage I, four (10%) in stage II, and 33 (80%) patients in stage III AKI during hospitalization. The causes of AKI included sepsis in 32 (78%), intrauterine death in 24 (60%), postpartum hemorrhage in 17 (41%), shock in 15 (36%), pre-eclampsia/eclampsia in seven (17%), and coagulopathy in three (7%) patients. Twenty-eight (68.3%) patients received hemodialysis during the hospital stay. Three-month follow-up showed complete resolution of AKI in 14 (34.2%) patients, partial resolution in seven (17%), end-stage renal disease in 10 (24.4%), and death in 10 (24.4%) patients.

Conclusion

The present study indicates that a vast majority of patients with obstetric AKI require dialysis. Residual renal dysfunction and end-stage renal disease were common at the three-month follow-up. Incidentally, sepsis and intrauterine death were the leading causes in this study population. Increased awareness and appropriate obstetrical care may have a significantly positive impact on decreasing the morbidity and mortality in these patients.

Snakebite Induced Thrombotic Microangiopathy Leading to Renal Cortical Necrosis

Renal complications from snakebite result in high mortality and morbidity. Acute kidney injury (AKI) occurs in 5–30% of cases. Renal manifestation could include acute tubular necrosis, cortical necrosis, interstitial nephritis, glomerulonephritis, and vasculitis. We present a case of thrombotic microangiopathy (TMA) resulting in renal cortical necrosis. Renal biopsy showed fibrin thrombi in glomeruli and arterioles with cortical necrosis. Our patient progressed to end-stage renal disease.

Tranexamic Acid-Induced Acute Renal Cortical Necrosis in Post-Endoscopic Papillectomy Bleeding

Acute renal failure can be the result of acute renal cortical necrosis (RCN), which commonly occurs from complications occurring during pregnancy. RCN is rarely caused by medications, although tranexamic acid, which is used in patients with acute bleeding for its antifibrinolytic effects, reportedly causes acute RCN in rare cases. An 82-year-old woman experienced gastrointestinal bleeding after endoscopic papillectomy of an ampullary adenoma. The bleeding was controlled with tranexamic acid administration; however, 4 days later, her urine volume decreased and she developed pulmonary edema and dyspnea. Serum creatinine levels increased from 0.8 to 3.9 mg/dL and dialysis was performed. Abdominal pelvic computed tomography with contrast enhancement revealed bilateral RCN with no renal cortex enhancement. Renal dysfunction and oliguria persisted and hemodialysis was continued. Clinicians must be aware that acute RCN can occur after tranexamic acid administration to control bleeding.

Clinicopathological spectrum of snake bite-induced acute kidney injury from India

AIM

To study the clinico-pathological spectrum of snake bite-induced acute kidney injury (AKI).

METHODS

A retrospective study of patients admitted at Indira Gandhi Medical College Hospital, Shimla with snake bite-induced AKI from July 2003 to June 2016. Medical records were evaluated for patient’s information on demographic, clinical characteristics, complications and outcome. Outcomes of duration of hospital stay, requirement for intensive care unit support, treatment with dialysis, survival and mortality were analyzed. The survival and non survival groups were compared to see the difference in the demographic factors, clinical characteristics, laboratory results, and complications. In patients subjected to kidney biopsy, the findings of histopathological examination of the kidney biopsies were also analyzed.

RESULTS

One hundred and twenty-one patients were diagnosed with snake bite-induced AKI. Mean age was 42.2 ± 15.1 years and majority (58%) were women. Clinical details were available in 88 patients. The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to 30 d. Eighty percent had oliguria and 55% had history of having passed red or brown colored urine. Coagulation defect was seen in 89% patients. The hematological and biochemical laboratory abnormalities were: Anemia (80.7%), leukocytosis (75%), thrombocytopenia (47.7%), hyperkalemia (25%), severe metabolic acidosis (39.8%), hepatic dysfunction (40.9%), hemolysis (85.2%) and rhabdomyolysis (68.2%). Main complications were: Gastrointestinal bleed (12.5%), seizure/encephalopathy (10.2%), hypertension, pneumonia/acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (9.1% each), hypotension and multi organ failure (MOF) (4.5% each). Eighty-two percent patients required renal replacement therapy. One hundred and ten (90.9%) patient survived and 11 (9.1%) patients died. As compared to the survival group, the white blood cell count (P = 0.023) and bilirubin levels (P = 0.006) were significant higher and albumin levels were significantly lower (0.005) in patients who died. The proportion of patients with pneumonia/ARDS (P = 0.001), seizure/encephalopathy (P = 0.005), MOF (P = 0.05) and need for intensive care unit support (0.001) was significantly higher and duration of hospital stay was significantly shorter (P = 0.012) in patients who died. Kidney biopsy was done in total of 22 patients. Predominant lesion on kidney biopsy was acute tubular necrosis (ATN) in 20 (91%) cases. In 11 cases had severe ATN and in other nine (41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis (AIN). One patient only had moderate AIN and one had patchy renal cortical necrosis (RCN).

CONCLUSION

AKI due to snake bite is severe and a high proportion requires renal replacement therapy. On renal histology ATN and AIN are common, RCN is rare.

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.