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| Year : 2013 | Volume
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| Issue : 1 | Page : 141-143 |
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| APLA in post-partum renal cortical necrosis another skeleton in the closet |
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Dilip Gude1, Sashidhar Chennamsetty2, Ratan Jha2, Srinivas Rao Bopparaju2
1 Department of Internal Medicine, Princess Durrushehvar Children's and General Hospital, Purana Haveli, Hyderabad-2, India
2 Department of Nephrology, Medwin Hospital, Chirag Ali Lane, Nampally, Hyderabad, India
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| Date of Web Publication | 22-Jan-2013 |
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How to cite this article:
Gude D, Chennamsetty S, Jha R, Bopparaju SR. APLA in post-partum renal cortical necrosis another skeleton in the closet. Saudi J Kidney Dis Transpl 2013;24:141-3 |
How to cite this URL:
Gude D, Chennamsetty S, Jha R, Bopparaju SR. APLA in post-partum renal cortical necrosis another skeleton in the closet. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2021 Mar 8];24:141-3. Available from: https://www.sjkdt.org/text.asp?2013/24/1/141/106313 |
To the Editor,
Having read with great interest the article titled "Pregnancy-related acute renal failure: A single-center experience" by Goplani et al, [1] we wanted to share our experience on the same. A 25-year-old female (G3P3L3A0) who underwent cesarean section for pre-eclampsia presented with anuria 12 hours in to the post-operative period that was refractory to fluid and diuretic challenge. She developed progressively worsening pedal edema and dyspnea. Laboratory values revealed Hb 7.5 gm%, total WBC 30,000; platelets 70,000; LFT showed total bilirubin 3.0 (direct 1.8), SGPT 185 IU/L, alkaline phosphatase 755 IU/L, blood urea 83 mg/dL, serum creatinine 4.8, uric acid 9.6 mg/ dL and LDH 1079 U/L. Serology was reported as ANA-negative and anti-phospholipid antibody (APLA): IgG negative (15 GPL units) and IgM positive (35 GPL units). Ultrasonography showed circumferential hypo-echoic cortical zone (arrows) adjacent to the renal capsule [Figure 1]. Contrast-enhanced computed tomography (CECT) delineated the circumferential peripheral zone of hypodensity, showing lack of enhancement of renal cortex (arrow) with normal renal medullary enhancement, suggesting bilateral diffuse renal cortical necrosis [Figure 2]. Renal biopsy showed diffuse loss of cellular architecture of glomeruli (ghost-like glomeruli) confirming renal cortical necrosis [Figure 3]. Hemodialysis was initiated but the general condition did not improve and she remained dialysis dependant even after four weeks. | Figure 1: Ultrasonography showing circumferential hypo-echoic cortical zone (arrows) adjacent to the renal capsule.
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 | Figure 2: Contrast-enhanced CT delineating the circumferential peripheral zone of hypodensity showing lack of enhancement of renal cortex (arrow) with normal renal medullary enhancement.
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 | Figure 3: 400× PAS stain showing diffuse loss of cellular architecture (ghost-like appearance) of glomerulus (thin arrow) and tubules (thick arrow).
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Regardless of the etiology, renal cortical necrosis (RCN) results from the ischemic necrosis of the renal cortex probably caused by significantly diminished renal arterial perfusion secondary to vascular spasm, microvascular injury, or intravascular coagulation. Renal biopsies have demonstrated thrombotic microangiopathy with fibrin-platelet thrombus material within the glomerular capillary lumina in such cases. [2]
Obstetric complications account for 50-70% of the causes of RCN. [1] There is a 10-30% incidence of RCN in obstetric acute kidney injury (AKI). Older age and multiparity compound the risk. Septic abortion, placental abruption, pre- and post-partum hemorrhage, amniotic fluid embolism, intra-uterine fetal demise, pre-eclampsia, eclampsia and HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelets) syndrome are some of the important causes of obstetric RCN. A conglomeration of causes like a hypercoagulable state, endothelial injury and intravascular thrombosis with/without disseminated intravascular coagulation may lead to renal ischemia.
The correlation between APLA and renal cortical necrosis has been well established with risk compounding in pregnancy. In primary anti-phospholipid syndrome, APLA has been directly incriminated in causing fibrous intimal hyperplasia, thrombotic microangiopathy, focal cortical atrophy and tubular thyroidization in the kidney. [3] Any underlying vasculitis (secondary APLA) would sport degenerative and proliferative abnormalities of the vascular walls, of the vascular walls, perivascular infiltrates (accelerated atherosclerosis), microinfarcts and micro hemorrhages, all of which further augment the thrombotic and vaso-occlusive state in the RCN.
Sonography, apart from excluding obstructive uropathy, may delineate the hypo-echoic cortical zone of tissue adjacent to the renal capsule, as in our case. Magnetic resonance imaging (MRI), especially blood oxygen level-dependant functional MRI (BOLD f MRI) [4] and CECT help in delineating the severity of cortical involvement. The obstetric setting per se, severe uremia, septicemia, pulmonary edema, gastrointestinal hemorrhage and hyper-kalemia increase the mortality in RCN, with the untreated mortality of over 90%. [5]
RCN, although rare, is a devastating entity with significant mortality, and red flags like anuria in pregnancy warrant paramount clinical suspicion index.
 Acknowledgment | |  |
The authors would like to thank their colleagues and the staff of the Nephrology Department.
| References | | |
| 1. | Goplani KR, Shah PR, Gera DN, et al. Pregnancy-related acute renal failure: A single-center experience. Indian J Nephrol 2008;18:17-21. 
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| 2. | Zaldivar J, Goetsch S, Gonzalez-Pelaez ME. Renal cortical necrosis and HELLP syndrome: A case presentation. Sajog 2008;14:62-4.
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| 3. | Nochy D, Daugas E, Droz D, et al. The intrarenal vascular lesions associated with primary antiphospholipid syndrome. J Am Soc Nephrol 1999;10:507-18.
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| 4. | Warner L, Glockner JF, Woollard J, Textor SC, Romero JC, Lerman LO. Determinations of renal cortical and medullary oxygenation using blood oxygen level-dependent magnetic resonance imaging and selective diuretics. Invest Radiol 2011;46:41-7.
[PUBMED] |
| 5. | Prakash J, Tripathi K, Pandey LK, Gadela SR, Usha. Renal cortical necrosis in pregnancy-related acute renal failure. J Indian Med Assoc 1996;94:227.
[PUBMED] |
Correspondence Address:
Dilip Gude
Department of Internal Medicine, Princess Durrushehvar Children's and General Hospital, Purana Haveli, Hyderabad-2
India
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DOI: 10.4103/1319-2442.106313 PMID: 23354213 
[Figure 1], [Figure 2], [Figure 3] |
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