Kidney Week

Abstract: PUB213

Crescents and Casts: Acute Tubular Necrosis in Pneumococcal-Associated Glomerulonephritis

Session Information

• Publication Only

Category: Pediatric Nephrology

• 1800 Pediatric Nephrology

Authors

• Lawanto, Stephanie Odelia, Children's Hospital of Philadelphia Department of Nephrology, Philadelphia, Pennsylvania, United States

Stephanie Odelia Lawanto, MD

• Kowalczyk, Sonya R., Children's Hospital of Philadelphia Department of Nephrology, Philadelphia, Pennsylvania, United States

Sonya R. Kowalczyk, MD

• Kurpiel, Brett, Children's Hospital of Philadelphia Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania, United States

Brett Kurpiel, MD

• McAteer, John, Children's Hospital of Philadelphia Department of Nephrology, Philadelphia, Pennsylvania, United States

John McAteer, DO, MPH

• Mazza, Dayna Rachel, Children's Hospital of Philadelphia Department of Nephrology, Philadelphia, Pennsylvania, United States

Dayna Rachel Mazza, MD

Introduction

Infection-related glomerulonephritis is an immune mediated glomerular injury that typically follows bacterial or viral infection. This typically presents with hematuria, proteinuria, elevated blood pressure, and in some cases can evolve into rapidly progressive glomerulonephritis with oliguria and severe acute kidney injury. Acute tubular necrosis (ATN) is often recognized as a secondary finding with glomerulonephritis and likely contributes to the severity of acute kidney injury. We present a case of a pediatric patient with oliguric acute kidney injury with concurrent low C3 with biopsy consistent with crescentic glomerulonephritis and severe ATN.

Case Description

A 4 year old previously healthy female presented with fever, vomiting and diarrhea, found to have elevated serum creatinine 6.39 mg/dL with severe electrolyte derangements notably hyponatremia, hyperkalemia and metabolic acidosis. Blood pressures were appropriate for age. Urinalysis with glucosuria, proteinuria and microscopic hematuria. C3 level was low at 28 mg/dL, normal C4. Blood culture was positive for streptococcus pneumoniae. Autoimmune workup included ANA 1:320, ANCA positive, but negative MPO and PR3. Renal biopsy was pursued given severity of renal dysfunction and showed exudative crescentic glomerulonephritis with co-dominant C3/IgG immune complex deposition and acute tubular injury. Due to oliguria and hyperkalemia, she was started on continuous renal replacement therapy and was transitioned to intermitted hemodialysis. She was dialysis dependent for about 1 week with eventual renal recovery. At 3 months post initial injury, repeat renal function is normal and C3 has normalized.

Discussion

Streptococcus pneumoniae is a less common, but recognized cause of infection-related glomerulonephritis. Compared with classic post-streptococcal glomerulonephritis caused by group A streptococcus, pneumococcal associated cases are often associated with active systemic infection, bacteremia, and severe acute kidney injury. Crescentic histologic findings on biopsy may also amplify renal dysfunction through both glomerular and tubular injuries. Transient ANA and ANCA positivity have also been reported, felt to reflect non-specific immune activation related to infection. While infection-related glomerulonephritis is classically noted to have favorable prognosis in children, concurrent ATN may intensify renal dysfunction and prolong recovery.