Acute Kidney Injury Due to Arsenic Contained in Alternative Medicines in the Setting of Adult Nephrotic Syndrome

Abstract

33 year old male presented to us with history of puffiness of face, edema feet of 2-3 weeks duration. 4-5 days before admission he developed oliguria with worsening of edema. There was no history of fever, upper respiratory tract symptoms, pyoderma, or jaundice preceding the illness. He also denied any history of hematuria, flank pain, prior similar episodes or recent NSAIDs use. His past history was significant for use of unlabeled alternative ayurvedic powder and liquid for eczematous skin lesions for last 6 months. On evaluation, he was afebrile, conscious, and alert with heart rate of 86 per minute, blood pressure 114/66 mmHg with no postural drop. He had edema upto knees and there was no pallor, lymphadenopathy, skin hyperpigmentation, nail changes, or icterus. Chest was clear to auscultation, heart sounds were normal, there was no hepatosplenomegaly. Higher mental functions were normal and there was no evidence of peripheral neuropathy. Laborotary evaluation showed: Hemoglobin 13.4 g/dl, leucocyte count of 11300 (with 68% polymorphs and 22% lymphocytes), platelets 2,33,100/cmm, Urine albumin 4+, no red blood cells, occasional pus cells and granular casts. 24 hr urine protein 4.2 gm/day, blood urea nitrogen 16mg/dl, creatinine 1.6mg/dl, total protein 5.5 g, albumin 2.4 g, sodium 132 mEq, potassium 3.8 mEq, chloride 101 mEq, serum total cholesterol 412 mg and triglyceride 344 mg/dl. Serologies for antinuclear antibodies and anti double stranded antibodies were negative and complement C3 and C4 levels were normal. A kidney biopsy was performed and in view of history of consumption of alternative medicines, samples of ayurvedic powder and liquid were sent for toxicological analysis. After admission patient remained oliguric and there was no response to volume expansion with 200 ml of 10% albumin with diuretics. Serum creatinine rose to the peak of 3.7 mg/dl. Patient was treated conservatively as a case of nephrotic syndrome with acute kidney injury. Renal replacement therapy was not required. After 8 days of oliguria patient went into diuretic phase and creatinine decreased to 1.1 mg/dl on day 14 of admission. Kidney biopsy showed predominant involvement of tubulointerstitium with glomeruli showing normal basement membrane and cellularity. Tubule showed denudation of epithelium and fraying of borders. Interstitium showed deposition of pink, rectangular, and polarizing crystals extending at places into the tubular epithelium and