Reversal of Severe Volume Deplete Acute Kidney Injury by Rasburicase

We report on a case of acute kidney injury in a patient with severe volume depletion from high ileostomy output and poor oral intake associated with hyperuricemia and hyperkalemia. The patient presented with similar features on three separate admissions. A conservative management approach was undertaken that included infusion of rasburicase, since the patient refused to undergo hemodialysis on each occasion. Rasburicase is a recombinant urate oxidase enzyme that converts uric acid to allantoin which is five to ten times more soluble than uric acid in urine, thereby enhancing urinary excretion. Rasburicase was administered each time and was followed by a prompt increase in urine output, rapid decrease in serum uric acid level, and recovery of renal function without the need for acute renal replacement therapy. We believe that rasburicase, with a molecular weight of 34 kDa, crossed the glomerular filtration barrier and entered the tubular fluid where it dissolved intra-tubular uric acid, thus relieving obstruction, thereby rapidly enhancing urine excretion and improving renal function. Based on this experience, we propose that rasburicase offers an alternative treatment for acute kidney injury in similar types of settings. To the best of our knowledge this is the first reported case in this situation.

Emphysematous Pyelonephritis in a Renal Transplant Patient

Emphysematous pyelonephritis (EPN) is a necrotizing bacterial infection of the kidney that is caused by gas-forming organisms. We report a case of a 58-year-old man with a renal transplant who presented to the emergency room with nausea, vomiting and right lower quadrant abdominal pain. At the time of presentation, he was hemodynamically stable, and the abdominal examination was significant for tenderness over the allograft. Urinalysis was positive for large amounts of leukocyte esterase and white blood cells. He received empiric antibiotic coverage with piperacillin/tazobactam. Over the following 24 hours, the patient developed septic shock manifested by hemodynamic instability. A non-contrast CT scan of the abdomen and pelvis elucidated a heterogeneous gas containing collection in the allograft. Emergent transplant nephrectomy was performed. Postoperatively, the patient rapidly recovered and was subsequently discharged home to commence outpatient hemodialysis. A review of the literature suggests that early recognition of the severity of EPN as manifested by hemodynamic instability dictates emergent transplant nephrectomy as the treatment of choice.

Xanthogranulomatous Pyelonephritis Associated with Crohn’s Disease and Primary Hyperparathyroidism

We report on a case of unilateral and diffuse xanthogranulomatous pyelonephritis (XGP) associated with Crohn’s disease and primary hyperparathyroidism (HPT). The patient had undiagnosed primary HPT for at least a year prior to presentation. The co-existence of Crohn’s disease and primary HPT caused calcium oxalate stone likely by the known mechanism of hypercalcemia and hyperoxaluria respectively. The patient developed XGP, a rare disease, as a result of infected calcium oxalate stone which was treated with antibiotics and unilateral nephrectomy. To the best of our knowledge, this is the first case of XGP associated with Crohn’s disease and primary HPT.