Acute Renal Failure Associated with Acute Non-fulminant Hepatitis A: A Case Report and Review of Literature

Figures & data

Figure 1.  (a) H&E stain of kidney biopsy shows mononuclear cells infiltration of the interstitium, suggesting interstitial nephritis. (b) H&E stain of kidney biopsy shows tubular necrosis.

Figure 2.  Clinical course of this patient. Abbreviations: H/D  =  hemodialysis, N/V  =  nausea/vomiting, Cr  =  creatinine (mg/dL), ALT  =  alanine aminotransferase (U/L). A-HAV IgM has a cutoff value of 1.2/ABBOTT. Bilirubin is measured in mg/dL.

Table 1  Demographic and clinco-pathological features

Case (reference)	Age	Sex	ALT	Bil	Cr	Proteinuria	Urine RBC/HPF	Dialysis	RF recovery	LF recovery	Renal biopsy	Urine Na	Complication
1a (1)	34	F	AST960	3.15	>1	NA	NA	HD	NA	NA	NA	2; 34	NA
1b (1)	49	M	AST860	5.06	8.22	NA	NA	HD	NA	NA	ATN	2; 98	Died
1c (1)	35	F	AST1100	3.8	8.25	NA	NA	HD	NA	NA	NA	30	NA
2 (9)	38	M	>2000	9.1	16.8	++	Numerous	HD	1M	10M	NA	NA	General convulsions
3 (28)	36	M	2827	3.4	14.3	++	NA	–	7W	5W	ATN	NA	NA
4 (27)	30	M	2590	5.8	11.9	++	2–3	HD	46D	17D	Mild MPGN	NA	NA
5 (26)	21	F	NA	NA	NA	NA		PP	NA	NA	NA	NA	NA
6 (4)	34	M	5780	12.7	10.9	NA	NA	HD	NA	NA	ATN	NA	Fulminant hepatitis, hepatic coma; died of subendocardial infarction
7 (29)	30	M	1480	6.78	11.2	++	8–10	PD	3M	3M	NA	38	NA
8a (30)	8	F	NA	NA	NA	NA	NA	NA	NA	NA	MPGN	NA	NA
8b (30)	10	F	NA	NA	NA	NA	NA	NA	NA	NA	ATN, MPGN,interstitial nephritis	NA	NA
9 (24)	43	F	1077	11.8	12	+/–	0–1	HD then PP	42D	50D	NA	NA	NA
10a (12)	32	M	833	8.8	13.9	++	Numerous	HD	2M	1M	NA	NA	DIC
10b (12)	30–40	M	5370	10.3	14.3	NA	NA	HD	<3M	Once case 9M	NA	NA	NA
10c (12)	30–40	M	4700	4.9	9.7	NA	NA	HD	<3M	Two cases<3M	NA	NA	NA
10d (12)	30–40	M	739	13.1	16.9	NA	NA	HD	<3M	Two cases<3M	ATN	NA	NA
11 (31)	43	M	6914	7.8	9.7	NA	NA	–	2M	2M	ATN	24	NA
12 (10)	51	M	341	13.2	8.2	9.54g/l	Numerous	HD	1M	1M	NA	83	Prolonged PT
13 (32)	39	M	932	10.4	12.2	+	0–5	HD	>14D	NA	NA	NA	Elevated endotoxin level
14 (33)	22	F	NA	2.6	6.7	NA	NA	–	NA	NA	NA	NA	NA
15 (23)	39	F	1486	2.45	5.6	+	6–10	HD	7D	1M	ATN with intraglomerular deposit of IgG	NA	Thrombocytopenia and leukopenia
16 (34)	7	M	634	13.6	8.4	+	6	PD	4W	4W	NA	NA	NA
17 (35)	28	M	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA
18 (36)	52	M	259	3.9	20	NA	A few	HD	6W	2W	Interstitial nephritis	NA	NA
19 (5)	21	M	4780	10.9	12.5	4g/day	2–4	HD	1M	NA	NA	104	NA
20 (14)	42	M	NA	20.4	14.39	++	NA	HD	7W	7W	Normal	NA	Recovery from primary pneumococcal peritonitis
21 (37)	42	F	4650	8.2	8.5	++++	1+	HD	7M	NA	ATN and acute glomerular ischemia	NA	NA
22 (11)	42	M	3228	3.0	+	+	NA	HD	NA	NA	ATN with intraglomerular deposition of fibrinogen	55	Elevated FDP level and prolonged PT
23 (25)	38	M	NA	NA	NA	NA	NA	PP	NA	NA	NA	NA	NA
24 (21)	42	M	358	11.3	12.2	+	0–1	HD	1M	1M	MPGN with granular deposit of IgA and C1q and interstitial nephritis	NA	NA
25 (7)	59	M	2432	33.4	7.37	NA	NA	HDF then HD	NA	NA	Degenerative changes of tubular epithelium	NA	Died of E. coli peritonitis
26a (38)	16	F	504	12.65	8.4	–	–	HD	2W	4D	NA	FeNA>3	NA
26b (38)	41	F	4720	10.1	6.9	500mg/day	–	–	10D	3D	NA	FeNA>3	NA
26c (38)	30	M	5134	7.5	13.2	560mg/day	–	PD	3W	6D	Mild interstitial nephritis and mild tubular necrosis	FeNA>3	NA
27 (6)	33	M	4070	1.5	5.2	25g/day	Trace	–	NA	8D	MPGN with IgM C3 deposits	NA	Prolonged PT, persistent renal insufficiency
28 (22)	35	F	>4000	2.9	8.2	++	2–3	–	NA	NA	Mesangial proliferation, IgA, IgM, IgG and C1q deposition, interstitial nephritis	34	NA
29 (18)	35	M	NA	NA	NA	NA	NA	HD	NA	NA	Normal	NA	NA
30 (39)	37	F	2100	5.6	11	30mg/dl	1, granular casts; 3+,RBC cast	–	2W	5W	ATN	NA	NA
31 (17)	30	M	2348	9.8	15.4	Trace	NA	HD	5W	4W	ATN	65	NA
32 (40)	36	M	1049	59.5	12.3	Trace	5–8	HD	4M	40D	NA	50	NA
33 (41)	26	M	1870	10.5	4.8	Mild	–	–	2W	2W	NA	54	NA
34 (13)	38	M	6629	10.7	21	NA	NA	HD	3M	3M	NA	NA	Type 2 DM
35 (42)	32	F	NA	NA	NA	NA	NA	–	1M	1M	NA	NA	NA(History of Cushing's disease)
36 (43)	NA	NA	NA	NA	3.99	NA	NA	HD	NA	NA	Interstitial nephritis and ATN	NA	NA
37 (8)	77	M	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	Pericarditis, died of septic shock
38a (44)	NA	NA	NA	NA	NA	NA	NA	HD	NA	NA	ATN	NA	NA
38b (44)	NA	NA	NA	NA	NA	NA	NA	–	NA	NA	NA	NA	NA
39	36	M	990	8.3	18.94	–	2+, 24	HD			Tubular necrosis with regeneration; Interstitial nephritis; Glomerulosclerosis and arteriolar sclerosis; IgM, C3+	88	NA

*Our case.

Abbreviations: RBC/HPF = red blood cells per high-power field, RF recovery = renal function recovery, LF recovery = liver function recovery, NA = not available, HD = hemodialysis, HDF = hemodiafiltration, PD = peritoneal dialysis, PP = plasmapheresis, D = days, W = weeks, M = months, FeNA = fraction excretion of sodium, ATN = acute tubular necrosis, MPGN = membranoproliferative glomerulonephritis, GTC = generalized tonic-clonic seizure, DIC = disseminated intravascular coagulation, PT = prothrombin time, FDP = fibrin degradation product, DM = diabetes mellitus.

Table 2  Clinical characteristics

Age	7–77 years
Male:female	31:14 (3 not mentioned)
ALT (U/L)	259–6629
Total bilirubin (mg/dl)	1.5–59.5
Creatinine (mg/dl)	3.99–21
UNa (meq/L)	24–98 (2→34, 2→98)

*Two cases with initial UNa 2, then increased up to 34 and 98, respectively.

Abbreviation: UNa = spot urine sodium concentration.

Table 3  Kidney biopsy (23 out of 48)

ATN	11
MPGN	3
Interstitial nephritis	2
Interstitial nephritis + ATN	3
Interstitial nephritis + MPGN	1
ATN + MPGN + interstitial nephritis	1
Normal	2

Abbreviations: ATN = acute tubular necrosis, MPGN = membranoproliferative glomerulonephritis.

Table 4  Renal replacement therapy

HD	27
PP	2
HD then PP	1
HDF then HD	1
PD	3
No renal replacement therapy	10
Not mentioned	4

Abbreviations: HD = hemodialysis, HDF = hemodiafiltration, PD = peritoneal dialysis, PP = plasmapheresis.

Table 5  Outcome

Death	4
Permanent renal insufficiency	1 (MPGN)
GTC	1
DIC or prolonged PT	4
Type 2 DM	1
Pneumococcal peritonitis	1

*Four cases died of (1) E.coli peritonitis, (2) pericarditis with septic shock, (3) fulminant hepatitis, hepatic coma, subendocardial infarction, and (4) unknown, respectively.

Abbreviations: GTC = generalized tonic-clonic seizure, DIC = disseminated intravascular coagulation, PT = prothrombin time, DM = diabetes mellitus.