Takayasu arteritis: differential diagnosis in a teenager with severe acute kidney injury - a case report / Arterite de Takayasu: diagnóstico diferencial em adolescente com lesão renal aguda grave - relato de caso

ABSTRACT Takayasu arteritis (TA) is a chronic granulomatous inflammatory condition of unknown cause that involves large vessels - particularly the aorta and its branches - such as the carotid, coronary, pulmonary, and renal arteries. The left subclavian artery is the most frequently involved vessel. Stenosis of the renal artery has been reported in 23-31% of the cases and may result in malignant hypertension, ischemic renal disease, decompensated heart failure, and premature death. Involvement of both renal arteries is uncommon. Early onset anuria and acute kidney injury are rare and have been reported only in a few cases in the literature. This report describes the case of a 15-year-old female with constitutional symptoms evolving for a year, combined with headache, nausea, and vomiting, in addition to frequent visits to emergency services and insufficient clinical examination. The patient worsened significantly six months after the onset of symptoms and developed acute pulmonary edema, oliguria, acute kidney injury, and difficult-to-control hypertension, at which point she was admitted for intensive care and hemodialysis. Initial ultrasound examination showed she had normal kidneys and stenosis-free renal arteries. The patient was still anuric after 30 days of hospitalization. A biopsy was performed and revealed her kidneys were normal. Computed tomography angiography scans of the abdominal aorta presented evidence of occlusion of both renal arteries. The patient met the diagnostic criteria for Takayasu arteritis and had a severe complication rarely described in the literature: stenosis of the two renal arteries during the acute stage of ischemic renal disease.

RESUMO A Arterite de Takayasu (AT) é uma doença inflamatória crônica, granulomatosa, de causa desconhecida, que afeta grandes vasos, principalmente a aorta e seus ramos, incluindo artérias carótidas, coronárias, pulmonares e renais, sendo a artéria subclávia esquerda o vaso mais acometido. A estenose da artéria renal é relatada em 23-31% dos casos e pode resultar em hipertensão maligna, insuficiência renal por isquemia, descompensação cardíaca e morte prematura. O acometimento bilateral de artérias renais é incomum, sendo rara a presença de anúria súbita e lesão renal aguda como sintoma inicial da doença, com poucos relatos na literatura. O caso reporta uma adolescente de 15 anos com sintomas constitucionais durante um ano de evolução, associados a problemas como cefaleia, náuseas e vômitos, com idas frequentes a serviços de emergência, sem adequada investigação clínica. Após 6 meses do início dos sintomas, a paciente evoluiu de forma grave, com quadro de edema agudo de pulmão, oligúria, lesão renal aguda e hipertensão arterial de difícil controle, sendo necessário suporte em Unidade de Terapia Intensiva e hemodiálise. A ultrassonografia inicial mostrava rins normais e artérias renais sem sinais de estenose. Após 30 dias de internamento, paciente permanecia anúrica, sendo realizada biópsia renal que se mostrou dentro dos padrões da normalidade. Angiotomografia de aorta abdominal evidenciou oclusão bilateral de artérias renais. A paciente descrita fechou critérios diagnósticos para arterite de Takayasu e manifestou uma complicação grave pouco descrita na literatura: estenose bilateral de artérias renais, ainda na fase aguda da nefropatia isquêmica.

Semiología renal y genitourinaria en pediatría: primera parte / Nephrologoy and urology semiology in children: first part

A pesar de los avances tecnológicos, la historia clínica y el examen físico continúan y continuarán siendo la base de un buen enfoque y aproximación diagnóstica correcta, por ésto, la semiología sigue siendo un área muy importante en la medicina. En ésta revisión se plantea una guía sistemática e integral para la evaluación del sistema nefro-urológico en el niño desde las herramienta básicas y fundamentales como la historia clínica, el examen físico con sus componentessemiológicos en lo normal y lo patológico, integrando además los métodos diagnósticos de laboratorio e imagen disponibles en la actualidad, para lograr un buen enfoque y aproximación diagnóstica en niños con enfermedad renal.

Despite technological advances, medical history and physical examination remain the foundation of a good approach and correct diagnosis; semiology remains a very important area in medicine. In this review a systematic and comprehensive guide for the evaluation of nephron urological system in children is presented, with emphasis in medical history, physical examination and semiotic aspects, in normal and pathological conditions; additionally laboratory and imaging studies available to achieve a good diagnostic approach in children with renal disease are presented.

Clinical outcome of patients presenting with acute oliguria after an acute gastroenteritis episode

The purpose of the study was to describe important characteristics of acute oliguria, developing after an episode of acute gastroenteritis. This study was carried out mainly in the Medical Unit I of Nishtar Hospital Multan. December 1999 to June 2001. The sample of study was randomized to two groups. Group A was administered low dose [renal dose] Dopamine infusion along with fluid replacement and other modalities of treatment, group B was given conventional treatment. 50 patients among the above study were randomized to the group A and were administered low dose dopamine along with other modalities of treatment. The average duration of diarrhea in this group was 3.04 +/- 0.9 days. Mean creatinine level among this group was 6.7 +/- 2.9 at presentation. Hyperkalemia occurred in 10 patients [20%] in this group all of them required treatment for hyperkalemic episodes either in form of drugs or hemodialysis. 2 patients in this group developed chronic renal failure 50 patients among the above study were randomized to the group B and were not administered low dose dopamine. Mean creatinine level among this group was 6.5 +/- 3.3 at presentation. The average duration of diarrhea in this group was 3.12 +/- 0.98 days. Hyperkalemia occurred in 6 patients. No patient developed chronic renal failure in this group. Infectious food was the main cause of gastroenteritis in this study. More patients in the group A [given dopamine] developed chronic renal failure

Clinical outcome of patients presenting with acute oliguria after an acute gastroenteritis episode

The purpose of the study was to describe important characteristics of acute oliguria, developing after an episode of acute gastroenteritis. This study was carried out mainly in the Medical Unit I of Nishtar Hospital Multan. December 1999 to June 2001. The sample of study was randomized to two groups. Group A was administered low dose [renal dose] Dopamine infusion along with fluid replacement and other modalities of treatment, group B was given conventional treatment. 50 patients among the above study were randomized to the group A and were administered low dose dopamine along with other modalities of treatment. The average duration of diarrhea in this group was 3.04 +/- 0.9 days. Mean creatinine level among this group was 6.7 +/- 2.9 at presentation. Hyperkalemia occurred in 10 patients [20%] in this group all of them required treatment for hyperkaleniic episodes either in form of drugs or hemodialysis. 2 patients in this group developed chronic renal.50 patients among the above study were randomized to the group B and were not administered low dose dopamine. Mean creatinine level among this group was 6.5 +/- 3.3 at presentation. The average duration of diarrhea in this group was 3.12 +/- 0.98 days. Hyperkalemia occurred in 6 patients. No patient developed chronic renal failure in this group. Infectious food was the main cause of gastroenteritis in this study. More patients in the group A [given dopamine] developed chronic renal failure

Renal dysfunction in enteric fever.

Twenty-five culture positive cases of enteric fever were studied to see the effect of the disease on various kidney functions. The parameters studied were urine examination, blood urea, serum creatinine, serum electrolytes, 24 hours urinary examination (proteins, creatinine, electrolytes), creatinine clearance rate, plain X-ray abdomen, intravenous urogram and circulating immune complexes. Fifteen patients with fever of non-specific origin served as controls. Renal dysfunction was observed in four patients (16%). Repeat tests showed that abnormalities of renal functions, though significant, were short lasting and reversible. Renal biopsy done in three of these cases did not reveal any abnormality.