| Abstract|| |
The syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP) is not uncommon in patients with pre-eclampsia and eclampsia. Acute renal failure is not common in patients with HELLP syndrome. We present here a young patient who developed HELLP syndrome on the first post-partum day complicated with acute renal failure which necessitated dialysis. The patient made complete recovery.
Keywords: Post-partum, Eclampsia, HELLP syndrome, Acute renal failure.
|How to cite this article:|
Abbade MA, Mohamed AO, Bernieh BO. Acute Renal Failure in a Patient with the HELLP Syndrome Developing in the Post-Partum Period. Saudi J Kidney Dis Transpl 1997;8:433-5
|How to cite this URL:|
Abbade MA, Mohamed AO, Bernieh BO. Acute Renal Failure in a Patient with the HELLP Syndrome Developing in the Post-Partum Period. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2020 Jun 7];8:433-5. Available from: http://www.sjkdt.org/text.asp?1997/8/4/433/39344
| Introduction|| |
The syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP) has, for many years, been recognized as a complication of pre-eclampsia-eclampsia. Weinstein  was the first to use the acronym HELLP when he described 29 patients and argued that this is a distinct syndrome. The incidence of HELLP among patients with eclampsia ranges from 4% to 14% and is generally associated with poor maternal and perinatal outcome  . In the largest series reported by Sibai and Ramadan  , the maternal mortality was 13% and perinatal mortality was 34%; also 72% of the births were pre-term.
Acute renal failure (ARF) is a rare complication of pre-eclampsia-eclampsia occurring in only 1% to 2% of the patients  . However, the incidence of ARF when pregnancies are complicated by the HELLP syndrome, rises to about 7.4%  . We herewith present a young patient who developed HELLP syndrome in the early postpartum period complicating pre-eclampsia-eclampsia. The patient had a favorable outcome although she developed ARF necessitating treatment with dialysis together with other supportive measures.
| Case Description|| |
A 25 years old Saudi housewife who is para three and gravida three, was being followed regularly during her last pregnancy in a private hospital. The antenatal period was uneventful followed by normal vaginal delivery of a 2.65 kg baby girl. On the day of delivery she developed pre-eclampsia with very high blood pressure (220/140), edema of the lower limbs and proteinuria (+ -f +) by dipstick. The blood pressure responded well to nifedipine and atenolol. However on the second day, she developed seizures which was treated with diazepam and carbamaze-pine. Her urine output dropped sharply following this and the serum potassium went up to 7.5 mmol/L. The liver enzymes were also noted to be very high. The patient was then transferred to our hospital (King Fahad Hospital, Madina) with a diagnosis of ARF and hepatic impairment. The patient had no past history of any disease and her family history was negative for hypertension, diabetes mellitus or renal disease.
On examination she looked ill, was fully conscious and jaundiced without pallor or cyanosis There was pitting edema of the lower limbs. Her blood pressure was 130/80 and pulse 80/min. Respiratory rate was 18/ min and temperature was 37 degree C. Clinically, the cardiovascular, respiratory and central nervous systems were normal. The uterus was felt just below the umbilicus; no other organs were felt. Ocular fundoscopy was normal.
Serial investigations of the hematological, biochemical and bleeding profiles are shown in [Table - 1],[Table - 2].
Blood film showed normocytic, normochromic picture with mild anisocytosis. A repeat film two days later showed marked anisocytosis and poikilocytosis; cells were markedly hypochromic and dimorphic (micro and macrocytosis) and there were few teardrop cells and schizocytes. Urine analysis on two occasions showed high urobilinogen, no bilirubin, albuminuria, leukocyturia and few red blood cells. Twenty-four hours urine analysis showed a volume of 550 ml, protein 0.05 g/dl, urea 6.7 mmol/L, creatinine 1.2 mmol/L, sodium 25 mmol/L and potassium 8.3 mmol/L.
Fibrinogen degradation products were present in the urine and the reported level was < 20 ng/ml.
The serum fibrinogen level was 310 mg% on admission and the level came down to 45 mg% by the fifth post admission day. Serology screening for Hbs Ag, HBsAb, HCV and HIV were negative.
Abdominal ultrasonography showed normal liver, gall bladder and spleen. Both kidneys showed increased echogenicity with prominent pyramids and a small subcapsular collection. Right kidney measured 10.6 cm and the left 11.0 cm. There was mild ascites. X-ray of the chest and ECG were within normal limits.
| Hospital Course|| |
The patient was initially treated with conservative measures. Lactulose was given to achieve two loose bowel motions per day. The blood pressure continued to be under control with atenolol and nifedipine. However, the renal functions deteriorated and the patient was dialyzed four times. The hemoglobin initially dropped but started to improve with the above treatment and the patient made progressive recovery and was discharged home on the tenth day at her request.
During the out-patient follow-up, the renal functions gradually improved to reach normal about a month after admission. The platelet count was at its lowest on the 3rd day after delivery (21 x 109 /L) and improved spontaneously to normal reaching 160 x 109/L on the 7th day of her stay in hospital and remained normal thereafter.
| Discussion|| |
This patient satisfied all the criteria of HELLP syndrome. She had hemolytic anemia as evidenced by dropping hemoglobin, high reticulocyte count, high urobilinogen in urine without bilirubin and the high LDH, elevated liver enzymes and serum bilirubin, and low platelets. She also had associated ARF which behaved like acute tubular necrosis with oliguria and return of renal function to normal (biopsy was not performed). Renal failure is not a part of HELLP syndrome but is a well recognized complication. Sibai and Ramadan  reported the highest incidence of 7.4% of ARF complicating HELLP syndrome but this observation has not been reported by other authors. Weinstein , reported one patient with renal cortical necrosis among 300 patients with the HELLP syndrome. Our patient did not require blood, platelets or blood products transfusion in contrast to those reported by Sibai and Ramadan  . In that series 31 out of 32 patients needed blood transfusion and 18 needed platelets transfusion. This probably suggests that early supportive therapy, which was started in our patient in less than 48 hours, is a corner stone in management especially in post-partum patients. The bleeding profile and fibrinogen levels remained normal in our patient. The fibrinogen degradation products were positive but at low levels of less than 20 ng/ml. This excluded disseminated intravascular coagulation (DIC) as a cause of ARF which is in contrast to the 84% incidence of DIC in patients with HELLP syndrome and ARF reported by others  . The favorable course of our patient indicates that ARF in patients with HELLP syndrome is not particularly indicative of a poor prognosis provided that the problems are recognized and dealt with very early. We are reporting this patient to draw the attention of the obstetricians and nephrologists to look for the association of ARF and HELLP syndrome in preeclarnptic-eclamptic patients even in the post-partum period.
| References|| |
|1.||Weinstein L. Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. Am J Obstet Gynecol 1982;142:159-67. [PUBMED] |
|2.||Sibai BM, Taslimi MM, El Nazer A, Amon E, Mabie BC, Ryan GM. Maternal perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes and iow platelets in severe preeclampsia-eclampsia. Am J Obstet Gynecol 1986;155:50l-9. |
|3.||Sibai BM. Ramadan MK. Acute renal failure in pregnancies complicatd by hemolysis, elevated liver enzymes, and low platelets. Am J Obstet Gynecol 1993;168:1687-90. |
|4.||Sibai BM, Villar MA, Mabie BC. Acute renal failure in hypertensive disorders of pregnancy. Pregnancy outcome and remote prognosis in thirty-one consecutive cases. Am J Obstet Gynecol 1990;162:777-83. |
|5.||Weinstein L. Pre-eclampsia/eclampsia with hemolysis, elevated liver enzymes and thrombocytopenia. Obstet Gynecol 1985;66:657-60. [PUBMED] |
Mohammed A Abbade
Nephrology Unit, King Fahad Hospital, Madinah Al Munawarah
[Table - 1], [Table - 2]