An interesting case of ARF

Prof.S.Shivakumar unitR.Anitha, MD PG

First Admission on 21/3/03

Mr.Gandhi,36yr old male, with symptoms of chronic cough and expectoration, heamoptysis and fever ,was diagnosed to have sputum +ve pulmonary TB.He was started on ATT on 8/3/03.3 weeks later the pt was admitted in the ward with h/o dyspnoea, oliguria, facial puffiness and pedal edema for 10 days.On evaluation of his clinical profile and lab data, he was diagnosed to have renal failure. His inv.reports as follows,

Lab reports RFTBld urea 153 mg/dlSr creat 21.1 mg/dlSr electrolytesNa+ 138 mg/dlK+ 3.9 mg/dl Sr uric acid 8 mg/dlSr phosphate 7.4

mg/dl

Urine analysisAlb +Sugar nilEpi cells 2-4Pus cells 4-624 hr urine pr 40

mg/LUrine c/s no growth

continued Complete

heamogramHb% 10.6 g%Pcv 32%TC 8600DC P61 L36 E3ESR 80/140Platelets 1 lak cells

LFTTotal bilirubin

1.0mg/dlSGOT 32 IU/dlSGPT 25 IU/dl Bld glucose 80 mg/dl Total protien 5.6 g% Total cholesterol 200

mg%

continued

Sr HIV –ve Sr HBsAg –ve VDRL NR ECG WNL CXR bil apical infiltrations s/o PT USG abd bil medical renal disease non specific

hepatomegaly

Provisional diagnosis

Acute Renal Failure ? Drug induced (rifampicin)

Treatment given ATT was stopped 60 cycles of PD given After stopping ATT and PD, his RFT

values were as follows (2003)Date 21/

322/3 28/

331/3

03/4 09/4

Urea mg/dl 153 186 168 98 86 48

CreatinineMg/dl

21.1

12.8 8.0 4.5 2.4 1.5

Discharge advise

Pt was advised to continue ATT without rifampicin

Second Admission on 24/9/06

The pt was readmitted 3yrs later with h/o fever with chills ,vomiting, loin pain, oliguria, heamaturia, puffiness of face, pedal edema. His past history revealed that he discontinued ATT after the last admission. Again he developed the symptoms of TB and was found to be sputum +ve and was restarted on ATT(18/09/06).

On examination

Pt was febrile.Had puffiness of face and pedal edema.

His BP was 160/90mmhg.Had basal creps in his lung fields

Lab Reports RFTBld urea 168 mg/dlSr creat 11.1 mg/dlSr electrolytesNa+ 138 mg/dlK+ 3.9 mg/dl Sr uric acid 8.3 mg/dlSr phosphate 6.3

mg/dl

Urine analysisAlb ++Sugar nilEpi cells 1-2Pus cells 10-12RBC’s 25-27/hpfBile salts&pigments

nil

Continued Complete

heamogramHb% 12.0 g%Pcv 36%TC 7200DC P54 L43 E3ESR 28/60Platelets 1.2 lak cells

LFTTotal bilirubin

1.0mg/dlSGOT 31 IU/dlSGPT 40 IU/dl Bld glucose 127

mg/dl Total protien 5.6 g% Total cholesterol 256

mg%

Continued

ECG WNL CXR bil apical infiltrations s/o PT USG abd bil medical renal disease non specific

hepatomegaly

Diagnosis

Acute Renal Failure Rifampicin Induced The occurence of renal failure

again ( second time ) definitely proves that Rifampicin is the cause.

Treatment given ATT was continued without rifampicin 7 cycles of HD given After stopping rifampicin and HD, his RFT

values were as follows (2006)

Date 26/9 28/9

05/10

09/10

12/10

16/10

Urea mg/dl 168 105 118 158 78 28

CreatinineMg/dl

11.0 10.7

9.0 7.1 2.0 1.2

Similar cited articles

Covic A, Goldsmith DA et al. Rifampicin induced ARF: a series of 60 patients.Nephrol Dial Transplant1983; 13:924-929

Muthukumar T et al.ARF due to rifampicin:a study of 25 patients.Am J Kidney Dis. 2002 oct;40(4):690-6

Discussion From the data of TRC chetpet, Of treating more

than 8000 pulm & extrapulm pts with rifampicin containing regimen from early 1970’s ,3cases of probably rifampicin induced ARF has been reported.

A data from nephrology department of MMC states that rifampicin induced ARF constituted 2.5% of all cases of ARF during the study period of 1990-2000.

ARF due to rifampicin usually occurs in pts receiving intermittent or interrupted therapy & rarely with continuous therapy.

Clinical picture The pt usually presents with gastrointestinal

and flu like symptoms and clinical signs of intravascular heamolysis.

Post-rifampicin ARF is characteristically ass. with autoimmune heamolysis, thrombocytopenia, DIC, hepatic injury &tubular defects, thus creating a polymorphic picture.

Frequent lab findings are anemia, leukocytosis, thrombocytopenia, hypergammaglobulinemia& evidence of hepatic injury.

Renal toxicity of rifampicin Acute tubulointerstitial nephritis and/or

tubular defects. Isolated or superimposed glomerular

injury presenting either with a RPGN or a frank nephrotic syndrome.

The presentation is usually oligoanuria. And the urinalysis reveals sterile leukocyturia, protienuria, heamaturia & heamoglobinuria.

Immune induced rifampicin toxicity

Acc. Of antirifampicin Abduring drug free interval

(I Ag - RBC’s & tubular epi)

Readministration of drug

Intense immune reaction

Intravascular heamolysis Immune complex deposition in blood vessels & interstitium

heamoglobinuria ATN AIN

Diagnosis of post-rifampicin ARF

The specific time course of events, in association with a previous normal renal function and absence of other potential causes for ARF, establishes rifampicin as the sole etiology.

Routine examination for antirifampicin Ab & renal biopsy are not considered essential for positive diagnosis.

Prognosis Clinical course is very favourable with

very rare mortality. Prognostic factors: duration of anuric

phase& the severity of the immunological abnormalities and inflammatory syndrome(heamolysis, leucocytosis& hypergammaglobulinemia)

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