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Acute Renal Failure Requiring Renal Replacement Therapy: Unusual Presentation of Multisystem Inflammatory Syndrome in Children
Journal of Paediatrics and Child Health ( IF 1.7 ) Pub Date : 2021-09-01 , DOI: 10.1111/jpc.15715
Rakesh K Pilania 1 , Swati Dokania 1 , Amber Kumar 1 , Reyaz Ahmad 2 , Shikha Malik 1 , Girish C Bhatt 1
Affiliation  

ACUTE RENAL FAILURE REQUIRING RENAL REPLACEMENT THERAPY: UNUSUAL PRESENTATION OF MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN

An 18-month-boy presented with fever for 7 days, facial puffiness, periorbital oedema and anuria. He had fever and cough briefly 3 weeks earlier. All family members had a similar illness at that time. Examination showed anasarca, pitting oedema and irritability. Investigations revealed haemoglobin 85 g/L, total leukocyte count 15.5 × 109/L (polymorphs 44%, lymphocytes 46%, monocytes 6% and eosinophils 3%) and platelet count 707 × 109/L with normal peripheral smear. Biochemical investigation showed serum sodium 129 mmol/L, potassium 6.6 mmol/L, blood urea 34.3 mmol/L and serum creatinine 999.9 μmol/L. Blood gas analysis showed pH 7.30, bicarbonate 11.2 mmol/L and serum lactate 1.1 mmol/L (normal: 0.5–1 mmol/L). His total urine output over the last 24 h was only 5 mL. As per Kidney Disease Improving Global Outcomes (KDIGO) classification, he was classified as having acute kidney injury (AKI) stage III. His serum C-reactive protein was 54.6 mg/L, d-dimer 3.8 μg/mL (normal: 0.1–0.5), serum fibrinogen 275.5 mg/dL (normal: 240–355) and serum interleukin-6 level 17.9 pg/mL (normal < 4.4). Aspartate transaminases and alanine transaminase were 32.9 U/L (<40 U/L) and 22.0 U/L (<40 U/L), respectively. Lactate dehydrogenase, serum ferritin, serum triglycerides, troponin and plasma B-type natriuretic peptide were 291.5 U/L (normal < 248), 403.9 ng/mL, 250.2 mg/dL (<150 mg/dL), negative and 11 pg/mL (<29.40 pg/mL), respectively. He was initiated on supportive therapy and peritoneal dialysis (PD) using percutaneously inserted peel-away sheath catheter by Seldinger technique. Urine examination showed proteinuria (+2), no casts or dysmorphic red blood cells. Spot urine protein/creatinine ratio was 1.4 (normal < 0.2). Blood and urine cultures were sterile. Human immunodeficiency virus enzyme-linked immunosorbent assay was non-reactive. Ultrasound of kidney, ureter and bladder (KUB) revealed normal sized kidneys with mildly increased echogenicity bilaterally. Doppler evaluation of the renal vessels was normal. Complement C3, C4, antinuclear antibodies, anticytoplasmic antibodies, serum albumin and cholesterol were normal.

In view of his fever, high inflammatory markers, thrombocytosis and the family's febrile respiratory illness 3 weeks prior, the clinical possibility of multisystem inflammatory syndrome in children (MIS-C) was considered. At the time of presentation of this case to hospital, the country was facing the second pandemic wave of COVID-19. The patient fulfilled the Royal College of Paediatrics and Child Health definition of paediatric multisystem inflammatory syndrome temporally associated with COVID-19.1 Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction was negative, while SARS-CoV-2 antibody titres (IgG: 12.56 index; normal < 1 index) were elevated, confirming a diagnosis of MIS-C. The patient was initiated on oral prednisolone (2 mg/kg/day) and subcutaneous low-molecular weight heparin (1 mg/kg/day). Gradually, his urine output improved to 1.3 mL/kg/h, and blood urea (5.95 mmol/L) and serum creatinine (61.88 μmol/L) normalised. PD was stopped on day 7 when his kidney function tests, electrolytes and urine examination were normal. The patient was discharged on tapering doses of oral prednisolone (over 6 weeks).

MIS-C is a post-infectious phenomenon usually appearing weeks after COVID-19 infection.2 It is difficult to differentiate recent SARS-CoV-2 infection from an infection several months prior based on just IgG positivity. Studies have shown that antibodies against SARS-CoV-2 may persist for several months after infection but IgG titres decrease significantly during the first 6 months after exposure.3, 4 Anderson et al. have shown that children with MIS-C have higher levels of IgG antibodies that neutralise SARS-CoV-2 more effectively compared to children with severe COVID-19.5 In our case, the history of a recent compatible illness, with multiple family members affected at the same time and high daily caseloads suggest recent infection.

Renal involvement in patients with MIS-C can manifest as proteinuria, haematuria and AKI. AKI has been reported in quarter to one-third of patients with MIS-C.6-8 McCulloch et al. have described a 9-year-old boy with MIS-C requiring PD.9 In one of the largest series of AKI in MIS-C (57 children with MIS-C), only 1 required dialysis.10 AKI may occur due to direct viral tropism to renal parenchyma, haemodynamic compromise, cytokine storm and multiorgan dysfunction.4 High levels of ACE2 receptor expression in proximal tubular epithelial cells may be responsible for viral tropism and kidney injury.6 To conclude, AKI requiring renal replacement therapy is an unusual presentation of MIS-C.



中文翻译:

需要肾脏替代治疗的急性肾功能衰竭:儿童多系统炎症综合征的异常表现

需要肾脏替代治疗的急性肾功能衰竭:儿童多系统炎症综合征的异常表现

一名 18 个月大的男孩出现发烧 7 天、面部浮肿、眶周水肿和无尿。3 周前,他曾短暂发烧和咳嗽。当时所有的家庭成员都患有类似的疾病。检查显示全身水肿、凹陷性水肿和易怒。检查显示血红蛋白 85 g/L,总白细胞计数 15.5 × 10 9 /L(多形体 44%,淋巴细胞 46%,单核细胞 6%,嗜酸性粒细胞 3%)和血小板计数 707 × 10 9/L 外周涂片正常。生化检查血钠129 mmol/L,钾6.6 mmol/L,血尿素34.3 mmol/L,血肌酐999.9 μmol/L。血气分析显示 pH 值 7.30,碳酸氢盐 11.2 mmol/L 和血清乳酸 1.1 mmol/L(正常值:0.5-1 mmol/L)。他过去 24 小时的总尿量仅为 5 mL。根据肾脏疾病改善全球结果 (KDIGO) 分类,他被归类为急性肾损伤 (AKI) III 期。他的血清 C 反应蛋白为 54.6 mg/L,d-二聚体 3.8 μg/mL(正常:0.1-0.5),血清纤维蛋白原 275.5 mg/dL(正常:240-355)和血清白细胞介素 6 水平 17.9 pg/mL(正常 < 4.4)。天冬氨酸转氨酶和丙氨酸转氨酶分别为 32.9 U/L (<40 U/L) 和 22.0 U/L (<40 U/L)。乳酸脱氢酶、血清铁蛋白、血清甘油三酯、肌钙蛋白和血浆 B 型利钠肽分别为 291.5 U/L(正常值 < 248)、403.9 ng/mL、250.2 mg/dL(<150 mg/dL)、阴性和 11 pg/ mL (<29.40 pg/mL),分别。他开始使用 Seldinger 技术经皮插入的剥离鞘导管进行支持治疗和腹膜透析 (PD)。尿液检查显示蛋白尿(+2),无管型或畸形红细胞。点尿蛋白/肌酐比值为 1.4(正常值 < 0.2)。血和尿培养物是无菌的。人类免疫缺陷病毒酶联免疫吸附测定是非反应性的。肾脏、输尿管和膀胱 (KUB) 的超声检查显示肾脏大小正常,双侧回声略有增加。肾血管的多普勒评估正常。补体C3、C4、抗核抗体、抗细胞质抗体、血清白蛋白和胆固醇均正常。

鉴于其发热、高炎症标志物、血小板增多以及3周前家人出现发热性呼吸道疾病,临床考虑儿童多系统炎症综合征(MIS-C)的可能性。在向医院介绍此病例时,该国正面临 COVID-19 的第二波大流行。该患者符合皇家儿科和儿童健康学院对与 COVID-19 暂时相关的儿科多系统炎症综合征的定义。1严重急性呼吸综合征冠状病毒-2 (SARS-CoV-2) 聚合酶链反应呈阴性,而 SARS-CoV-2 抗体滴度(IgG:12.56 指数;正常 < 1 指数)升高,证实了 MIS-C 的诊断。患者开始口服泼尼松龙(2 mg/kg/天)和皮下注射低分子量肝素(1 mg/kg/天)。逐渐地,他的尿量改善至 1.3 mL/kg/h,血尿素 (5.95 mmol/L) 和血清肌酐 (61.88 μmol/L) 恢复正常。当他的肾功能检查、电解质和尿液检查正常时,PD 在第 7 天停止。患者在逐渐减少口服泼尼松龙剂量(超过 6 周)后出院。

MIS-C 是一种感染后现象,通常在 COVID-19 感染后数周出现。2仅根据 IgG 阳性很难区分最近的 SARS-CoV-2 感染与几个月前的感染。研究表明,针对 SARS-CoV-2 的抗体可能在感染后持续数月,但 IgG 滴度在暴露后的前 6 个月内显着下降。3, 4安德森等人。已经表明,与患有严重 COVID-19 的儿童相比,患有 MIS-C 的儿童具有更高水平的 IgG 抗体,可以更有效地中和 SARS-CoV-2。5在我们的案例中,近期有兼容疾病的病史,多个家庭成员同时受到影响,并且每天的病例数很高,这表明最近感染了。

MIS-C 患者的肾脏受累可表现为蛋白尿、血尿和 AKI。四分之一到三分之一的 MIS-C 患者报告了 AKI。6-8麦卡洛克。描述了一个需要 PD 的 MIS-C 的 9 岁男孩。9在 MIS-C 中最大的 AKI 系列之一(57 名患有 MIS-C 的儿童)中,只有 1 名需要透析。10 AKI 的发生可能是由于病毒对肾实质的直接嗜性、血流动力学受损、细胞因子风暴和多器官功能障碍。4近端肾小管上皮细胞中高水平的 ACE2 受体表达可能是病毒嗜性和肾损伤的原因。6 总之,需要肾脏替代治疗的 AKI 是 MIS-C 的一种不寻常表现。

更新日期:2021-10-01
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