Abstract
Viral nephropathy is a term defines glomerular, tubular and/or vascular injury in kidney caused by viruses itself or virus-induced immune mechanisms. It is difficult to prove causality between the renal disease and the viral infection, however, renal biopsy findings can help in this regard. Several viruses such as hepatitis B and C, Human immun deficiciency virus (HIV), Hantavirus, Cytomegalovirus (CMV), an recently Coronavirus are shown to affect the kidney. Treatment of viral nephropathies are unique regarding the diagnosis which can be made only with renal biopsy in most of the situations. We present two patients presented with acute kidney injury and thrombocytopenia caused by different viruses (Hantavirus and HIV) that affect multiple areas in kidney that revealed with kidney biopsy. Supportive treatment in the patient with Hantavirus nephropathy and HIV treatment along with eculizumab and supportive treatment in the patient with HIVAN were successfully implemented.
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Case presentations
We report two patients who presented with acute kidney injury (AKI) and thrombocytopenia caused by different viruses, revealed through kidney biopsies, that affect multiple compartments in the kidney.
Case 1
A 34-year-old male without any comorbidities presented with fever (39 °C), fatigue and myalgias that had been going on for a week. He reported possible contact with mice in his office. Physical examination was unremarkable. On first admission, blood chemistry revealed mild hepatic enzyme elevation and normal creatinine level [alkaline phosphatase (ALP), 210 U/L; gamma-glutamyl transpeptidase (GGT), 200 U/L; alanine aminotransferase (ALT), 30 U/L; aspartate aminotransferase (AST), 69 U/L; lactate dehydrogenase (LDH), 354 U/L; direct bilirubin, 0.18 mg/dL; indirect bilirubin, 0.53 mg/dL; creatinine 0.97 mg/dL]. His blood count showed thrombocytopenia (30 × 109/L) without any schistocytes on the peripheral blood smear. His creatinine level increased to 2.29 mg/dL in 4 days along with nephrotic range proteinuria (spot urine protein/creatinine, 5,000 mg/g) and hypoalbuminemia (serum albumin, 2.9 g/dL). Viral serologies were sent for hepatitis A, B, and C, HIV, CMV, and Leptospirosis, all coming back negative. ADAMTS 13 activity was 90%, so thrombotic thrombocytopenic purpura (TTP) was excluded. While awaiting the results, his creatinine level continued to go up (3.02 mg/dL) and his thrombocyte level began to increase as well (120 × 109/L). We performed a renal biopsy in order not to miss a diagnosis of cresentic glomerulonephritis (Fig. 1). Serological tests for Hantavirus came back positive. We followed the patient under conservative treatment. Ten days after the first symptoms, his serum creatinine level returned to the normal range (0.94 mg/dL) and proteinuria resolved to normal.
Case 2
A 69-year-old male presented with watery diarrhea, fatigue, abdominal pain, and fever. He had no other disease history except for a kidney stone 24 years earlier. Checking the remote laboratory results, his hemoglobin level was found to have been 15 g/dL and his creatinine level was 1.02 mg/dL one year ago. It was revealed that 3 days earlier in another center his serum creatinine level was 1.91 mg/dL, thrombocytes 72 × 109/L, hemoglobin 12.1 g/dL, and LDH 527 U/L However, no peripheral blood smear had been performed. In our center’s follow-up, the creatinine level was found to be 3.03 mg/dL, and it increased rapidly to 5.74 mg/dL within 4 days. Physical examination was unremarkable. Because of an acute kidney injury and prior thrombocytopenia, several laboratory tests were carried out: ADAMTS 13 activity was 52%, haptoglobin 2.26 g/L (0.36–1.95), LDH 627 U/L, direct Coombs test was negative, hemoglobin 14.5 g/dL, no schistocytes in the peripheral blood smear, serological markers for hepatitis B and C were negative, CMV was negative. HIV serology was found to be positive. HIV RNA PCR measured 5,277,174 IU/mL. Initial urine analysis showed only proteinuria. Renal ultrasonography revealed two enlarged kidneys with simple cysts. Because of ongoing renal deterioration, a renal biopsy was performed on the tenth day which revealed HIV-associated collapsing glomerulopathy (HIVAN), diffuse infiltrative lymphocytosis syndrome (DILS), and thrombotic microangiopathy (TMA) (Fig. 2). Prednisolone and eculizumab were initiated in addition to HIV treatment (lamivudine and dolutegravir). After 1 week, his serum creatinine and LDH levels decreased to 2.62 mg/dL and 198 U/L, respectively. After 2 months, serum creatinine level was 1.20 mg/dL. Genetic analysis for atypical HUS was carried out and revealed no mutations. Six months later, after HIV RNA became negative, eculizumab and steroids were stopped.
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Eren Sadioglu, R., Eyupoglu, S., Kiremitci, S. et al. Two patients, two viruses and multiple sites of injury in the kidney. J Nephrol 34, 263–265 (2021). https://doi.org/10.1007/s40620-020-00838-6
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DOI: https://doi.org/10.1007/s40620-020-00838-6