Acute renal failure caused by leptospirosis.

Three patients with severe leptospirosis leading to anuria and treated with haemodialysis are reported. One patient died. The pathomechanism and the underlying pathological and histological changes of the renal failure are discussed. It is stressed that the clinical diagnosis of leptospirosis is often difficult, as other infectious diseases,first of all infectious hepatitis, frequently present the same symptoms.     

Acute renal failure: a common manifestation of leptospirosis

Leptospirosis is an infectious disease caused by pathogenic leptospires and may vary in degree from an asymptomatic infection to severe and fatal illness. Sixteen patients (all males; aged 40+/-17 years) with leptospirosis were admitted to Si?li Etfal Training and Research Hospital between July 1998 and August 2003 and were retrospectively reviewed. Age, gender, occupation, clinical presentation, laboratory features, seasonal distribution of the disease, diagnostical approach, and prognostic factors were evaluated. Eleven patients were cured with no complication; four patients died of hepatic and/or renal failure. Eight patients presented with acute renal failure; seven of them needed dialytic support. One patient developed chronic renal failure and had to undergo regular hemodialysis. All deceased patients (aged 61+/-7 years) were anuric at admission and their serum bilirubin changed between 39-44 mg/dL (mean 41.3+/-2.2 mg/dL). Cured patients ranged in age from 14-62 years (34+/-14 years) and their serum bilirubin levels ranged from 9-35 mg/dL (23.1+/-11.4 mg/dL). Crystalline penicillin G 12 million U/day was administered to all patients. Six patients also received hepatic coma treatment. This study emphasizes that leptospirosis presenting with renal failure is a severe disease, and mortality is frequently related to delays in diagnosis due to lack of clinical understanding. The association of acute renal failure and jaundice should lead the clinician to suspect leptospirosis. We concluded that old age, oliguria/anuria, high serum bilirubin levels (>36 mg/dL), and high serum potassium levels might be risk factors that increase mortality in leptospirosis.     

Acute renal failure of leptospirosis: nonoliguric and hypokalemic forms

Acute renal failure induced by leptospirosis was studied in 56 patients. A higher frequency of nonoliguric renal failure was observed with lower morbidity and mortality rates than in oliguric forms. In addition, 45% of the patients in this series were hypokalemic, and no hyperkalemic patients were seen. A prospective study in 11 patients showed an initially elevated urinary fractional potassium excretion that fell simultaneously with the high urinary fractional sodium excretion and the urinary K/Na ratio, suggesting an increased distal potassium secretion due to an increased distal sodium delivery consequent to functional impairment of the proximal reabsorption of sodium.     

Acute renal failure due to leptospirosis in a renal transplant recipient: a brief review of the literature

We present the case of a 43-year-old renal transplant patient who presented with fever, malaise, pruritus, headache, and severe jaundice of 3-week duration following work in a rice field. He was found to have acute renal failure and severe hyperbilirubinemia with a positive serum leptospira antibody titer, making the diagnosis of Weil's disease. The patient responded to reduction in immunosuppressive medications and intravenous penicillin therapy with no need for dialysis. This is the second case of leptospirosis in a kidney transplant patient reported in the English literature.     

Acute renal failure in the elderly

Acute renal failure in elderly patients is common and likely to become more so as life expectancy in France continues to grow. The chances of acute renal failure occurring in the elderly are increased by changes in renal function and the effects of various chronic diseases such as diabetes, hypertension and obstructive urological disorders, all of which increase in incidence with age. The elderly may develop all types of the disease but are most prone to drug-related acute renal failure. The diagnostic and therapeutic strategies adopted are the same as those for adult patients but should take into account the potential risks and benefits in this specific age group. However, age should no longer be considered as the sole determining factor in diagnostic and therapeutic decisions. The elderly are among those who benefit most from preventive measures against acute renal failure.     

Hypotension,renal failure,and pulmonary complications in leptospirosis

During a recent outbreak of leptospirosis in northeastern Thailand, 148 patients with serologically diagnosed leptospirosis were seen in Loei hospital. The common serotypes were L. pyrogenes, and L. sejroe. Hypotension with a mean arterial pressure less than 70 mmHg upon admission or within 24 h after admission was observed in 94 patients or 64%. 30 patients had normal renal function; 30 patients had prerenal azotemia with mild pulmonary complication in 2; and 34 patients had acute renal failure. 29 patients with acute renal failure had pulmonary complications including pulmonary hemorrhage in 8, pulmonary edema in 3, acute respiratory distress syndrome (ARDS) in 14 and interstitial pneumonitis in 4. 54 patients had normal blood pressure. In this group 5 patients had acute renal failure; 16 had prerenal azotemia and 33 had normal renal function. Interstitial pneumonitis was noted in one patient with prerenal azotemia. Less renal complication and minimal pulmonary complication were seen in leptospirosis patients with normal blood pressure. The patients with normal renal function had no pulmonary complication. Good association existed between hypotension, renal failure and pulmonary complications.     

Acute toxic renal failure

Acute renal failure (ARF) is a common problem in intensive care medicine. Even modest degrees of ARF not requiring dialysis treatment increase the risk of death approximately fivefold. Despite the widespread appreciation of the role of nephrotoxic drugs in their contribution to ARF, these drugs continue to have an ongoing aetiological role. Potentially nephrotoxic drugs include non-steroidal anti-inflammatory drugs, radiocontrast agents, antimicrobial and anaesthetic agents. Endogenous compounds such as myoglobin and haemoglobin may furthermore cause toxic nephropathy. Tubular injury initiated by toxins often results from a combination of acute renal vasoconstriction and direct cellular toxicity due to intracellular accumulation of the toxin, or, alternatively, may be mediated immunologically in case of interstitial nephritis. Patients with reduced renal functional reserve, cardiovascular co-morbidity, diabetes mellitus, and advanced age are at increased risk. Awareness of the range of toxins on the one hand and simple measures such as adequate pre-hydration of the patient and drug monitoring on the other hand may be sufficient to avoid drug-induced ARF or minimize its clinical severity in susceptible patients.     

Acute renal failure in the neonatal period

Acute renal failure (ARF) is a common problem in the neonatal intensive care unit (NICU). In most cases, ARF is associated with a primary condition such as sepsis, metabolic diseases, perinatal asphyxia and/or prematurity. This retrospective study investigated the course of illness, therapeutic interventions, early prognosis and risk factors associated with development of ARF in the neonatal period. A total of 1311 neonates were treated in our NICU during the 42-month study period, and 45 of these babies had ARF. This condition was defined as serum creatinine level above 1.5 mg/dL despite normal maternal renal function. The data collected for each ARF case were contributing condition, cause and clinical course of ARF, gestational age and birth weight, age at the time of diagnosis, treatment, presence of perinatal risk factors and need for mechanical ventilation. The frequency of ARF in the NICU during the study period was 3.4%. Premature newborns constituted 31.1% of the cases. The mean birth weight in the group was 2863 +/- 1082 g, and the mean age at diagnosis was 6.2 +/- 7.4 days. The causes of ARF were categorized as prerenal in 29 patients (64.4%), renal in 14 patients (31.1%) and postrenal in 2 patients (4.4%). Forty-seven percent of the cases were nonoliguric ARF. Asphyxia was the most common condition that contributed to ARF (40.0%), followed by sepsis/metabolic disease (22.2%) and feeding problems (17.8%). Therapeutic interventions were supportive in 77.8% of the cases, and dialysis was required in the other 22.2%. The mortality rate in the 45 ARF cases was 24.4%. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were associated with significantly increased mortality (p<0.05). There were no statistical correlations between mortality rate and perinatal risk factors, oliguria, prematurity or blood urea nitrogen and creatinine levels. The study showed that, at our institution, ARF in the neonatal period is frequently associated with preventable conditions, specifically asphyxia, sepsis and feeding problems. Supportive therapy is effective in most cases of neonatal ARF. Acute renal failure of renal origin, need for dialysis, and need for mechanical ventilation were identified as indicators of poor prognosis in these infants. Early recognition of risk factors and rapid effective treatment of contributing conditions will reduce mortality in neonatal ARF.     

Acute renal failure in the surgical setting

Acute renal failure (ARF) is an unwelcome complication of major surgical procedures that contributes to surgical morbidity and mortality. Acute renal failure associated with surgery may account for 18-47% of all cases of hospital-acquired ARF. The overall incidence of ARF in surgical patients has been estimated at 1.2%, although is higher in at-risk groups. Mortality of patients with ARF remains disturbingly high, ranging from 25% to 90%, despite advances in dialysis and intensive care support. Appreciation of at-risk surgical populations coupled with intensive perioperative care has the capacity to reduce the incidence of ARF and by implication mortality. Developments in understanding the pathophysiology of ARF may eventually result in newer therapeutic strategies to either prevent or accelerate recovery from ARF. At present the best form of treatment is prevention. In this review the epidemiology, pathophysiology, diagnosis, treatment and possible prevention of ARF will be discussed.     

Acute renal failure in infants in the tropics

This study records our experience with 40 infants who developed acute renal failure in a tropical environment over a period of 2 years. All the patients required intermittent peritoneal dialysis. Septicaemia (88%) and acute gastroenteritis (55%) constituted the leading causes of acute renal failure. Haemolytic uraemic syndrome was present in six (18%) patients. An elevated serum creatinine (85%), metabolic encephalopathy (75%), uncompensated metabolic acidosis (75%) and hyperkalaemia (48%) were the major indications for dialysis, while fluid overload was present in only 18% of the infants. Intermittent peritoneal dialysis was used in all the patients and was found to be effective. Procedural complications were minor and infrequently encountered. The clinical course and laboratory data consistent with haemolytic uraemic syndrome was observed in six patients, and acute tubular necrosis was the predominant renal lesion in the remainder. Mortality was 75%. The aetiology of acute renal failure in infants in the tropics differs significantly from that in the West, and even within a given country marked regional variations exist.