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| Year : 2007 | Volume
: 18
| Issue : 3 | Page : 422-425 |
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| Acute Renal Failure in a Patient with Non-fulminant Hepatitis A Infection |
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RT Parakkadavathu1, SV Pisharath2, AP Chekkura1, A Khandekar3, SS Soni4, RM Parameswaran5, A Melothvalapil6
1 Krishna Nursing Home, Kanhangad, India
2 Dhanalakshmi Hospital, Kannur, Kerala, India
3 Hinduja National Hospital & Medical Research Centre, Mumbai, India
4 Medicity Hospital, Hyderabad, India
5 A.P., Pariyaram Medical College, Kannur, Kerala, India
6 Govt. Medical College, Calicut, Kerala, India
Click here for correspondence address and email
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 Abstract | | |
Acute viral hepatitis A is a common cause of jaundice with a very low mortality. Acute renal failure occurs very rarely in hepatitis A. We report a case of non-fulminant hepatitis A in a 45-year-old man complicated by acute renal failure. The patient was treated successfully with hemodialysis resulting in complete recovery. Kidney biopsy was not performed in view of improving clinical picture. Keywords: Renal, Failure, Non-fulminant Hepatitis A.
How to cite this article:
Parakkadavathu R T, Pisharath S V, Chekkura A P, Khandekar A, Soni S S, Parameswaran R M, Melothvalapil A. Acute Renal Failure in a Patient with Non-fulminant Hepatitis A Infection. Saudi J Kidney Dis Transpl 2007;18:422-5 |
How to cite this URL:
Parakkadavathu R T, Pisharath S V, Chekkura A P, Khandekar A, Soni S S, Parameswaran R M, Melothvalapil A. Acute Renal Failure in a Patient with Non-fulminant Hepatitis A Infection. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2022 Jul 1];18:422-5. Available from: https://www.sjkdt.org/text.asp?2007/18/3/422/33763 |
| Introduction | |  |
Hepatitis A is a self limiting condition with a very low mortality. The clinical spectrum of disease ranges from asymptomatic infection to fulminant hepatitis. Well described atypical manifestations include prolonged cholestasis, extrahepatic symptoms, autoimmune diseases, and relapse. Acute renal failure is extremely rare in hepatitis A with less than 50 cases reported so far.
Kidney biopsy performed in such cases usually show immune related mechanisms, direct pigment toxicity, and direct viral cytopathic effects. Reports of HLA- B27 association with hepatitis A and renal failure raises the possibility of genetic predisposition for this entity. However, detailed HLA association with hepatitis A infection has not been adequately studied. The prognosis is generally good and treatment is mainly supportive. Here we describe a patient who developed acute renal failure along the course of hepatitis A with favorable outcome.
| Case Report | | |
A 45-year-old man presented with high grade fever, body aches, nausea and vomiting of four days prior to admission. He had unremarkable past history, and was not a habitual alcohol abuser or smoker. The patient was treated with doxycycline 100 mg twice daily and acetaminophen 500 mg thrice daily by prescribed by a general practitioner for a presumptive diagnosis of leptospirosis. His symptoms persisted and over the following two days, he developed oliguria and Jaundice. On admission, he was clinically stable, euvolemic with normal central venous pressure, and his chest was clear to auscultation. However, he was icterus with tender hepatomegaly.
The laboratory investigations included the following: hemoglobin 132 g/L, total leukocyte count 3000/µL with 65% polymorphs and 35% lymphocytes, and platelet count 120,000/µL. Urinalysis revealed 1+ albumin , many granular casts, and few RBCs/ HPF and no eosinophils. BUN was 50 mmol/L, serum creatinine 327 µmol/L, serum sodium 138 mmol/L, potassium 4.5 mmol/L, bicarbonate 19 mmol/L, and chloride 98 mmol/L. Liver function test showed total bilirubin of 3.6 mg/dl, direct bilirubin 2.2 mg/dl, indirect bilirubin 1.4 mg/dl, alkaline phosphatase 200 U/L, ALT 8000 U/L, AST 6000 U/L, and LDH 180 U/L. Complement levels (C3, C4), serum ceruloplasmin, and myoglobin levels were normal. HAV- IgM was strongly positive. Serological tests for other viral hepatitis were negative. The patient was negative for HLAB27. Endemic diseases including malarial fever, Leptospirosis and Dengue fever were excluded. Ultrasound of abdomen revealed mild hepatomegaly and normal sized kidneys.
The patient's urine output improved over a period of nine days during which he required seven hemodialysis sessions and was discharged on day 14. BUN and creatinine normalized in three weeks and liver enzymes returned to normal in four weeks. The patient remained asymptomatic at the end of one year follow-up.
| Discussion | | |
Our patient had acute renal failure, which is not the usual presentation in Hepatitis A infection. Renal involvement in hepatitis A is usually characterized by mild proteinuria, microscopic hematuria and slight urinary sediment abnormalities. [1] In a review of 32 cases, 2 kidney biopsy showed immune complex deposition in five, acute tubular necrosis, or interstitial nephritis in 12. In isolated case reports the biopsy findings also showed IgA dominant glomerulonephritis along with cutaneous cryoglobulinemic vasculitis, [3],[4] thrombotic microangiopathy [5] and fibrinogen deposits. [6]
Various mechanisms hypothesized as etiologies for renal failure that include volume depletion and prerenal azotemia due to nausea and vomiting, [7] drug toxicity, immune complex deposition, direct viral cytopathic effect (animal studies), [8] hyperuricemia and cryoglobulinemia. [5]
Hyperbilirubinemia may be a major factor in the acute renal failure associated with Hepatitis A infection. Tubulointerstitial nephritis due to the toxic effect of bilirubin on tubular epithelium can produce renal failure.[5] Hyperbilirubinemia can lead to intrarenal vasoconstriction or shunting of the blood away from the renal cortex. [9] Simultaneous retention of bile salt may have a toxic effect on the renal tubules. [10] It may also sensitize renal vasculature to circulating vasoconstricting stimuli and produce vasoconstriction.[11]
Endotoxemia can also directly impair renal blood flow. [5] Disseminated intravascular coagulation occurs as a result of endotoxemia can also result in renal failure. [12]
Acute renal failure has been reported to occur with hepatitis A in several special conditions that include Cushing's disease, [11] anorexia nervosa, [13] relapsing hepatitis A, [5] cholestatic hepatitis A, [14],[15] postpartum period, [16] human immunodeficiency viral infection, [17] and HLAB27 positive patients. [18] Other associated conditions include Guillain-Barre like sybdrome with thrombocytopenia [19] and acute pericarditis. [20] In a patient with glucose-6-phosphate dehydrogenase deficiency, acute viral hepatitis was associated with prolonged renal failure. [21]
Management of acute renal failure associated with hepatitis A infection is generally supportive and the condition has a mortality rate of approximately 10%. [22] Other reported treatments with good results include corticosteroids and cyclophosphamide in a patient with cholestatic hepatitis and thrombotic microangiopathy. [5] Furthermore, plasmapheresis [23],[24],[25[ and high dose of acetylcysteine were also reported as modalities of therapy. [26] Our patient had normal complement levels, never had volume depletion, and urine did not contain eosinophils rendering the immunological, prerenal and drug induced causes of renal failure less likely. Renal biopsy was not performed due to the favorable clinical course of the patient.
We conclude that the patient most probably had acute tubular necrosis following hepatitis A. Though leptospirosis and malaria should strongly be considered in differential diagnosis of hepatorenal syndrome in endemic areas, the diagnosis of renal failure associated with hepatitis A can be entertained.
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Correspondence Address:
R T Parakkadavathu
Consultant Physician, Krishna Nursing Home, Kanhangad, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 17679757 
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