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Kidney Week

Abstract: PO0178

AKI in a Patient with COVID-19, G6PD Deficiency, Acetaminophen Overdose, and Methemoglobinemia: What a Broad Differential!

Session Information

  • AKI Mechanisms - 1
    October 22, 2020 | Location: On-Demand
    Abstract Time: 10:00 AM - 12:00 PM

Category: Trainee Case Report

  • 103 AKI: Mechanisms

Authors

  • Morales-Alvarez, M. Catalina, Mount Sinai Beth Israel Hospital, New York, New York, United States
  • Benhuri, Benjamin, Mount Sinai Beth Israel Hospital, New York, New York, United States
  • Shah, Michelle, Mount Sinai Beth Israel Hospital, New York, New York, United States
  • Kim, Boram, Mount Sinai Beth Israel Hospital, New York, New York, United States
Introduction

Acute kidney injury (AKI) is a common complication in hospitalized and critically-ill patients. Prompt evaluation and subsequent management is warranted to avoid long term kidney dysfunction. However, a clear diagnostic pathway is not always possible. We present a case and the diagnostic analysis of intrinsic AKI in an unusual confluence of comorbidities.

Case Description

39 year-old man with no past medical history referred from another institution with COVID-19 pneumonia, for which he completed 4 days of hydroxychloroquine. On admission, patient was found to have SCr of 2.0 mg/dL, which increased to 10.8 mg/dL during a 3-day period. Urinalysis showed dysmorphic RBCs but no casts. Total albumin/cr ratio in urine was 3.2 mg/g and FeNa >1%. Renal ultrasound showed no obstruction or masses. Other laboratory results showed methemoglobinemia (14 mg/dL), acute liver failure, schistocytes in the peripheral smear and a G6PD assay with marked deficiency. Other serologies were negative. Patient reported prior ingestion of 1 gr acetaminophen (APAP) every 4 hrs for several days; treated with 48 hrs of N-acetylcysteine infusion. The AKI was complicated by hyperkalemia, severe anion gap metabolic acidosis and volume overload requiring long term renal replacement therapy after failure of resuscitation with crystalloid, albumin, and vasopressors.

Discussion

Our patient presented with significant abnormalities in multiple organ systems, including AKI. An analysis of comorbid conditions and typical AKI diagnostics allowed an expansive differential diagnosis (fig 1). One remaining interrogate was the value of a kidney biopsy. Although the etiology of his AKI would remain uncertain and presumably multifactorial, the lack of a clear therapeutic option and both hemodynamic instability and high risk of complications impeded a kidney biopsy. This case exemplifies the challenging but common scenarios and dilemmas that nephrologists face every day. AKI is a well-described entity, yet its diagnosis is complex and dynamic.