Case Reports in Nephrology最新文献

Thrombotic microangiopathy (TMA) is characterized by microvascular thrombosis, microangiopathic hemolytic anemia (MAHA), and thrombocytopenia. TMA can lead to acute kidney injury (AKI) due to the formation of thrombi within the renal microvasculature causing ischemic injury. AKI in the setting of TMA requires early recognition, comprehensive serologic evaluation, and timely intervention due to the risk of irreversible renal damage. Due to many potential causes, both hereditary and acquired, the workup of renal TMA includes analysis of ADAMTS13 activity, genetic testing, and antibody analysis to rule out extraneous etiologies. Ultimately, renal pathology is used to confirm the diagnosis. Recommended treatment of renal TMA is dependent on the underlying etiology and varies from therapeutic plasma exchange and anticomplement therapy to renal replacement therapy and supportive care. This case report highlights an underrecognized cause of renal TMA: hypertensive emergency. Pathological histology imaging of renal tubules can be used to diagnose renal TMA due to evidence of schistocytes and tubular necrosis. Diagnosing TMA can have life-saving consequences as delayed hemodialysis can be fatal. Renal pathological imaging should be an important diagnostic tool when presented with hypertension cases, especially those associated with the aforementioned symptoms. Blood pressure control is the primary focus for management of hypertensive emergency-associated TMA. We present a case of TMA-associated AKI in a hypertensive patient that had a characteristic onion-skin lesion seen on renal pathology.

Proteinuria in a patient with long-standing Type 1 diabetes mellitus (T1DM) usually suggests diabetic kidney disease (DKD). However, DKD occurs late in the disease and is associated with hypertension and retinopathy. We report an adolescent with T1DM who, 1 year after initial diagnosis, developed nephrotic syndrome (NS). He was treated with steroids but developed frequent relapses and became steroid-dependent. A subsequent kidney biopsy revealed minimal change disease (MCD) and mild DKD. He was treated with mycophenolate mofetil (MMF) and remains in remission. Primary podocytopathy, such as MCD, is a rare cause of NS in a patient with T1DM. Indications for kidney biopsy and treatment options are similar to those of other children with a diagnosis of NS. This report highlights that, although rare, primary glomerulopathy can occur in pediatric diabetic patients and should be considered in the differential diagnosis of proteinuria, as early recognition and intervention can lead to favorable outcomes.

Background: After percutaneous nephrolithotomy (PCNL), intravenous misplacement of a nephrostomy tube is a very rare clinical occurrence. This report summarizes the characteristics and management of intravenous misplacement of a nephrostomy tube. Case Presentation: We present a rare case of intravenous nephrostomy catheter misplacement after PCNL in a 63 years old male. The tip of the tube was located in the left renal vein. The patient was managed conservatively and treated safely. Conclusion: Intravenous nephrostomy tube misplacement is a rare PCNL complication. Good Imaging can rule out through and through renal vein perforation and thus patients can be safely managed using conservative approach.

The cause of acute skeletal muscle damage, defined as rhabdomyolysis, is multifactorial. Medicines are prominent among the most important reasons. The clinical significance of rhabdomyolysis lies in the fact that it can cause acute kidney injury (AKI) in 10%-40% of patients. In this presented case, oxcarbazepine, which is a preferred drug in the treatment of epilepsy and also in neuropathic pain in clinical practice, triggered rhabdomyolysis and subsequently caused the development of AKI. Through this case report, we aimed to emphasize that some serious side effects should not be forgotten when prescribing drugs in clinical practice.

Background: BRASH syndrome is a life-threatening condition that involves bradycardia, renal failure, atrioventricular blockade, shock, and hyperkalemia. It is often resistant to conventional treatments and requires prompt diagnosis and management. We report a case of BRASH syndrome successfully treated in the Emergency Department and Nephrology Department. Case Presentation: A 57-year-old man with hypertension, diabetes, ischemic heart disease, and chronic kidney disease presented with severe diarrhea, lethargy, and shock. He had hyperkalemia, metabolic acidosis, and acute kidney injury. His electrocardiogram showed sinus bradycardia with complete AV block. He was on bisoprolol, which was discontinued. He received hemodialysis, potassium-lowering agents, and vasoactive drugs. His renal function improved, and his heart rate normalized with first-degree AV block. He was discharged with advice to avoid AV-blocking agents and follow-up with nephrology and cardiology. Conclusions: BRASH syndrome is a serious complication of hyperkalemia, hypotension, and bradycardia in patients with kidney dysfunction and AV-blocking medications. It may require hemodynamic support and temporary pacemaker insertion. Early recognition and treatment of this entity can reduce mortality and morbidity.

This report details the remarkable improvement in kidney function and quality of life in an ESKD 93-year-old male patient under conservative management in Israel. The patient, with previous postrenal obstruction due to prostate enlargement and recurring infections, exhibited significant kidney deterioration, reaching a creatinine level of 7.6 mg/dL and a GFR of 6.7 mL/min/1.73 m² in December 2023. Following numerous hospitalizations and ER visits over the previous year, the patient opted for palliative care, prioritizing life quality over life-extending interventions. Over a 6 month period (December 2023-May 2024), the patient received comprehensive palliative care: nurse visits, bimonthly doctor consultations, and medication adjustments based on biochemical home blood tests. Despite initial severe kidney impairment, the patient's creatinine levels improved to 3.2 mg/dL and GFR increased to 18.2 mL/min/1.73 m². Potassium and phosphorus stabilized, and no further ER visits were recorded. Clinically, the patient showed enhanced cognition, memory, and communication and managed peripheral edema effectively. This case underscores the potential benefits of conservative palliative management in an Israeli elderly patient, a phenomenon that is recognized in the US and Canada more often, but not highlighted in the Middle Eastern elderly population. Coordinated efforts of a skilled palliative care team and supportive home hospice care contributed to the patient's clinical improvement. These findings challenge the notion that is often communicated to Israeli ESKD patients, Hatoum and Sperling, that palliative treatment leads to further kidney function deterioration, suggesting that, in some cases, it can result in improved outcomes in an underreported population.

Cefepime is widely used in sepsis owing to its broad spectrum of activity with coverage against Pseudomonas. Though it is usually well-tolerated, in the presence of certain risk factors, renal impairment, high doses, and critical illness, it is associated with the development of neurotoxicity. Those most susceptible are at high risk for developing complications of their underlying illness and the clinical manifestations of cefepime-related neurotoxicity are nonspecific, with reduced level of consciousness, confusion, myoclonus, and seizures, thus a high index of suspicion is required to make a diagnosis. The management includes drug discontinuation, seizure prophylaxis in the right clinical setting, and hemodialysis in severe cases. This case reinforces the need to renally adjust medications in the setting of acute kidney injury to avoid uncommon complications while using common medications.

Gynecomastia is a benign proliferation of the glandular tissue of the male breast. It is a common physiological condition during infancy and puberty and typically resolves spontaneously in most cases. However, adult-onset gynecomastia requires proper evaluation to identify the underlying cause. Several medications are associated with gynecomastia in adults, with some having a clear pathophysiologic mechanism while others do not. We report a 78-year-old male with chronic kidney disease (CKD) who developed painful gynecomastia following the administration of darbepoetin. The gynecomastia resolved upon cessation of darbepoetin but recurred upon its reintroduction. Extensive evaluation did not identify any other underlying cause. To our knowledge, this is the first case describing an association between darbepoetin and gynecomastia. In addition to presenting the case, we briefly discuss the hormonal changes in CKD patients and the potential effects of synthetic erythropoiesis-stimulating agents (ESAs) on hormone regulation.

Autosomal recessive polycystic kidney disease (ARPKD) is a form of hereditary cystic disease with a highly variable phenotypic expression that ultimately leads to chronic kidney disease. Severe cases may warrant surgical intervention with unilateral or bilateral nephrectomy to alleviate thoracic and abdominal compression from massive nephromegaly. Hypotension has been identified as a potential complication following nephrectomy in pediatric patients. We present the case of an infant with end-stage kidney disease secondary to ARPKD who developed refractory hypotension following elective bilateral nephrectomies. We describe the use of angiotensin-II infusion with a significant increase in mean arterial blood pressure and successful reduction in other inotropic and vasopressor support. This case suggests that angiotensin-II may represent another valuable therapeutic agent in the treatment of refractory hypotension in anephric infants.

Renal hemosiderosis, marked by the buildup of hemosiderin in the renal cortex due to chronic intravascular hemolysis, can lead to acute kidney injury. Iron deposited may exacerbate renal damage through processes like lipid peroxidation and free radical formation, impacting cellular function and precipitating renal disease. Although seen commonly with chronic intravascular hemolysis in the setting of sickle cell anemia, thalassemia, and in the setting of prosthetic cardiac valves. While acute renal failure following prosthetic cardiac valve placement is relatively uncommon, some cases of renal injury in the setting of mechanical hemolysis have been reported, in the postsurgical period, typically within 2 weeks. In this case report, we present a 67-year-old male patient, following mitral valve repair, who developed anemia within 2 weeks of the repair. Evaluation with echocardiography did not initially show findings of worsening mitral regurgitation, however, his anemia and kidney function worsened over the next 6 months. Further evaluation, during that time showed worsening mitral valve regurgitation in repeated echocardiography, with renal hemosiderosis confirmed via kidney biopsy, revealing glomerulosclerosis with hemosiderin deposits. Due to persisting anemia and worsening kidney function, the patient is being planned for a mitral valve replacement. The potential recovery of renal function remains uncertain. Despite the common occurrence of intravascular hemolysis following prosthetic valve placement or valve repair, only a few cases of acute renal failure have been reported. In these cases, severe hemolytic anemia developed shortly after surgery, within 2 weeks, with increased levels of creatinine, even reported as high as 8.2 mg/dL and renal biopsy revealed acute tubular injury and widespread tubular hemosiderosis, resembling the findings in the index case. Diagnosis depends on the evaluation of anemia, showing signs of hemolysis, with echocardiology findings of worsening valvular abnormalities, and kidney biopsy findings showing hemosiderin deposits. Treatment strategies encompass the management of anemia alongside considerations for either mitral valve replacement or repair. This case underscores the importance of considering the possibility of renal hemosiderosis, associated with mitral valve repair. The delay in diagnosis observed in this case is not uncommon, and timely recognition becomes pertinent to prevent irreversible renal injury and improve long-term outcomes.