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Renal biopsy case

Renal biopsy case. Niels Marcussen Odense University Hospital Denmark. Case history. 77-year-old male was in January 2010 operated for colon adenocarcinoma. For many years he has been treated for hypertension with beta-blockers, diuretics and alfa-blockers.

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Renal biopsy case

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  1. Renal biopsy case Niels Marcussen Odense University Hospital Denmark

  2. Case history • 77-year-old male was in January 2010 operated for colon adenocarcinoma. • For many years he has been treated for hypertension with beta-blockers, diuretics and alfa-blockers. • In April 2010 he underwent colonoscopy which did not show any signs of recurrent disease. Prior to the colonoscopy, he was orally given sodium phosphate (OSP) bowel purgative.

  3. Case history II • Two weeks later he was again admitted to hospital due to intestinal bleeding. At the time of admission his s-creatinine was 700 mmol/l and after rehydration 450 mmol/l. Proteinuria 1.1 g/d. No hyperphosphatemia or hypercalcemia. • A renal biopsy was done in May 2010.

  4. Immunofluorescense (normal) and Electron microscopy

  5. Acute Phosphate Nephropathy (APhN) • Described in 2003 by S. Desmeules et al. (N Engl J M 349:1006, 2003) • Two weeks after ingesting phosphosoda a 71-year-old woman presented with malaise and elevated s-creatinine. • Analysis of the renal biopsy by X-ray dispersion spectrum: Desmeules et al. 2003

  6. Pathogenesis of APhN • Massive phosphate intake • Diarrhea-induced hypovolemia • Decreased proximal tubular reabsorption of phosphate, especially following second dose of OSP • Hypovolemia leads to salt and water reabsorption in the tubules • Marked increase in Ca-Ph product in the distal tubular lumen Markowitz and Perazella KI 76:1027-34, 2009

  7. Risk factors for APhN • Advanced age • Female gender • Lower body weight • Chronic renal disease • Hypertension • ACE-inhibitors, Angiotensin-receptor blockers, diuretics

  8. Case II • 77-years-old woman with known hypertension, treated with Ca-antagonist and diuretics was admitted with increased s-creatinine (224 mmol/l). 3 months prior to admission her s-creatinine was 54 mmol/l. • The patient had 2 months prior to admission received OSP. • Urine stix was negative for blood, 1+ for protein og 2+ for leucocytes. No hypercalcemia or hyperphosphatemia. • Ultrasound normal. • Renal biopsy was performed.

  9. Clinical outcome • Markowitz et al. 2005 and 2009: • 21 patients • 4 progressed to end-stage renal failure. • 16 declined in s-creatinine to a mean of about 210 mmol/l • 4 reached a creatinine of less then 176 mmol/l No one returned to baseline.

  10. APhN, pathological changes • Acute changes (up to 3 weeks): • Acute tubular degenerative changes • Interstitial edema • Abundant tubular calcium phosphate deposits • Chronic changes (after 3 weeks): • Tubular atrophy • Interstitial fibrosis • Abundant tubular calcium phosphate deposits

  11. Acute phosphate nephropathy • Diagnostic criteria: • AKI • Recent exposure to OSP bowel purgatives • Renal biopsy with characteristic findings • No hypercalcemia • No other known significant renal injury Markowitz & Perazella- Kidney Int 76:1027, 2009

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