Fatal renal and hepatic failure following silver nitrate instillation for treatment of chyluria

Abstract

Sir, Toxic acute tubular necrosis (ATN) accounts for the largest number of cases of acute renal failure (ARF) after ischaemic ATN. We discuss here a case of fulminant hepatic and renal failure following instillation of silver nitrate. This patient underwent silver nitrate instillation in the renal pelvis for treatment of chyluria. The exact quantity and concentration were not available since the patient was transferred to our institute from another hospital. He developed severe hepatic and renal failure within 24 h of instillation. All other causes of liver and renal failure were ruled out by appropriate laboratory investigations and imaging techniques. He was given a trial of N-acetyl cysteine in view of severe toxic hepatitis. He was treated with haemodialysis for renal failure. His course was complicated by the development of epistaxis despite reasonably acceptable coagulation parameters. He underwent ligation of the nasal septal artery in view of the same, but this did not stop the bleeding and post-operative ventilatory support was required. In light of a progressive deterioration in liver function, we decided to add an activated charcoal cartridge to the haemodialysis circuit to remove protein-bound toxins secondary to liver failure, e.g. bilirubin, bile acids, etc. We first processed dialyzed blood through a plasma filter, which separated plasma-containing protein-bound toxins. This process avoided thrombocytopaenia, which can occur with the use of a charcoal cartridge. This plasma with protein-bound toxins was subsequently processed through activated charcoal. Blood from the plasma filter and plasma from the charcoal cartridge were returned to the body. Low-dose heparin was used throughout the procedure. With this extracorporeal circuit there was no thrombocytopaenia secondary to the charcoal cartridge and no loss of albumin. Neither was there a need for albumin as a dialysate as required in a molecular adsorbent recycling system [1]. With the above management, the patient’s general condition and epistaxis improved. His liver function tests also showed improvement. He was extubated and started on oral feeds; however, 2 days later the patient had a sudden cardiorespiratory arrest from which he could not be revived. Probable cause of death was thought to be pulmonary embolism or aspiration pneumonia. Chyluria is a common problem in India, Hong Kong, Taiwan and Japan [2]. Although silver nitrate instillation (0.5–1%) for the treatment of chyluria is a relatively safe procedure with a 70–80% success rate [3], two case reports have described ARF following silver nitrate instillation [4,5]. Possible mechanisms for ARF in these patients were ATN and acute papillary necrosis. In the present case, an unknown quantity of silver nitrate was used. This was possibly absorbed systemically through larger lymphatic channels, which resulted in fulminant hepatic and renal failure. Silver nitrate causing both hepatic and renal failure as in this case has not been described to best of our knowledge.