Severe acute kidney injury due to oxalate crystal induced severe interstitial nephritis:A case report

BACKGROUND Acute kidney injury(AKI)due to interstitial nephritis is a known condition primarily attributed to various medications.While medication-induced interstitial nephritis is common,occurrences due to non-pharmacological factors are rare.This report presents a case of severe AKI triggered by intratubular oxalate crystal deposition,leading to interstitial nephritis.The aim is to outline the case and its management,emphasizing the significance of recognizing uncommon causes of interstitial nephritis.CASE SUMMARY A 71-year-old female presented with stroke-like symptoms,including weakness,speech difficulties,and cognitive impairment.Chronic hypertension had been managed with hydrochlorothiazide(HCTZ)for over two decades.Upon admis-sion,severe hypokalemia and AKI were noted,prompting discontinuation of HCTZ and initiation of prednisolone for acute interstitial nephritis.Further investigations,including kidney biopsy,confirmed severe acute interstitial nephritis with oxalate crystal deposits as the underlying cause.Despite treatment,initial renal function showed minimal improvement.However,with prednisolone therapy and supportive measures,her condition gradually improved,high-lighting the importance of comprehensive management.CONCLUSION This case underscores the importance of a thorough diagnostic approach in identifying and addressing uncommon causes of interstitial nephritis.The occurrence of interstitial nephritis due to oxalate crystal deposition,especially without typical risk factors,emphasizes the need for vigilance in clinical practice.

Reversible Chronic Interstitial Nephritis Induced by Tacrolimus —Tacrolimus Chronic Interstitial Nephritis

Calcineurin inhibitors (CNI) are potent immunosuppressive agents in prophylaxis against graft rejection and autoimmune diseases including primary glomerulopathies. Previous research showed reversible;acute afferent arteriolar vasculopathy and irreversible chronic interstitial fibrosis associated with CNI nephrotoxicity. In this case report we describe a patient, with minimal change disease, that had developed chronic and progressive renal disease while receiving therapeutic dose of Tacrolimus. His serum creatinine had reached 537 umol/L and his nephrotic state worsened. Kidney biopsy showed chronic interstitial nephritis. Tacrolimus was discontinued and he was treated with 1 mg/kg prednisone in addition to Mycophenolate mofetil (MMF) 1 g twice daily. By the 2nd month;serum creatinine returned to normal and by the 3rd month serum albumin too. After 1 month of therapy;the dose of Prednisone was tapered down gradually till 5 mg daily by the end of 3rd month. Moreover, the dose of MMF was reduced to 500 mg X2 by the end of 3rd month. After 2 years of follow up;he remained stable and without relapse of NS or renal failure. In conclusion, reversible renal disease, due to chronic interstitial nephritis can be induced by CNI which is amenable to treatment with Prednisone and MMF.

A Case of Staphylococcus Associated Glomerulonephritis Confused with Acute Interstitial Nephritis

Staphylococcus associated glomerulonephritis (SAGN) is an uncommon infection-related glomerulonephritis. Although infection is typically ongoing when patients present with SAGN, in the case of deep-seated infections, the presence of infection may not be apparent. The aim of this study is to highlight the importance of renal biopsy when the diagnosis is not obvious. We present a case of staphylococcus associated glomerulonephritis in a patient treated with beta-lactam antibiotics for staphylococcus bacteraemia. A renal biopsy helped differentiate between interstitial nephritis and staphylococcus associated glomerulonephritis.

Fabry disease combined with acute interstitial nephritis:one case and literature review

Objective:To explore the clinical and pathological features of Fabry disease complication of acute interstitial nephritis.Methods:A retrospective analysis of a patient with Fabry disease and acute interstitial nephritis diagnosed and in the Department of Nephrology,Children’s Hospital Affiliated to Capital Institute of Pediatrics in January 2017 was performed.A literature search was performed with“Fabry disease,acute interstitial nephritis”as the keywords in Wanfang database and PubMeds database.Result:The patient was 10-years-old with acute renal dysfunction.Electron microscopy showed stratified myelin-like bodies,zebra bodies and fused foot segment.The patient was finally diagnosed with the combination of Fabry disease and acute interstitial nephritis.By now,such cases have been reported.Conclusion:Whether Fabry's disease and acute interstitial nephritis shared the common pathogenic mechanism is unclear.Early renal biopsy is important for the diagnosis of this disease.

Monocyte chemoattractant protein 1 expression in renal tissue is associated w ith monocyte recruitment and tubulo-interstitial lesions in patients with lup us nephritis

Objective To investigate the pattern of monocyte chemoattractant prolein-1 (MCP-1) distribution in the renal interstitium and evaluate its pathogenic role in tubulo-interstitial lesions in patients with lupus nephritis, the distribution of MCP-1 in renal tissue was observed.Methods Eighteen female patients with biopsy-proven lupus nephritis were enrolled in this study. No intensive immunosuppresive therapy was used in these patients during the 3 months prior to renal biopsy. The distribution of MCP-1, infiltration of CD68+ (macrophage/monocyte), CD4+ and CD8+ cells in the tubulo-interstitium of patients with lupus nephritis was detected using immunohistochemical staining with specific antibodies. Renal specimens from patients with minimal change glomerulonephritis were used as controls. Results MCP-1 protein was widely distributed in the renal tissue of patients with lupus nephritis, mainly located at the baso-lateral surface of tubular epithelial cells (16/18 biopsies), and on the wall of interstitial blood vessels (9/18 biopsies). In contrast, tubular MCP-1 staining was weak and rare in renal tissue from controls (7.4±6.2% vs 26.7±22.8%, P<0.01). Tubulo-interstitial infiltration of CD68+, CD4+ and CD8+ cells was markedly increased in patients with lupus nephritis as compared to controls. The tubular expression of MCP-1 was strongly associated with the amount of CD68+ cell infiltration in the interstitium (r=0.5420, P<0.05) and the extent of interstitial fibrosis. There was no correlation between MCP-1 production in tubules and the degree of urinary protein excretion in patients with lupus nephritis (r=0.0547, P>0.05).Conclusions The expression of MCP-1 in the renal tubules and vascular wall was markedly increased in patients with lupus nephritis. The overproduction of MCP-1 in renal tissue may contribute to monocyte recruitment in the interstitium and thus result in tubulo-interstitial damage in lupus nephritis.

Characteristics and clinical outcome of nonsteroidal anti-inflammatory drug-induced acute hepato-nephrotoxicity among Chinese patients

AIM: To determine the clinicopathological characteristics of nonsteroidal anti-inflammatory drug (NSAID)-induced acute hepato-nephrotoxicity among Chinese patients.

Nephropathy in dietary hyperoxaluria:A potentially preventable acute or chronic kidney disease

Hyperoxaluria can cause not only nephrolithiasis and nephrocalcinosis,but also renal parenchymal disease histologically characterized by deposition of calcium oxalate crystals throughout the renal parenchyma,profound tubular damage and interstitial inflammation and fibrosis.Hyperoxaluric nephropathy presents clinically as acute or chronic renal failure that may progress to endstage renal disease(ESRD).This sequence of events,well recognized in the past in primary and enteric hyperoxalurias,has also been documented in a few cases of dietary hyperoxaluria.Estimates of oxalate intake in patients with chronic dietary hyperoxaluria who developed chronic kidney disease or ESRD were comparable to the reported average oxalate content of the diets of certain populations worldwide,thus raising the question whether dietary hyperoxaluria is a primary cause of ESRD in these regions.Studies addressing this question have the potential of improving population health and should be undertaken,alongside ongoing studies which are yielding fresh insights into the mechanisms of intestinal absorption and renal excretion of oxalate,and into the mechanisms of development of oxalate-induced renal parenchymal disease.Novel preventive and therapeutic strategies for treating all types of hyperoxaluria are expected to develop from these studies.

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 to30 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.

Trauma-related xanthogranulomatous interstitial nephritis: a clinicopathological analysis

Objective: To investigate the pathogenesis, exact nature, histologic feature of xanthogranulomatous interstitial nephritis (XGIN) as well as its significance in clinical medicine. Methods: The medical histories concerned were collected with diagnostic images including CT scanning, ultrasonography, intravenous urography (IVU) and laboratory data being synthesized by comparison with what was discovered during operations and pathologic examinations. Results: All patients were ever struck on their loins or backs by blunt violence over 4-12 years. The diseases were clinically diagnosed as “renal cancer” before, during and after operations, and treated with radical nephrectomy. Located at cortical parts, the tumor focus had penetrated the renal capsules and invaded other organs. However, immunohistochemistry demonstrated that the lesions were xanthogranulomas, not tumors, in which there were stacks of foam cells and lymphocytes with vast extends of fibrotic tissues obliterating the cortical interstitial structures. Urinary tracts yielded no bacterium, obstruction or calculus. Conclusions: XGIN is likely to be one kind of immunologic mediated granuloma following blunt renal trauma. It is imperative to clarify pathogenesis and character of this lesion so as to find out any approach to diagnosis and cure of such an unusual nephropathy.

Epidemiological, Clinical and Follow-Up Data in a Series of Thirteen Renal Insufficiencies Complicating Sarcoidosis

The sarcoidosis is a systemic granulomatosis affecting most frequently the lungs and the mediastinum. An acute renal failure reveals exceptionally this disease. It’s a retrospective study implicating 13 cases of sarcoidosis complicated of acute renal failure. The aim of this study is to determine epidemiological, clinical, biological and histological profile in these cases and the interest of considering sarcoidosis diagnosis in case of unexplained renal failure. Extra-renal complications, therapeutic modalities and the outcome were determined in all patients. Our series involved 13 women with an average age of 41 years. Biological investigations showed an abnormal normocalcemia in 8 cases, a hypercalcemia in 5 cases, a hypercalciuria in 11 cases and polyclonal hypergammaglobulinemia in 7 cases. An acute renal failure was found in all patients with a median creatinin of 540 umol/L. The renal echography was normal in all patients. The kidney biopsy performed in all patients showed tubulo-interstitial nephritis. The extra-renal signs were: pulmonary interstitial syndrome in 5 cases, a sicca syndrome in 4 cases, mediastinal lymphadenopathy in 2 cases, a lymphocytic alveolitis in 3 cases, an anterior granulomatous uveitis in 3 cases and a polyarthritis in 6 cases. Six patients benefited from hemodialysis. The treatment consisted of corticosteroid in all cases. The follow up was marked by complete resolution of clinical and biological signs. The diagnosis of renal sarcoidosis should be made rapidly in order to avoid end stage renal failure.

Hypokalemic Paresis Revealing a Primary Sjogren’s Syndrome

Hypokalemic acidosis can complicate a primary Sj&ouml;gren’s syndrome. The clinical feature is rarely revealed by manifestations due to hypokalemia. We report the case of a 46-year-old woman, admitted to explore a paresthesia and paresis of inferior limbs. The diagnosis of Sj&ouml;gren’s syndrome was retained since there was the association of xerophthalmia, sialadenitis at the labial biopsy and positive immunological results (anti-SSA and anti-SSB). The absence of another auto-immune or systemic illness allowed us to consider that the Sj&ouml;gren’s syndrome was primary. The biological explorations revealed a hyperchloremic and hypokalemic acidosis. The treatment was based on corticosteroid and potassium supplementation. The follow-up was marked by a clinical and biological amelioration.