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Kidney Week

Abstract: PO0276

Leishmania infantum-Induced Acute on Chronic Interstitial Nephritis

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • Vasquez-Rios, George, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, New York, United States
  • Sanchez Russo, Luis F., Icahn School of Medicine at Mount Sinai Department of Medicine, New York, New York, United States
  • Dellepiane, Sergio, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, New York, United States
  • Salem, Fadi E., Icahn School of Medicine at Mount Sinai, New York, New York, United States
  • Chan, Lili, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, New York, United States
  • Kim, Tonia K., Icahn School of Medicine at Mount Sinai Department of Medicine, New York, New York, United States
Introduction

Leishmania is an exceedingly rare yet important cause of acute and chronic interstitial nephritis (CIN) that can lead to severe renal dysfunction, necessitating dialysis if unaddressed.

Case Description

A 53-year-old man presented with a progressive rash, cyclic fevers, 20 kg weight loss over 1 year, and prominent hepato-splenomegaly. He resided in Russia and had traveled to South Asia and Africa multiple times. Due to compressive symptoms and pancytopenia, the patient underwent splenectomy and lymph node biopsy which yielded Leishmania infantum (Figure 1A). In our institution, he was oliguric and hypertensive. Labs showed Na 129, K 5.3, HCO3 8.8, BUN 144, Cr 12.6 mg/dL (baseline Cr 0.8 last year), and elevated LFTs. UA showed ATN casts. 24-hour urine protein was 1.8 grams. SPEP/UPEP and K/L ratio were normal. Due to concerns for AIN, CIN, infectious GN vs. amyloidosis, a kidney biopsy was pursued after HD initiation. Biopsy revealed chronic active tubulointerstitial nephritis associated with marked interstitial plasma cell infiltrates and moderate fibrosis without evidence of glomerular disease (Figure 1B). Amphotericin B was started. Steroids were not initiated given moderate fibrosis and risk for blunting response against Leishmania. His rash and LFTs improved rapidly yet, he required HD 3 times a week at discharge. 9 weeks after amphotericin initiation, his HD requirement is now reduced to twice weekly and pre-HD creatinine levels continue to decrease.

Discussion

Leishmaniasis is a rare cause of kidney injury in the US. CIN is the most common underlying pathology in these patients. A high index of suspicion in the appropriate clinical context is necessary to institute timely interventions to prevent long-term sequelae. Patients with visceral leishmania and kidney dysfunction should be evaluated for interstitial nephritis as a potential cause when alternative etiologies have been ruled out.

Figure 1:
A. Lymph node with Leishmania amastigotes seen as a cytoplasmic organisms in macrophages (arrow) B. Kidney biopsy shows diffuse active interstitial inflammation with a background of interstitial fibrosis and frequent tubular injury (H&E).