Acute renal failure in the course of HIV infection: a single-institution retrospective study of ninety-two patients anad sixty renal biopsies.

BACKGROUND: Acute renal failure syndromes are frequently encountered in patients with human immunodeficiency virus (HIV) infection. Most reported cases of acute renal failure are related to acute tubular necrosis, but many other causes of renal failure have been described in these patients. METHODS: The present work is a single-institution retrospective study of 92 HIV-infected patients with acute or rapidly progressing renal failure. In 60 cases, a renal biopsy was performed. For each patient we analysed clinical and pathological data, as well as the short-term prognosis. RESULTS: Ten different causes of acute or rapidly progressing renal failure were documented: (i) haemolytic uraemic syndrome (32 patients); (ii) acute tubular necrosis either of ischaemic-toxic origin (18 patients) or due to rhabdomyolysis (six patients); (iii) obstructive renal failure which was either extrinsic (two patients), drug-induced (13 patients) or secondary to paraprotein precipitation (one patient); (iv) HIV-associated nephropathy (14 patients); (v) acute interstitial nephritis (two patients); (vi) various glomerulonephritis (four patients). In most cases, renal failure was severe (the mean creatinine clearance at entry was 12 ml/min). Most patients had a significant improvement in renal function with only symptomatic treatment. Eighteen per cent of the patients died within 2 months of the diagnosis of renal failure. Renal biopsy seems important for the diagnosis but also for the prognosis, at least in the cases of haemolytic-uraemic syndrome, HIV-associated nephropathy and drug-induced micro-obstructive renal failure. CONCLUSION: Vascular and glomerular diseases are frequent causes of acute or rapidly progressing renal failure in HIV-infected patients. Renal biopsy appears to be safe and useful for the diagnosis and the prognosis of the renal failure. High mortality rate is only observed in patients with ischaemic/toxic causes of acute renal failure.     

The lack of clinical value of laboratory parameters in predicting outcome in acute renal failure

In 55 patients with either the oliguric and nonoliguric form of acute renal failure, some laboratory parameters for the analysis of prerenal and intrinsic types of acute renal failure were examined. The parameters were analyzed within 7 days of the clinically known beginning of the illness. The parameters were analyzed as follows: sodium in urine, creatinine urine/plasma ratio, urine osmolality, osmolality urine/plasma ratio, renal failure index, and fractional excretion of filtered sodium. Hemodialysis was performed in 29 of the 55 patients. The oliguric form of acute renal failure was present in 49 of the 55 patients. In relation to renal failure index, prerenal acute renal failure was present in 7 patients and intrinsic acute renal failure in 48. It appears that in patients with a clinical diagnosis of prerenal acute renal failure, the urinary parameters do not separate them from those with acute tubular necrosis. It also appears that in patients with laboratory diagnosis of prerenal acute renal failure (i.e., a RFT less than 1.0), the response to treatment is unpredictable and in fact may have a worse prognosis than in those with a RFI greater than 1.0 (5/7 deaths vs 10/48 deaths).     

The Lack of Clinical Value of Laboratory Parameters in Predicting Outcome in Acute Renal Failure

In 55 patients with either the oliguric and nonoliguric form of acute renal failure, some laboratory parameters for the analysis of prerenal and intrinsic types of acute renal failure were examined. The parameters were analyzed within 7 days of the clinically known beginning of the illness. The parameters were analyzed as follows: sodium in urine, creatinine urine/plasma ratio, urine osmolality, osmolality urine/plasma ratio, renal failure index, and fractional excretion of filtered sodium. Hemodialysis was performed in 29 of the 55 patients. The oliguric form of acute renal failure was present in 49 of the 55 patients. In relation to renal failure index, prerenal acute renal failure was present in 7 patients and intrinsic acute renal failure in 48. It appears that in patients with a clinical diagnosis ofprerenal acute renal failure, the urinary parameters do not separate them from those with acute tubular necrosis. It also appears that in patients with laboratory diagnosis of prerenal acute renal failure (i.e., a RFT < 1.0), the response to treatment is unpredictable and in fact may have a worse prognosis than in those with a RFI > 1.0 (5/7 deaths vs 10/48 deaths).     

Oliguric acute renal failure due to glue-sniffing. Case report

A 38-year-old male developed acute oliguric renal failure following repeated glue sniffing for about 8 hours. In addition, he had severe liver cell injury, mild myonecrosis and bone marrow depression indicating generalized tissue toxicity. The high urinary spot sodium during the oliguric phase and the total renal functional recovery after a period of oliguria followed by polyuria favoured a diagnosis of acute toxic tubular necrosis causing acute renal failure. Toluene which is used as the solvent is presumably the toxic agent involved in glue sniffing. It is advised that toluene inhalation be considered in the differential diagnosis of acute renal failure especially in the young. Literature on the renal toxicity of toluene is briefly reviewed.     

Acute renal failure due to acute pyelonephritis

We report a case of acute renal failure due to acute pyelonephritis with microabscess formation. Despite antibiotic therapy renal function deteriorated, necessitating peritoneal dialysis. Although rare, acute pyelonephritis is an important consideration in the differential diagnosis of acute renal failure, and prompt antibiotic therapy is crucial to insure a favourable outcome.     

Mannitol-induced acute renal failure

Mannitol is an osmotic diuretic widely used in the diagnosis and prevention of acute oliguric renal failure, acute cerebral edema and acute glaucoma. Mannitol, though ordinarily a benign substance, may accumulate in renal failure with potentially deleterious consequences. Mannitol intoxication is ordinarily characterized by confusion, lethargy, stupor, and if severe enough, coma. The use of mannitol in renal failure has rarely been associated with a worsening of the preexistent renal dysfunction. We report a case of acute oliguric renal failure solely attributable to mannitol administered in the course of therapy for acute glaucoma.     

Postoperative acute renal failure secondary to rhabdomyolysis from exaggerated lithotomy position.

Perioperative renal dysfunction is a common problem following urogenital surgery. The most common causes of renal failure include ischemic or nephrotoxic acute tubular necrosis, renal vascular injury, and urinary tract obstruction. This case conference describes a patient who developed acute renal failure, secondary to rhabdomyolysis after a 7-hour urologic surgical procedure in an exaggerated lithotomy position. Early diagnosis and aggressive treatment are essential to prevent or limit the severity of acute renal failure. A review of the literature and pathophysiology of acute renal failure secondary to rhabdomyolysis is included.     

Scrub Typhus: A Frequently Overlooked Cause of Acute Renal Failure

Acute renal failure associated with scrub typhus infection is not rare as previously thought. The possibility of scrub typhus should be borne in mind when patients present with fever and varying degrees of acute renal failure, particularly if an eschar exists, along with a history of environmental exposure in an area like Taiwan, where scrub typhus is endemic. Prompt diagnosis and the use of appropriate antibiotics can rapidly alter the clinical course of the disease and prevent the development of serious or fatal complications. To illustrate the above point, this study reports 3 cases of scrub typhus associated with acute renal failure. They were seen at Chang Gung Memorial Hospital in a 2-year interval. Case 1 was referred from district hospital with clinical features of multiple organ dysfunctions, including shock, fever, acute respiratory failure, acute renal failure, and acute hepatitis. Case 2 was admitted with the chief problems of shock, fever, acute renal failure, and DIC. Case 3 visited our outpatient clinic due to fever, maculopapular rash and acute renal failure. In all these patients, the diagnosis was confirmed using immunofluorescence techniques, which showed that Orientia tsutsugamushi had an IgM titer of 1:80 or greater. Notably, despite having varying degrees of acute renal deterioration, the patients responded very well to doxycycline therapy and recovered completely. Additionally, a total of 4 similar cases of scrub typhus associated with acute renal failure were reviewed from th past literature.     

Scrub typhus: a frequently overlooked cause of acute renal failure

Acute renal failure associated with scrub typhus infection is not rare as previously thought. The possibility of scrub typhus should be borne in mind when patients present with fever and varying degrees of acute renal failure, particularly if an eschar exists, along with a history of environmental exposure in an area like Taiwan, where scrub typhus is endemic. Prompt diagnosis and the use of appropriate antibiotics can rapidly alter the clinical course of the disease and prevent the development of serious or fatal complications. To illustrate the above point, this study reports 3 cases of scrub typhus associated with acute renal failure. They were seen at Chang Gung Memorial Hospital in a 2-year interval. Case 1 was referred from district hospital with clinical features of multiple organ dysfunctions, including shock, fever, acute respiratory failure, acute renal failure, and acute hepatitis. Case 2 was admitted with the chief problems of shock, fever, acute renal failure, and DIC. Case 3 visited our outpatient clinic due to fever, maculopapular rash and acute renal failure. In all these patients, the diagnosis was confirmed using immunofluorescence techniques, which showed that Orientia tsutsugamushi had an IgM titer of 1:80 or greater. Notably, despite having varying degrees of acute renal deterioration, the patients responded very well to doxycycline therapy and recovered completely. Additionally, a total of 4 similar cases of scrub typhus associated with acute renal failure were reviewed from the past literature.     

Rhabdomyolysis and acute renal failure in a child with influenza A infection

A 13-year-old previously healthy girl developed rhabdomyolysis and acute renal failure during influenza A infection. The patient recovered renal function completely with supportive therapy. This complication has been described in adult patients, but progression to acute renal failure in this context has not been reported previously in children. This diagnosis should be considered in the differential diagnosis of a pediatric patient presenting with acute renal failure and viral symptomatology. Received July 16, 1996; received in revised form and accepted November 6, 1996     

Acute renal failure due to acute pyelonephritis

We report a case of biopsy-proved acute pyelonephritis which caused acute renal failure. Despite appropriate antibiotic therapy, recovery of renal function was slow and incomplete. Renal papillary necrosis was an apparent complication, which the patient may have been predisposed to by alcoholism. Although rare, acute pyelonephritis is an important consideration in the differential diagnosis of acute renal failure because of the need for specific therapy.     

Acute renal failure caused by Klebsiella pneumoniae pyelonephritis.

We report a 34-year-old male patient without prior medical history who presented with acute renal failure due to acute bacterial pyelonephritis. Both blood and urine cultures grew Klebsiella pneumoniae. Although a kidney biopsy revealed extensive necrosis and no viable glomeruli, renal function recovered to near normal after intermittent hemodialysis and antibiotic therapy. We believe that it is important to include this entity in the differential diagnosis of acute renal failure since proper diagnosis and treatment is essential for recovery of renal function. Furthermore, we would like to draw attention to Klebsiella pneumoniae as an important potential pathogen in such cases, in addition to Escherichia coli.     

Renal Disease Is a Prodrome of Multiple Myeloma: An Analysis of 50 Patients from Eastern India

This study describes a spectrum of renal diseases that can precede the diagnosis of multiple myeloma (MM). Patients presenting manifestations of renal disease were recorded as individual patients of MM. Fifty patients (male 41; female 9) were included in this study. Diagnosis of MM was confirmed by two or more of the following four features: lytic bone lesions, serum or urine monoclonal peak, Bence Jones proteinuria, and greater than 20% plasma cells in bone marrow. Renal disease was present in 42 of 50 (84%) patients before MM was diagnosed. In only eight of 50 (16%) patients, diagnosis of MM preceded the detection of renal disease. Renal diseases consisted of acute renal failure in 26 patients (52%), chronic renal failure in 15 patients (30%) and nephrotic syndrome in 9 patients (18%). Some of the patients with acute or chronic renal failure also had heavy proteinuria. Percutaneous renal biopsy was done in 17 patients. Renal histopathology showed amyloidosis (n = 10), cast nephropathy (n = 5), nodular glomerulosclerosis (n = 1), and mesangioproliferative glomerulonephritis with plasma cell infiltration (n = 1). Hypercalcemia (calcium 11–13.8 mg/dL) was the most common precipitating factor for acute renal failure. All 50 patients received combination chemotherapy of melphalan and prednisolone or vincristine, Adriamycin, and dexamethasone. More than half of the total number of patients did not complete chemotherapy because of death or lost to follow-up. Nineteen patients with acute renal failure and eight patients with chronic renal failure were treated with hemodialysis. Fourteen patients (28%) with acute renal failure had recovery of renal function. Twenty-three patients (46%) were lost to follow-up. Seven patients (14%) died from sepsis, uremia, or hyperkalemia. Remission of MM was found in 9 of 21 (42.8%) patients who completed chemotherapy. Thus, acute renal failure is the most common renal disease preceding the diagnosis of MM. Reversal of renal function is achieved with chemotherapy and hemodialysis treatment.     

Acute renal failure without fibrotic skin changes in progressive systemic sclerosis

Scleroderma renal crisis (SRC) is defined as sudden development of accelerated hypertension, hyperreninemia, and acute renal failure in a patient with progressive systemic sclerosis (PSS). Although the diagnosis of PSS is generally straightforward because of dermal fibrosis, we report 2 patients who had PSS with SRC without the characteristic fibrotic skin changes of scleroderma. PSS should be considered in the differential diagnosis of unexplained acute renal failure and accelerated hypertension even though the cutaneous fibrotic manifestations of the disease may be absent.     

Survival from acute renal failure after severe burns

We describe a patient with 50 per cent, third degree flame burns who had a history of paint thinner inhalation for over 10 years. Moreover, chlorpromazine had been administered for the treatment of insomnia caused by chronic thinner intoxication. He developed oliguric acute renal failure soon after the burn injury, although adequate resuscitation therapy was given, and survived following frequent haemodialysis. Although survival from acute renal failure after severe burns is rare, once the diagnosis of acute renal failure has been made, haemodialysis should be instituted as early as possible. Furthermore, in a severely burnt patient with episodes of chronic and acute intoxication from organic chemicals or drugs which may have caused renal damage, acute renal failure may occur, so that careful observation is advised.     

Clinical characterization of acute renal failure in multiple organ dysfunction syndrome

Background Acute renal failure frequently occurs as a complication of multiple organ dysfunction syndrome (MODS). Various forms of therapy for MODS, including endotoxin absorption and anticytokine therapy, have been attempted. Methods We retrospectively studied the pathophysiologic characteristics of acute renal failure in 152 MODS patients examined in our department over the past 5 years. The diagnosis of MODS was based on the criteria of the Japanese Association for Critical Care Medicine. The diagnosis of systemic inflammatory response syndrome (SIRS) and sepsis was conducted in accordance with the definition proposed at the 1992 Consensus Conference of the American College of Chest Physicians/ Society of Critical Care Medicine. Results Acute renal failure occurred as a complication of secondary MODS with a high frequency of 76.3% (116/152 patients). Significant associations have been found between the respective frequencies of acute renal failure and disseminated intravascular coagulation occurring as complications of SIRS. An increase in the number of cases undergoing continuous hemodiafiltration was noted, in an attempt to improve the survival rate of MODS complicated with acute renal failure. Conclusion Acute renal failure seen in secondary MODS is thought to be derived from a pathogenesis differing from that of conventional intrinsic acute renal failure, such as ischemic and nephrotoxic forms. Acute renal failure associated with secondary MODS appears to be a disease entity that arises as a sequela of SIRS, similar to disseminated intravascular coagulation.     

头孢曲松结石所致急性肾功能衰竭的成因与诊治

头孢曲松结石是由于患者使用头孢曲松钠后所致的一种药物性结石,其成分是头孢曲松钙。与“天然”结石的临床后果不同,头孢曲松结石的主要危害是导致急性肾功能损害,其中近半数为急性肾后性肾功能衰     

Acute glomerulonephritis in a patient with Rocky Mountain spotted fever

It is generally assumed that acute tubular necrosis is the etiology of renal failure that can occur during the course of Rocky Mountain spotted fever (RMSF). However, histologic examination of kidneys has been mainly limited to autopsy cases of fulminant infections. Acute glomerulonephritis due to glomerular immune complex deposition has not been reported in RMSF. We describe a case of acute oliguric renal failure that developed more than 2 weeks following the onset of RMSF. Renal biopsy showed acute glomerulonephritis with inflammatory cell infiltration and subendothelial immune deposits. Thus, acute glomerulonephritis should be in the differential diagnosis of acute renal failure that occurs in RMSF.     

Acute renal failure due to bilateral matrix renal calculi – A diagnostic dilemma

We report an unusual case of acute renal failure caused by bilateral matrix calculi. The difficulties in diagnosing the cause of renal failure and the management of the case are discussed. Matrix calculi are rare causes of acute renal failure. Being radiolucent they can be elusive and systematic investigation and a diligent search are required for correct diagnosis and appropriate treatment.     

Acute renal failure secondary to carcinomatous lymphatic metastases to kidneys

We report a rare case of acute renal failure secondary to bilateral renal parenchymal metastases from carcinoma. Despite clinical investigation the cause of the renal failure remained undiagnosed and was discovered only upon microscopy at autopsy, which revealed metastatic gastric adenocarcinoma. The pattern of tumor infiltration was predominantly lymphatic involvement limited to the vascular bundles at the corticomedullary junction, and the lymphatics adjacent to the calices and pelves. The significance of lymphatic obstruction in the pathogenesis of renal failure is discussed. Renal parenchymal metastases should be considered in the differential diagnosis of acute renal failure in patients with carcinoma.