A COMMON YET UNCOMMON CAUSE OF ACUTE KIDNEY INJURY IN ELDERLY FEMALE

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute kidney injury (AKI) is characterized by acute rise in serum creatinine or decline in urine output. Causes are classified into three different categories; pre-renal, intrinsic (renal) and post renal. We present a unique case of acute kidney injury in an elderly woman. CASE PRESENTATION: A 57 years old woman with history of diabetes mellitus, COPD and hypertension presented with shortness of breath and productive cough for two weeks and lower extremity edema for 2 days. She was recently treated with azithromycin for shortness of breath and cough. Upon presentation, hemodynamics were stable. Initial blood workup revealed WBCs 14.17X10X3 U/L ( 4-11X10x3 U/L), Hb 11.5 g/dl (11-16 g/dl), platelets 513X10x3 U/L( 140-400 10x3 U/L), sodium 139 mEq/L ( 136-145 mEq/L), potassium 5.7 mEq/L ( 3.5-5.1 mEq/L), BUN 65 mg/dl (7-18 mg/dl), creatinine 2.6 mg/dl(0.5-1.1 mg/dl), AST 22 U/L (15-37 U/L), ALT 20 U/L (12-78 U/L). Urinalysis showed proteinuria 500 mg/dl, RBCs 1000 U/L, WBCs 151 U/L and protein/Cr ratio was 2.9. CXR showed chronic fibrotic changes with suspected acute infiltrates. CT scan showed chronic inflammatory changes and ground glass opacities within lungs. Suspecting COPD exacerbation with community acquired pneumonia, patient was started on doxycycline, methylprednisolone and Lasix for peripheral edema.Repeat workup showed worsening creatinine 3.07 mg/dl. Patient did report history of daily ibuprofen use which was already discontinued on admission. Further workup revealed hypocomplimentemia C3 42 mg/dl (90-180 mg/dl), C4 2.9 mg/dl (10-40 mg/dl). HIV, HCV, HBV serology along with ANA and ANCA screen were unremarkable. Eventually, renal biopsy showed diffuse proliferative glomerulonephritis with C3 deposits consistent with Post-infectious glomerulonephritis. ASO titer was undetectable. Systemic steroids were initiated. Over the course of days, renal function declined further necessitating hemodialysis. Patient was eventually discharged with prednisone and out-patient hemodialysis. She did not require hemodialysis beyond 3 months and was weaned off of prednisone after 5 months. DISCUSSION: Acute post-streptococcal glomerulonephritis (PSGS) is the most common cause of acute nephritis in children of low socioeconomic countries. Less commonly, it can also cause glomerulonephritis in older adults. Renal injury is caused by glomerular immune complexes deposition. Presentation can be variable form being asymptomatic to full blown nephritic syndrome. Diagnosis usually is made by nephritic presentation and evidence of recent Group-A streptococcal infection but biopsy may be required in uncertain cases. Management is generally supportive and may include dialysis in cases of severe acute renal failure. Steroids have been used especially in patients with severe crescentic glomerulonephritis or rapidly progressive glomerulonephritis. Most patients completely recover beginning in two weeks but some go on to develop late complications including hypertension and chronic kidney disease. CONCLUSIONS: Acute post-streptococcalglomerulonephritis is more common in children but should be kept in differentials for adult and elderly patients as well. Reference #1: Wang D, Li L, Wei L, Liu Y, Sun S. Acute postinfectious glomerulonephritis associated with scabies in the elderly: A case report. Parasitol Int. 2017;66(6):802-805. doi:10.1016/j.parint.2017.08.008 Reference #2: Samih H. Nasr, Mary E. Fidler, Anthony M. Valeri, Lynn D. Cornell, Sanjeev Sethi, Amy Zoller, Michael B. Stokes, Glen S. Markowitz and Vivette D. D'Agati Postinfectious glomerulonephritis in elderly JASN January 2011, 22 (1) 187-195; DOI: https://doi.org/10.1681/ASN.2010060611 Reference #3: Volpi A, Meroni M, Battini G, et al. Postinfectious glomerulonephritis in the elderly. Am J Nephrol. 1988;8(5):431-432. doi:10.1159/000167632 DISCLOSURES: No relevant relationships by Muhammad Afzal, source=Web Response