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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2017  |  Volume : 28  |  Issue : 6  |  Page : 1453-1454
An unusual cause of anuria in a young patient with hypertension


1 Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India
2 Department of Pathology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India

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Date of Web Publication18-Dec-2017
 

How to cite this article:
Yadla M, Khandalvelli P, Uppin M. An unusual cause of anuria in a young patient with hypertension. Saudi J Kidney Dis Transpl 2017;28:1453-4

How to cite this URL:
Yadla M, Khandalvelli P, Uppin M. An unusual cause of anuria in a young patient with hypertension. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2019 Dec 8];28:1453-4. Available from: http://www.sjkdt.org/text.asp?2017/28/6/1453/220857


To the Editor,

A 30-year-old female with a three-month history of hypertension presented with vomiting, breathlessness, and anuria of threeday duration. She did not report any history of fever, diarrhea, pedal edema, ingestion of herbal medicine, or other over the counter nephrotoxic drugs. On examination, her pulses were absent in the limbs, and blood pressure (BP) discrepancy was noted. The BP was 190/110 mm Hg in right upper limb, 190/100 mm Hg in left upper limb, 200/100 in right lower limb, and 220/110 in left lower limb. Fundus examination showed bilateral papilledema; cotton wool spots suggestive of hypertensive retinopathy. Her hemoglobin was 10 g/dL (normal: 12–16 g/dL), total leukocyte count was 10,800/mm3, and platelets were 150,000/mm3 (normal: 150,000–450,000/mm3). Blood urea was 126 mg/dL (normal: 2.5–7.1 mmol/L) and serum creatinine was 7.5 mg/dL (normal: 0.6–0.9 mg/dL). Serum sodium was 137 meq/L (normal: 135–145 meq/L) and serum potassium was 4.5 meq/L (Normal: 3.5–5 meq/L). Complete urine analysis was unre-markable. Ultrasound abdomen showed renal asymmetry with right kidney of 9.4 cm and left kidney of 11 cm in size. A computed tomography angiogram revealed narrowing of the aorta below the origin of inferior mesenteric artery till the bifurcation, and the renal arteries could not be visualized. Collateral vessels were present near the left kidney. These features are highly suggestive of Takayasu’s arteritis – type 4 [Figure 1].
Figure 1: Reconstructive computed tomography angiogram showing gross narrowing of the aorta from the level below the origin of inferior mesenteric artery till the bifurcation. Bilateral renal arteries could not be visualized. Collateral vessels can be identified on left side.

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The presence of hypertension and pulselessness disease is thought to be secondary to Takayasu’s arteritis, but the presence of anuria could not be explained with the above radiology findings. The renal biopsy was performed to evaluate the renal impairment and showed unremarkable glomeruli with loss of medullary architecture along with areas of necrosis suggestive of medullary infarct [Figure 2] and [Figure 3]. Evaluation for the possible co-existence of small vessel vasculitis was done. Serologies for antinuclear antibodies, anti-double-stranded DNA, anti-neutrophil cytoplasmic antibodies, and antiphospholipid antibodies were negative. The clinical impression was this patient had Takayasu’s arteritis type 4 with acute kidney injury due to renal medullary infarct.
Figure 2: Histopathology of renal biopsy showing diffuse necrosis of medulla on H and E (low power).

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Figure 3: Higher magnification of renal biopsy showing diffuse medullary necrosis.

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Renal infarct or renal papillary necrosis (RPN) is rare in Takayasu’s arteritis. Literature search showed a review by stating that intrarenal vasculitis with hemorrhage can occur in large vessel vasculitis.

RPN is a consequence of ischemia to renal medulla and RPN in Wegener’s granulomatosis and other small vessel vasculitis have been reported. However, a clinical presentation of occurrence of RPN in Takayasu’s arthritis has not been previously reported.

In our patient, the screening for small vessel vasculitis is normal. Hence, a coexistence of small vessel vasculitis along with Takayasu is unlikely. The possible mechanism of RPN may be intrarenal vasculitis though this could not be made out on renal biopsy.

During the hospital stay, she continued to be anuric and dialysis dependent. Steroids were considered along with anticoagulation. As she was in sepsis with high levels of procalcitonin, steroids could not be continued. At the last follow-up for dialysis, she was anuric. Points of interest in this patient are two-fold:

  1. Takayasu’s arteritis is a rare cause of secondary hypertension in young and can lead to renal failure
  2. RPN can be one of the clinical presenting manifestations of Takayasu’s arteritis.


Conflict of interest: None declared.



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Correspondence Address:
Manjusha Yadla
Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana
India
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DOI: 10.4103/1319-2442.220857

PMID: 29265069

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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