Attacked from All Sides: A Confounding Case of Renal Failure

1Beth Israel Deaconess Medical Center, Boston, MA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 357

Case Presentation:

A 63‐year‐old man with chronic stag‐horn nephrolithiasis and chronic kidney disease presented with generalized arthralgias of 3 weeks’ duration, worse in the morning. In the days prior to presentation, he noticed pink urine and dull right flank pain. A staghorn calculus in the right kidney and nephrolithiasis in both ureters were diagnosed months prior. His medications included lisinopril 5 mg daily as well as self‐prescribed naproxen 800 mg and ibuprofen 800 mg, both every 6 hours for pain. He reported no family history of renal or rheumatologic disease. Vital signs were stable. Examination showed 11 bilateral pedal edema. Serum creatinine was 4.9 from a baseline of 1.8, blood urea nitrogen was 58, and there was gross hematuria. Renal ultrasound confirmed bilateral nephrolithiasis with moderate hydronephrosis in the right kidney. A stent was placed in the right ureter, but renal clearance did not improve. He began hemodialysis for oli‐guria. On hospital day 5, a purpuric rash was found on the left foot. c‐ANCA was found to be positive (1:640). Concurrently, urinalysis showed red blood cell (RBC) casts and dysmorphic RBCs. Serum anti‐GBM was negative, and complement levels were normal. Renal biopsy showed fibrinoid necrosis of the vasa recta walls. High‐dose glucocorticoids and cyclophosphamide were begun. Six treatment sessions of plasmapheresis were completed. Subsequently, hemodia‐lysis was discontinued, and the patient was discharged in good condition with a down‐trending creatinine of 2.4.

Discussion:

Several etiologies of renal failure were suggested by this patient's presentation. Bilateral nephrolithiasis with hydronephrosis and hematuria put postrenal obstruction on top of the initial differential. Excessive use of nonsteroidal anti‐inflammatories also raised concern for acute interstitial nephritis. Not until RBC casts and dysmorphic RBCs were found in the urinary sediment was glomerular disease indicated. The differential diagnosis for acute glomerulonephri‐tis includes pauci‐immune processes, immune‐complex deposition disease, and anti‐GBM disease. A positive c‐ANCA, vessel‐wall fibrinoid necrosis, and a purpuric rash all pointed to Wegener's granulomatosis. This patient's presentation was absent of respiratory tract involvement, which is a presenting symptom in 90% of patients with Wegener's granulomatosis (Ann Intern Med. 1992;116:488–98). Combination oral cyclophosphamide and glucocorticoids induce remission in 85%–90% of patients (Ann Intern Med. 2009;150:670–680). For patients with severe disease, 5– 7 sessions of plasmapheresis improve renal function and reduce the risk of progression to end‐stage renal disease (J Am Soc Nephrol. 2007;18:2180–2188).

Conclusions:

This case encourages the understanding of the major categories of acute glomerulonephritis. It presents an atypical presentation for a systemic vasculitis and demonstrates the evidence‐based treatment of a pauci‐immune glomerulonephritis.

Disclosures:

B. J. Oldfield ‐ none; R. L. Salazar ‐ none; D. Castillo ‐ none; A. Vanka ‐ none

To cite this abstract:

Oldfield B, Salazar R, Castillo D, Vanka A. Attacked from All Sides: A Confounding Case of Renal Failure. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 357. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/attacked-from-all-sides-a-confounding-case-of-renal-failure/. Accessed September 20, 2019.

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