Another TB patient with renal Another TB patient with renal failure - PowerPoint PPT Presentation

Another TB patient with renal Another TB patient with renal failure failure Inter- -hospital renal meeting hospital renal meeting Inter 21/3/2007 21/3/2007 KWH KWH Drs. SF Chan and SK Mak Mak Drs. SF Chan and SK

Case presentation Case presentation � 59/M 59/M � � Chronic smoker, nondrinker Chronic smoker, nondrinker � � History of pulmonary tuberculosis in 2000 History of pulmonary tuberculosis in 2000 � completed 6 months treatment with HRZM completed 6 months treatment with HRZM ( isoniazid isoniazid, , rifampicin rifampicin, , ethambutol ethambutol and and ( pyrazinamide ) ) pyrazinamide � Treatment course uneventful Treatment course uneventful �

History of present illness History of present illness � Presented to chest clinic with chronic Presented to chest clinic with chronic � cough in 2006 cough in 2006 � Sputum culture positive for Mycobacterium Sputum culture positive for Mycobacterium � tuberculosis tuberculosis � Started on TB treatment on 13/1/2007 Started on TB treatment on 13/1/2007 � � isoniazid isoniazid, , rifampicin rifampicin, , ethambutol ethambutol, , � pyrazinamide and streptomycin and streptomycin pyrazinamide

� Tolerate treatment in the first week Tolerate treatment in the first week � … � However, on FU in the second week However, on FU in the second week … �

� Complained of Complained of � � Fever, chills and rigor Fever, chills and rigor � � Bilateral loin pain Bilateral loin pain � � Dark Dark coloured coloured urine with decreased urine output urine with decreased urine output � � Vomiting and Vomiting and diarrhoea diarrhoea � � Blood streaks in sputum Blood streaks in sputum � � Denial recent travel/insect bite/herbs nor over Denial recent travel/insect bite/herbs nor over- -the the- - � counter drugs intake counter drugs intake

0 C 39 0 � Septic looking with fever 38 Septic looking with fever 38- -39 C � � Dehydrated with hypotension BP Dehydrated with hypotension BP � 98/60mmHg 98/60mmHg � Sinus tachycardia with HR ~ 120bpm Sinus tachycardia with HR ~ 120bpm � � Jaundice and mild pallor Jaundice and mild pallor �

21/1/2007 22/1/2007 23/1/2007 24/1/2007 21/1/2007 22/1/2007 23/1/2007 24/1/2007 WCC 13.4 19.4 23.1 12.7 WCC 13.4 19.4 23.1 12.7 Hb Hb 14.7 14.7 14.6 14.6 14 14 11.9 11.9 Platelet Platelet 191 191 168 168 179 179 112 112 INR INR 1.6 1.6 1.8 1.8 1 1 APTT APTT 51 51 50 50 23 23 Na Na 140 140 142 142 140 140 138 138 K K 4.9 4.9 5 5 5.2 5.2 6.3 6.3 Cl 106 106 110 108 Cl 106 106 110 108 Urea 10.1 12.5 24.5 31.7 Urea 10.1 12.5 24.5 31.7 Creatinine 170 247 573 883 Creatinine 170 247 573 883 TP 58 56 TP 58 56 Albumin 31 30 26 Albumin 31 30 26 Globulin 27 30 Globulin 27 30 Total bilirubin bilirubin 101 93 11 Total 101 93 11 ALP 110 101 67 ALP 110 101 67 AST 238 327 316 AST 238 327 316

Progress Progress � Rapidly became Rapidly became anuric anuric � � Haemodialysis started Haemodialysis started �

Further investigations Further investigations

� Bilirubin Bilirubin: : unconjugated unconjugated mainly mainly � � LDH 3636 IU/L ( 94 LDH 3636 IU/L ( 94- -250 ) 250 ) � � Haptoglobin Haptoglobin 0.18 mg/L ( 0.36 0.18 mg/L ( 0.36- -1.95 ) 1.95 ) � � Urine test: Urine test: � � haemoglobulin haemoglobulin 4+ 4+ � � RBC 100/uL RBC 100/uL � � myoglobulin myoglobulin not detected not detected � � urobiliogen urobiliogen: unfit for test : unfit for test � � No No haemosiderin haemosiderin pigments pigments � ’ test positive: Anti � Direct Direct coombs coombs ’ test positive: Anti- -IgG IgG and Anti and Anti- -c c � positive positive � Uric acid 0.48 Uric acid 0.48 mmol mmol/L /L � � Schistocytes Schistocytes negative negative �

Further investigations Further investigations � Malaria screening negative Malaria screening negative � � Leptospira Leptospira IgM IgM negative negative � � Hanta virus negative Hanta virus negative � � G6PD activity normal G6PD activity normal � � Anti Anti- -HCV negative HCV negative � � Anti Anti- -HIV negative HIV negative � � ANCA negative ANCA negative � � ANF/Anti ANF/Anti- -GBM GBM Ab Ab negative negative �

� USG abdomen USG abdomen � � Increased renal parenchymal Increased renal parenchymal echopattern echopattern � without focal renal mass without focal renal mass � No renal stones or hydronephrosis No renal stones or hydronephrosis � � No No ascites ascites �

Renal biopsy on Day 7 7 Renal biopsy on Day

Renal biopsy Renal biopsy � Glomeruli Glomeruli � � 13/28 13/28 glomeruli glomeruli are are sclerosed sclerosed � � The vascular The vascular glomeruli glomeruli show normal show normal cellularity cellularity � and only mild increase in mesangial matrix and only mild increase in mesangial matrix � Capillary loops are patent and basement Capillary loops are patent and basement � membrane is normal membrane is normal � No No vasculitis vasculitis or thrombosis is identified or thrombosis is identified � � IF: IF: - -ve ve �

Renal biopsy Renal biopsy � Tubules Tubules � � Interstitial edema with mild Interstitial edema with mild � lymphoplasmacytic cells and focal cells and focal intratubular intratubular lymphoplasmacytic mononuclear cells; eosinophils eosinophils not not mononuclear cells; conspicuous conspicuous � Proximal tubules with prominent cell swelling Proximal tubules with prominent cell swelling � � Many tubules contain fragmented red cells or Many tubules contain fragmented red cells or � granular casts and some contain necrotic granular casts and some contain necrotic cellular debris cellular debris

Iron stain Iron stain

Iron stain Iron stain Fe deposit: Very fine blue dots in some of the tubular epithelial cells (intracytoplasmic)

Summary Summary � Acute Acute haemolytic haemolytic anaemia anaemia with acute with acute � tubular necrosis 1 week after the second tubular necrosis 1 week after the second introduction of anti- -TB treatment TB treatment introduction of anti

Progress Progress � Haemolysis Haemolysis subsided soon after cessation of subsided soon after cessation of � anti- -TB treatment TB treatment anti � Normal Normal Bilirubin Bilirubin on day 2 on day 2 � ’ s � Negative Negative Coomb Coomb ’ s test day 9 test day 9 � � Haptoglobin Haptoglobin level raised to normal on day 9 level raised to normal on day 9 � � Dialysis dependent, require HD 2X per week Dialysis dependent, require HD 2X per week � � Gradual return of urine output with slowly Gradual return of urine output with slowly � improving renal function improving renal function � Last HD session 3 weeks after presentation Last HD session 3 weeks after presentation �

Progress Progress � Restarted on Restarted on isoniazid isoniazid and and pyrazinamide pyrazinamide � since 13/2/2007; later levofloxacin levofloxacin and and since 13/2/2007; later ethambutol ethambutol � Polyuria Polyuria up to 5000ml/day require fluid up to 5000ml/day require fluid � replacement replacement � latest RFT : Urea 9.1mmol/L, Cr latest RFT : Urea 9.1mmol/L, Cr � 128nmol/L 128nmol/L

LDH H aem odialy sis 14/2 25/1 AST 128 Creatinine 20/1 27/1 3/2 10/2 17/2 24/2 3/3

Haemoglobinuria and Acute and Acute Haemoglobinuria renal failure renal failure

Adult haemoglobin haemoglobin Adult � Consists of two alpha and Consists of two alpha and � two beta globulin chain two beta globulin chain � A A haem haem group is bound to group is bound to � each globulin chain each globulin chain � The The haem haem group has a group has a � porphyrin ring with a ring with a porphyrin ferrous atom which can ferrous atom which can reversibly bind one oxygen reversibly bind one oxygen molecule molecule

Normal RBC breakdown Normal RBC breakdown � In the In the reticuloendothelial reticuloendothelial system system � � The The haem haem group will be broken down into group will be broken down into � Iron ( reutilized ) and Bilirubin Bilirubin ( excreted ( excreted Iron ( reutilized ) and via the biliary biliary system ) system ) via the � No free No free haem haem pigments in the circulation pigments in the circulation �

Intravascular Haemolysis Haemolysis Intravascular � Destruction of RBC within the circulation Destruction of RBC within the circulation � liberate the haemoglobulin haemoglobulin liberate the � The free plasma The free plasma Hb Hb initially bound to initially bound to � plasma haptoglobulin haptoglobulin but soon become but soon become plasma saturated saturated � Filtered by the renal Filtered by the renal glomerulus glomerulus and enter and enter � the urine causing haemoglobinuria haemoglobinuria the urine causing