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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 3  |  Page : 422-425
Acute Renal Failure in a Patient with Non-fulminant Hepatitis A Infection

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

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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 Top

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 Top

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 Top

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.

   References Top

1.Zikos D, Grewal K, Craig K, Cheng J, Peterson D, Fisher K. Nephrotic syndrome and acute renal failure associated with hepatitis A virus infection. Am J Gastroenterol 1995;90:295-8.  Back to cited text no. 1    
2.McCann UG, Rabito F, Shah M, Nolan CR, Lee M. Acute renal failure complicating nonfulminant hepatitis A. West J Med 1996 ;165(5):308-10.  Back to cited text no. 2    
3.Cheema SR, Arif F, Charney D, Meisels IS. IgA-dominant glomerulonephritis associated with hepatitis A. Clin Nephrol 2004; 62(2):138-43.  Back to cited text no. 3    
4.Al-Homrany M. Immunoglobulin A nephropathy associated with hepatitis A virus infection. J Nephrol 2001;14(2):115-9.  Back to cited text no. 4    
5.Tagle M, Barriga JA, Gutierrez S, Valdez LM, Castle J, Antunez De Mayolo A. Relapsing viral hepatitis type A complicated with renal failure. Rev Gastroenterol Peru 2004; 24(1):92-6.  Back to cited text no. 5    
6.Kamura M, Nagashima T, Imai T, Furukawa K, Yamamoto N, Ikeda Y. A case of acute hepatitis A with renal failure caused by fibrinogen deposits. Nippon Shokakibyo Gakkai Zasshi 1993; 90(11):2936-9.  Back to cited text no. 6    
7.Konishi N, Takeshita K, Yasui H, Hatta I. A case of acute hepatitis A associated with acute renal failure from the onset. Nippon Jinzo Gakkai Shi 1993; 35(9):1103-6.  Back to cited text no. 7    
8.Mathiesen LR, Drucker J, Lorenz D. Localization of hepatitis A antigen in marmoset organs during acute infection with hepatitis A virus. J Infect Dis 1987; 138:369-77.  Back to cited text no. 8    
9.Green J, Beyar R, Bomzon L, Finberg J, Better O. Jaundice, the circulation and the kidney. Nephron 1984; 37:145-52.  Back to cited text no. 9    
10.Wilkinson S, Moodie H, Stamatakis J, Kakkar V, Williams R. Endotoxaemia and renal failure in cirrhosis and obstructive Jaundice. Br Med J 1976; 2:1415-8.  Back to cited text no. 10    
11.Adas M, Tanakol R, Yarman S, Boztepe H, Ecder T, Alagol F. Acute renal failure associated with nonfulminant hepatitis A virus infection. Ren Fail 2002;24(1):97-102.  Back to cited text no. 11    
12.Lin CC, Chang CH, Lee SH. Acute Renal Failure in Non-Fulminant Hepatitis A. Nephrol Dial Transplant 1996; 11:2061-66.  Back to cited text no. 12    
13.Yasar B, Akbayir N, Celik S, et al. Acute oligo-anuric renal failure during the course of non-fulminant hepatitis A in a patient with anorexia nervosa. Turk J Gastroenterol 2002; 13(3):164-7.  Back to cited text no. 13    
14.Wolf M, Oneta CM, Jornod P, et al. Cholestatic hepatitis A complicated by acute renal insufficiency. Z Gastroenterol 2001;39(7):519-22.  Back to cited text no. 14    
15.Nachbaur K, Konig P, Rumpelt HJ, Schobel B, Lhotta K, Vogel W. Acute renal failure complicating non-fulminant hepatitis A. Clin Nephrol 1996;45(6):398-400.  Back to cited text no. 15    
16.Villanueva LA, Aragon Hernandez JP, Arevalo Gonzalez A, Garcia Lara E. Viral hepatitis A and postpartum acute renal failure. Report of a case and review of the literature. Ginecol Obstet Mex 2000; 68:46-9.  Back to cited text no. 16    
17.Patri B, Doazan H, N'guyen Phuong T, Dubrisay J. Acute hepatitis and renal insufficiency associated with seroconversion to human immunodeficiency virus. Presse Med 1988;17(21):1094-5.  Back to cited text no. 17    
18.Brncic N, Matic-Glazar D, Viskovic I, Grzetic M, Racki S. Acute renal failure complicating nonfulminant hepatitis in HLA-B27 positive patient. Ren Fail 2000; 22(5):635-40.  Back to cited text no. 18    
19.Lee DK, Do JK, Kim YJ. Guillain-Barre like syndrome associated with acute renal failure and thrombocytopenia following acute viral hepatitis A. J Korean Med Sci 1997 ;12(2):151-6.  Back to cited text no. 19    
20.Beyazit Y, Guven GS, Kekilli M, Koklu S, Yolcu OF, Shorbagi A. Acute pericarditis and renal failure complicating acute hepatitis A infection. South Med J 2000; 99(1):82-4.  Back to cited text no. 20    
21.Al-Rasheed SA, Al-Mugeiren MM, Al­Salloum AA, Al-Fawaz IM, Al-Sohaibani MO. Acute viral hepatitis, glucose-6­phosphate dehydrogenase deficiency and prolonged acute renal failure: a case report. Ann Trop Paediatr 1995;15(3):255-7.  Back to cited text no. 21    
22.Malbrain ML, De Meester X, Wilmer AP, Frans E, Peeters J, Nevens F. Another case of acute renal failure (ARF) due to acute tubular necrosis (ATN), proven by renal biopsy in non-fulminant hepatitis A virus (HAV) infection. Nephrol Dial Transplant 1997;12(7):1543-4  Back to cited text no. 22    
23.Watanabe S, Nomoto H, Matsuda M, et al. A case of acute renal failure associated with type A acute hepatitis responds dramatically to plasmapheresis. Tokai J Exp Clin Med 1986; 11(1):1-4.  Back to cited text no. 23    
24.Suga M, Shibata K, Akahonai Y. A case of type A fulminant hepatitis with renal failure cured with plasma exchange. Acta Hepatol 1984; 25:241-5.  Back to cited text no. 24    
25.Corpechot C, Cadranel JF, Hoang C. Cholestatic hepatitis A in adults-Clinical, biological, and histopathological study of 9 cases. Gastroenterol Clin Biol (Paris) 1994; 18:743-50  Back to cited text no. 25    
26.Shroff GR, Badve SV, Joshi AG, Desai DC, Abraham P, Sirsat RA. Acute renal tubular injury with acute hepatitis A infection: is it just a coincidence? Nephrology (Carlton) 2004;9(1):44-6.  Back to cited text no. 26    

Correspondence Address:
R T Parakkadavathu
Consultant Physician, Krishna Nursing Home, Kanhangad, Kerala
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Source of Support: None, Conflict of Interest: None

PMID: 17679757

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