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Acute Bilateral Renal Cortical Necrosis in ELLP FREE TO VIEW

Caleb Hsieh, MD; Nikhil Barot, MD; Jimmy Gordon, MD
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Olive View Medical Center - UCLA, Sylmar, CA

Chest. 2014;146(4_MeetingAbstracts):293A. doi:10.1378/chest.1991788
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SESSION TITLE: Critical Care Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Bilateral renal cortical necrosis (BRCN) is a rare but devastating form of acute kidney injury (AKI) disproportionately seen in critical obstetric illness. We present a unique case of BRCN in which the absence of hemolysis hindered the definitive early diagnosis BRCN etiology.

CASE PRESENTATION: A 40 year-old female G6P4014 presented at 32 weeks with sudden onset of contractions and vaginal bleeding. Her medical history was significant for preeclampsia. On admission, she was afebrile, blood pressure 157/113 mmHg, with a fetal ultrasound suggested intrauterine fetal demise. Initial lab results revealed normal chemistry, complete blood count, and liver function tests. Vaginal delivery was scheduled for the next day. Overnight, she became altered, pale, diaphoretic and abruptly anuric with a 3g/dL decrease in hemoglobin and increase in creatinine from 0.8 to 1.4 mg/dL. Concern for placental abruption prompted emergent induced vaginal delivery. Peri-partum lab results revealed uptrending liver enzymes (peak AST 743 Units/L, peak ALT 296 Units/L), lactate dehydrogenase 3809 Units/L, D-dimer (>9999), decreased platelets (nadir 33 x10^3/uL), and fibrinogen (nadir 112mg/dL). Serum bilirubin remained normal. Schistocytes and fragmented cells were absent on repeated peripheral smears. A non-contrast CT abdomen suggested bilateral cortical radiolucency consistent with BRCN. DIC was treated with low-dose heparin infusion. The patient was initiated on hemodialysis and had resolution of DIC, transaminitis, and thrombocytopenia several days post-partum.

DISCUSSION: Acute BRCN is a rare cause of AKI in pregnancy occurring in less than 1 in 10,000 pregnancies in the developed world (3). In our case, the presence of DIC, partial HELLP syndrome and placental abruption obscures an exact etiology of BRCN, but effects were likely cumulative. While HELLP accounts for up to 60% of severe AKI in pregnancy (3), in the absence of hemolysis (i.e., ELLP), it is usually more benign and managed conservatively. BRCN can be difficult to recognize initially, but the sudden development of oliguria/anuria is highly suggestive. Partial recovery of renal function occurs in up to 40%, but the majority remain dialysis dependent.

CONCLUSIONS: BRCN remains an important differential to consider in the complex oliguric/anuric obstetric patient. Pre-eclampsia, DIC, placental abruption, TTP-HUS and HELLP are important risk factors. Following delivery, treatment is primarily supportive with most patients remaining dialysis dependent.

Reference #1: Gupta A et al. Acute Oliguric Renal Failure in HELLP Syndrome: Case report and Review of Literature Renal Failure, 2012; 34(5):653-656

Reference #2: Mwoko R, Plecas D, Garovic VD. Acute kidney injury in the pregnant patient. ClinNephrol. 2012; 78(6):478-86

Reference #3: Drakeley AJ, Le Roux PA, Anthony J, Penny J. “Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit”. Am J Obstet Gynecol. Feb 2002; 186(2).

DISCLOSURE: The following authors have nothing to disclose: Caleb Hsieh, Nikhil Barot, Jimmy Gordon

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