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Kidney Week

Abstract: SA-PO038

Started With the Kidneys, Followed by the Lungs: A Rare Case of Sarcoidosis

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical‚ Outcomes‚ and Trials

Authors

  • Song, Rui, Abington Memorial Hospital, Abington, Pennsylvania, United States
  • Walters, Laura, Abington Memorial Hospital, Abington, Pennsylvania, United States
  • Memon, Rahat Ahmed, Abington Memorial Hospital, Abington, Pennsylvania, United States
  • Arif, Ali, Abington Memorial Hospital, Abington, Pennsylvania, United States
  • Shu, Winston, Abington Memorial Hospital, Abington, Pennsylvania, United States
Introduction

Sarcoidosis is a multisystem disorder. Only 8% of patients present with disease at extra-pulmonary sites without lung involvement. Granulomatous interstitial nephritis (GIN) is the classic kidney lesion found in sarcoidosis. However, clinically significant renal sarcoidosis is exceedingly rare. We present a case with acute renal failure (ARF) requiring temporary dialysis due to GIN without lung involvement on presentation.

Case Description

A 39-year-old female with a history of hypertension presented to the emergency room with nausea and vomiting. Labs showed a serum creatinine (Cr) 13.29 mg/dL (1.1mg/dL 3 months prior), blood urea nitrogen 106 mg/dL, bicarbonate 13 mg/dL. Arterial blood gas showed a pH of 7.23 with PaCO2 of 33 mmHg. Urinalysis showed 1+ protein and 2 red blood cells. Dialysis was started for acidosis and uremia. Renal ultrasound showed no obstruction or chronic changes. IV methylprednisolone was started and she underwent kidney biopsy for ARF. Pathology showed GIN. The angiotensin-converting enzyme was 156 nmol/mL/min, and calcium was normal. CT scan of the chest showed no adenopathy or pulmonary disease. She was weaned off dialysis with adequate urine output and a Cr of 2mg/dL. She was discharged on 60 mg prednisone daily for 2 weeks followed by a 3-month taper. After stopping steroids, she developed nausea and vomiting again and presented to the ER with a Cr >10mg/dL. Repeat CT scan of the chest now showed bilateral hilar adenopathy. Bronchoscopy was performed and lymph node biopsy showed non-caseating granulomas confirming sarcoidosis. She subsequently improved clinically with standard steroid treatment.

Discussion

The most common renal feature of sarcoidosis is nephrocalcinosis caused by dysregulated calcium homeostasis, followed by GIN. About 4-10% of renal sarcoidosis may progress to end-stage renal disease. Corticosteroids are the mainstay treatment. In this case, the patient was first found to have GIN with normocalcemia and was treated timely with steroids. Lung involvement was absent until steroids were tapered off 3 months later highlighting the importance of closely monitoring lung features if renal sarcoidosis is detected. Given the lack of treatment guidelines, a longer course of steroids for clinically significant renal sarcoidosis may be needed to prevent full-blown lung sarcoidosis.