Severe acute kidney injury due to oxalate crystal induced severe interstitial nephritis: A case report.

BACKGROUND: Acute kidney injury (AKI) due to interstitial nephritis is a known condition primarily attributed to various medications. While medication-induced interstitial nephritis is common, occurrences due to non-pharmacological factors are rare. This report presents a case of severe AKI triggered by intratubular oxalate crystal deposition, leading to interstitial nephritis. The aim is to outline the case and its management, emphasizing the significance of recognizing uncommon causes of interstitial nephritis. CASE SUMMARY: A 71-year-old female presented with stroke-like symptoms, including weakness, speech difficulties, and cognitive impairment. Chronic hypertension had been managed with hydrochlorothiazide (HCTZ) for over two decades. Upon admission, severe hypokalemia and AKI were noted, prompting discontinuation of HCTZ and initiation of prednisolone for acute interstitial nephritis. Further investigations, including kidney biopsy, confirmed severe acute interstitial nephritis with oxalate crystal deposits as the underlying cause. Despite treatment, initial renal function showed minimal improvement. However, with prednisolone therapy and supportive measures, her condition gradually improved, highlighting the importance of comprehensive management. CONCLUSION: This case underscores the importance of a thorough diagnostic approach in identifying and addressing uncommon causes of interstitial nephritis. The occurrence of interstitial nephritis due to oxalate crystal deposition, especially without typical risk factors, emphasizes the need for vigilance in clinical practice.

Daptomycin-induced hyperkalemia: A case report and brief description of mechanism.

Key Clinical Message: Daptomycin causes serious side effects like rhabdomyolysis at high doses. At lower doses it can cause isolated hyperkalemia without frank rhabdomyolysis. Checking BMP along with CK helps taking timely measures to prevent adverse consequences. Abstract: Hyperkalemia is a common yet challenging clinical condition faced daily by physicians worldwide. Accurate etiology and timely management are paramount in correcting this preventable yet life-threatening electrolyte imbalance. Very seldom has Daptomycin been implicated as a culprit for hyperkalemia. We present one such unique case where a low dose of Daptomycin led to hyperkalemia, and timely identification improved patient outcomes. We present a 69-year-old woman with multiple comorbidities admitted to the intensive care unit to manage diabetic ketoacidosis and sepsis. She developed acute kidney injury due to intravenous contrast, volume depletion, and obstructive uropathy. Interestingly although initially normokalemic, as her renal function started improving with sound urine output, she developed recurrent hyperkalemia, which required medical management. The etiology of hyperkalemia was initially unclear, but on closer review, it was discovered that Daptomycin was the potential culprit. Although case studies with high-dose Daptomycin causing rhabdomyolysis and hyperkalemia have been reported, low-dose Daptomycin causing hyperkalemia without rhabdomyolysis has never been reported, bringing forth the uniqueness of our article.

A Case of Ischemic Monomelic Neuropathy After Arteriovenous Fistula Placement.

Ischemic monomelic neuropathy (IMN) is a relatively uncommon and under-recognized complication of vascular access creation for arteriovenous (AV) fistula in hemodialysis patients. They usually develop distal muscle weakness, sensation loss, and severe acute pain without muscle necrosis soon after AV fistula creation. Physicians should be aware of this condition as prompt diagnosis and timely vascular interventions are necessary to save the limbs and prevent permanent functional disability. Once the diagnosis of IMN is made, the patients will need emergent ligation of the fistula to restore the distal perfusion. We report a case of a 59-year-old male patient with End-stage Renal Disease on hemodialysis who developed severe pain, weakness, and loss of sensation in the left arm a few hours after left brachiocephalic vascular access creation. He was subsequently diagnosed with ischemic monomelic neuropathy and underwent emergent AV fistula ligation. Symptoms were relieved immediately after the ligation.

Beyond Human Limits: Harnessing Artificial Intelligence to Optimize Immunosuppression in Kidney Transplantation.

The field of kidney transplantation is being revolutionized by the integration of artificial intelligence (AI) and machine learning (ML) techniques. AI equips machines with human-like cognitive abilities, while ML enables computers to learn from data. Challenges in transplantation, such as organ allocation and prediction of allograft function or rejection, can be addressed through AI-powered algorithms. These algorithms can optimize immunosuppression protocols and improve patient care. This comprehensive literature review provides an overview of all the recent studies on the utilization of AI and ML techniques in the optimization of immunosuppression in kidney transplantation. By developing personalized and data-driven immunosuppression protocols, clinicians can make informed decisions and enhance patient care. However, there are limitations, such as data quality, small sample sizes, validation, computational complexity, and interpretability of ML models. Future research should validate and refine AI models for different populations and treatment durations. AI and ML have the potential to revolutionize kidney transplantation by optimizing immunosuppression and improving outcomes. AI-powered algorithms enable personalized and data-driven immunosuppression protocols, enhancing patient care and decision-making. Limitations include data quality, small sample sizes, validation, computational complexity, and interpretability of ML models. Further research is needed to validate and enhance AI models for different populations and longer-term dosing decisions.

Seronegative Atypical Anti-Glomerular Basement Membrane Glomerulonephritis Associated With Thrombotic Microangiopathy: Case Report and Literature Analysis.

Anti-glomerular basement membrane (GBM) antibody nephritis is defined by linear immunofluorescence staining of GBM by immunoglobulin G (IgG), typically associated with GBM rupture, fibrinoid necrosis, and crescent formation. Clinically, the patients present with rapidly worsening renal function, often with hematuria. Typical renal pathologic findings include necrotizing and crescentic glomerulonephritis. In contrast, thrombotic microangiopathy (TMA) is characterized by microvascular thrombosis, which can also lead to acute kidney injury. Thrombotic microangiopathy is associated with some systemic diseases and has characteristic clinical features of microangiopathic hemolytic anemia, platelet consumption, and multiple organ failure. Anti-GBM nephritis associated with TMA has rarely been reported. We describe an unusual case of atypical anti-GBM disease without crescent formation or necrosis but with light microscopic and ultrastructural features consistent with endothelial cell injury and glomerular-limited TMA.

An Uncommon Presentation of Vasopressin-Induced Purpura Fulminans.

Purpura fulminans (PF) is a rarely encountered rapidly evolving dermatological manifestation of ischemia, particularly in critically ill patients. Considered one of the very few dermatological emergencies, it has high mortality rate where patients often succumb to the illness. It can manifest in three forms: neonatal, idiopathic, and the more commonly infectious variety, which can be secondary to mostly bacterial and rarely viral etiology. It is also reported to be highly associated with disseminated intravascular coagulation (DIC), heparin-induced thrombocytopenia (HIT), and acute hepatic failure (AHF). Hereditary or acquired deficiency of protein C and dysregulation of the coagulation cascade, mainly protein C-thrombomodulin, has been implicated in the pathogenesis. We present a 55-year-old male admitted to the intensive care unit for diabetic ketoacidosis (DKA) and septic shock. Along with initiating management protocol for DKA and broad-spectrum antibiotics, he was initially started on norepinephrine for septic shock. Because of persistent refractory septic shock, he was subsequently initiated on phenylephrine and vasopressin to maintain adequate perfusion. The following day, he was found to have sharply demarcated blackish non-blanching discoloration on bilateral knees, lower limbs, and scrotum, sparing the acral regions. This cutaneous manifestation persisted throughout his hospital course, although it improved after discontinuation of vasopressin while continuing with other pressors. Vasopressin has been implicated in a few instances of skin necrosis; however, PF has rarely been documented and never within 1 day like ours. This case demonstrates a unique development of PF likely from vasopressin after ruling out the diagnoses of DIC, HIT, thrombotic thrombocytopenic purpura, and AHF.

Megadose Vitamin C Prescription Through Alternative Medicine Leading to End-Stage Renal Disease: Case Study and Literature Review.

Modern medicine has made tremendous advancements and succeeded in increasing longevity through adequate screening and diagnosis and various new therapeutic approaches. However, alternative medicine is a branch of health care practicing different traditional and unconventional, potentially hazardous therapies to treat commonly known ailments. Standard low-dose vitamin C, ie, 500-1000 mg, is approved in medical conditions like methemoglobinemia, scurvy, burns and also helps iron absorption in anemia. However, toxic doses carry high nephrotoxicity potential like in our case. We present a 74-year-old Caucasian female falling victim to one such alternative therapy leading to acute kidney injury requiring lifelong hemodialysis. She had endometrial cancer and received 100 gm of intravenous vitamin C weekly through a provider for the last 6 weeks as part of this alternate approach to cure her cancer. Upon admission, the serum creatinine level was elevated at 8.2 mg/dl, which subsequently did not improve with conservative management. Renal biopsy revealed diffuse acute tubular injury with polarized microscopy demonstrating calcium oxalate crystals. While her blood vitamin C levels were high, the serum oxalate level was normal. She ended up requiring renal replacement therapy permanently. Alternative medicine continues to be a significant health care hazard with the potential to cause unwanted irreversible nephrotoxicity. Public attention is necessary at various social levels to counter the detrimental outcomes of alternative medicine.

Incidental detection of operational tolerance in a deceased donor kidney transplant recipient lost to follow-up for more than 10 years: A case report and literature review.

Graft tolerance is a clinical state of absence of an immune response in the recipient toward a donor allograft without any exogenous immunosuppression. Although more prevalent in liver transplantation recipients, it has rarely been reported in renal transplant recipients. We present a 62-year-old deceased donor kidney transplant recipient who exhibited operational tolerance as they stopped immunosuppressant medications for more than 10 years and yet demonstrated stable graft function. Although various hypotheses, such as deletion, anergy, immunoregulation, and clonal exhaustion, have been experimentally validated, clinical "operational tolerance" of a renal allograft on a prolonged basis has been infrequently reported in the medical literature. This review intends to highlight possible etiologies and make clinicians aware of this possible rare condition to which more research is needed.

Risk of New-Onset Diabetes Mellitus as a Post-COVID-19 Condition and Possible Mechanisms: A Scoping Review.

Long-term effects of COVID-19 are becoming more apparent even as the severity of acute infection is decreasing due to vaccinations and treatment. In this scoping review, we explored the current literature for the relationship between COVID-19 infection and new-onset diabetes mellitus four weeks after acute infection. We systematically searched the peer-reviewed literature published in English between 1 January 2020 and 31 August 2022 to study the risk of new-onset diabetes mellitus post-COVID-19 infection. This scoping review yielded 11 articles based on our inclusion and exclusion criteria. Except for one, all studies suggested an increased risk of new-onset diabetes mellitus 4 weeks after acute infection. This risk appears most in the first six months after the acute COVID-19 infection and seems to increase in a graded fashion based on the severity of the initial COVID-19 infection. Our review suggests a possible association of new-onset diabetes mellitus 4 weeks after acute COVID-19 infection. Since the severity of COVID-19 infection is associated with the development of post-infectious diabetes, vaccination that reduces the severity of acute COVID-19 infection might help to reduce the risk of post-COVID-19 diabetes mellitus. More studies are needed to better understand and quantify the association of post-COVID-19 conditions with diabetes and the role of vaccination in influencing it.

Rhizobium radiobacter-Induced Peritonitis: A Case Report and Literature Analysis.

Rhizobium radiobacter (R. radiobacter) is a gram-negative bacterium, primarily a soil contaminant and rarely pathogenic to humans. Only a few cases of peritonitis secondary to R. radiobacter have been reported worldwide. A 66-year-old male with end-stage renal disease who was on peritoneal dialysis (PD) developed R. radiobacter-induced peritonitis. We have treated the infection successfully with intraperitoneal antibiotics and managed to keep his PD catheter intact without interruption in PD treatment. More prolonged antibiotic therapy and frequent clinical follow-up is required to treat this infection. Better clinician awareness is needed to prevent this rare infection.

Elevated Anion Gap Metabolic Acidosis With High Osmolar Gap and Increased Serum Acetone Level: A Case Report.

Acetone poisoning, although not very common, can present with varied signs and symptoms. High acetone levels in serum can be due to exogenous exposure or endogenous production of acetone. Unlike certain alcohol toxicities, acetone does not cause high anion gap metabolic acidosis. A 69-year-old male presented to our service with shock and acute encephalopathy and required intensive care support. Initial laboratory investigation showed high anion gap metabolic acidosis with high osmolar gap. Serum acetone level was elevated. Clinicians need to be aware of how to elucidate such metabolic disturbances and associated toxicities.

Acute Interstitial Nephritis Induced by Clozapine.

Acute interstitial nephritis (AIN) classically presents as acute kidney injury most often induced by offending drugs. Less frequently it is secondary to infections, autoimmune disorders, or idiopathic conditions. Development of drug-related AIN is not dose dependent and a recurrence can occur with re-exposure to the drug. We present a 50-year-old male with treatment resistant schizoaffective disorder who developed clozapine-induced AIN, confirmed with kidney biopsy within 2 months of taking this medication. His kidney function improved with removal of the drug and treatment with steroids. However, his kidney function was again significantly impaired when rechallenged with even a lower dose of clozapine a year later. Kidney function returned to baseline after stopping clozapine. Monitoring of kidney function during clozapine therapy is essential to therapy. Prompt diagnosis is imperative as discontinuation of offending agent can prevent acute kidney injury.

Brevibacterium casei Induced Peritonitis in a Patient Undergoing Continuous Cycler Peritoneal Dialysis: Case Report and Literature Review.

Brevibacterium casei is an extremely rare organism that can lead to peritonitis in End-stage renal disease patients of peritoneal dialysis. Out of only five overall Brevibacterium species peritonitis reported worldwide, only two of them had B. casei subspecies peritonitis detected, with both needing peritoneal dialysis catheter removal and change in dialysis modality to hemodialysis. Our patient, an elderly 63-year-old Hispanic male, was on peritoneal dialysis at home and presented with features suggestive of peritonitis. He was diagnosed subsequently with B. casei and started on broad spectrum intraperitoneal antibiotics. However, he did not need dialysis modality change and recovered fully after 3 weeks of appropriate intraperitoneal antibiotics therapy. Longer antibiotics therapy and frequent clinical follow-up plus better clinician awareness are needed to prevent this rare infection.

Hepatitis B-Associated Lupus-Like Glomerulonephritis Successfully Treated With Antiretroviral Drugs and Prednisone: A Case Report and Literature Review.

Kidney involvement with hepatitis B virus is varied and mostly limited to nephrotic syndrome with membranous nephropathy and nephritic syndrome with membranous proliferative glomerulonephritis. Lupus nephritis is associated with nephritic or nephrotic range proteinuria with most common finding of sub-endothelial electron-dense deposits and immunological stain demonstrating full-house picture with all immunological marker staining. Our case discusses a young male patient presenting with rapidly worsening renal function along with proteinuria, found to be positive for both hepatitis B core antibody along with hepatitis B surface antibody plus positive anti-neutrophilic antibody but negative anti-double-stranded DNA. Kidney biopsy demonstrated hepatitis B-associated lupus-like glomerulonephritis. He responded successfully with antiretroviral therapy and high-dose prednisone. Patient did not need lupus-specific treatment and recovered with antiretroviral therapy only. Hepatitis B-associated lupus-like glomerulonephritis has rarely been reported and possess a diagnostic and therapeutic challenge to all nephrologists.

A Contrast Frugal Approach to Transcatheter Aortic Valve Replacement in Chronic Kidney Disease: A Pilot Study.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is now regarded as a viable treatment option for all cases of severe aortic stenosis (AS). Acute kidney injury (AKI) is common and lowers the survival of patients after TAVR and iodine-based contrast-induced nephropathy (CIN) plays a significant adverse role in AKI. Therefore, in chronic kidney disease (CKD) patients requiring pre-operative evaluation for TAVR, the risk of CIN is of particular concern. METHODS: It was a single-center study including eight CKD patients who underwent pre-operative evaluation for TAVR with minimized contrast exposure by means of pre-operative contrast-sparing evaluation and intra-operative contrast minimization. All patients had glomerular filtration rate (eGFR) calculated before TAVR and on a follow-up about one month and one year post-operatively to document the impact of this TAVR protocol on prognosis of kidney function in patients with advanced CKD. RESULTS: New York Heart Association (NYHA) functional classification demonstrated significant improvement of symptomatology (p = 0.0001) by one-year post-TAVR. Patients' mean AS gradient was significantly improved (p = 0.00004) after the TAVR procedure. No significant post-operative paravalvular aortic regurgitation was noted on follow up echocardiogram. eGFR data showed mean eGFR for the group was slightly better (27.38 ml/min/per 1.73 m2 BSA vs. 30.38 ml/min/per 1.73 m2 BSA) after TAVR. CONCLUSIONS: "Contrast frugal" approach is feasible and safe for pre-TAVR evaluation and the procedure itself. Our pilot study showed no significant paravalvular leak of the prosthetic valve following this proposed protocol. No statistically significant decrease in eGFR was noted on a one-year follow-up.

Roseomonas mucosa-Induced Peritonitis in a Patient Undergoing Continuous Cycler Peritoneal Dialysis: Case Report and Literature Analysis.

Roseomonas species, a rare Gram-negative microorganism, has seldom been reported to cause peritonitis in end-stage renal disease patients on peritoneal dialysis. Only seven cases of peritonitis by this rare microorganism have been reported worldwide. Treatment options can be challenging if not detected early and can lead to significant morbidity and mortality along with the switching of the dialysis modality to hemodialysis which is highly undesirable. Our patient is a 65-year-old Caucasian female who needed to be changed to emergency hemodialysis due to inability to perform peritoneal dialysis from suspected peritonitis and was subsequently discovered to have peritonitis from Roseomonas mucosa. She recovered with a prolonged antibiotics course and returned to peritoneal dialysis in 3 months following her treatment completion. Prompt diagnosis and prolonged antibiotics are a cornerstone in the management of this rare microorganism to prevent mortality and morbidity from peritonitis.

Successful Treatment of Calciphylaxis in a Young Female With End-Stage Renal Disease on Peritoneal Dialysis With Parathyroidectomy, Intensification of Dialysis, and Sodium Thiosulphate-A Case Report and Literature Review.

Calcific uremic arteriolopathy, commonly referred to as "calciphylaxis," is a rare life-threatening condition observed in patients with chronic kidney disease and end-stage renal disease on dialysis. This results in necrotic, ischemic, tender dermal lesions anywhere in the body, but mainly on the abdominal wall and lower extremities, where subcutaneous tissue is abundant. Histologically, it is defined by calcification in dermal capillaries, arterioles, and subcutaneous adipose tissues. It can occur in all advanced stages of chronic kidney disease as well as end-stage renal disease patients on hemodialysis or peritoneal dialysis. Our case highlights a successful case of calciphylaxis in a young female patient who underwent parathyroidectomy and intensification of peritoneal dialysis regimen along with the infusion of sodium thiosulphate injection resulting in complete resolution of the lesion in 3 months. With limited evidence of treatment options and increased frequency of this condition in a dialysis patient, our case highlights the key aspects of calciphylaxis management in a young end-stage renal disease patient who didn't need a change of dialysis modality. We also review the risk factors and current practiced management options of this condition in our article.

Hyponatremia and Fever in a Patient on Ipilimumab and Nivolumab (Immune Checkpoint Inhibitors): A Case Report.

Immune checkpoint inhibitors (ICIs) are novel anticancer therapy approved in multiple tumors and their use is rapidly increasing. They are associated with various systemic side effects that are immune-mediated and clinically coined as "immune-related adverse effects" (irAE). Hyponatremia is a possible side effect in patients receiving ICIs. Fever is another side effect that is mostly non-infectious. There are different mechanisms leading to hyponatremia in patients on ICIs, which could be (1) hypovolemic hyponatremia due to hemodynamic disturbance secondary to volume depletion (eg, from irAE like colitis and enteritis) or hypervolemia due to congestive heart failure, cirrhosis, or nephrosis; (2) syndrome of inappropriate antidiuretic hormone (SIADH) secretion (especially from underlying lung cancer or neurological irAE like encephalitis and meningitis) with elevated urine sodium and urine osmolarity; and (3) irAE-related endocrinopathies such as hypophysitis, adrenal insufficiency, and hypothyroidism leading to euvolemic hyponatremia. We describe an interesting case of hyponatremia and fever in a patient receiving Ipilimumab and Nivolumab. The possible etiology of hyponatremia, in this case, was hypovolemia and volume depletion secondary to fever.

The Emerging Uncommon Non-Albicans Candida: Candida Parapsilosis Peritonitis in a Peritoneal Dialysis Patient.

Candida parapsilosis can cause invasive fungal infection which is associated with significant morbidity and mortality. Timely management of this uncommon Candida pathogen is essential to prevent peritoneal dialysis patients from succumbing to the infectious complications of peritonitis related to it. We present a 75-year-old Caucasian female with end-stage renal disease, on peritoneal dialysis at home, who presented with peritonitis features found to be related to this rare Candida species. She was treated with four weeks course of oral fluconazole and was switched to incenter hemodialysis. Physicians need to be aware of this notorious Candida species in peritoneal dialysis patients and prompt management is essential in successful patient outcomes.

COVID-19 and APOL-1 High-Risk Genotype-Associated Collapsing Glomerulonephritis.

Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily affects the lungs and can lead to acute respiratory distress syndrome (ARDS). The ongoing global pandemic has created healthcare and economic crisis for almost every nation of the world. Though primarily affecting the lungs, it has also affected the kidney in various ways including acute kidney injury (AKI), proteinuria, and hematuria. It has been increasingly shown that African American (AA) individuals affected with COVID-19 and presenting with AKI and nephrotic-range proteinuria are very susceptible to focal segmental glomerulosclerosis (FSGS). The APOL-1 gene, associated with the African American population, has been increasingly recognized as a risk factor for FSGS affected with COVID-19. Our case highlights a similar case of COVID-19 in a 65-year-old AA descendant with biopsy-proven FSGS and genetically confirmed APOL-1 alleles.