A case of postpartum renal failure

Dr.E.Thiulogachandar

Prof.S.Tito’s unit

Shanthi 20 / F Primi

Married 2 yrs before, booked primi

EDD – 12.4.10

Admitted in RSRM with labour pain

Emergency LSCS done

Ind :Foetal Distress / Meconium stained liquor

DOS :17.04.10, referred to medicine dept on 24.05.10

On 4th POD, Patient developed jaundice anddecreased urine output.

Developed nausea and vomiting

Noh/o undue Bleeding

Noh/o fever

Noh/o vag. discharge

Noh/o seizures / LOC

Noh/o abd.pain

No h/o burning micturition

Past History:

Noh/o DM2 / HT / BA/TB / Seizures

Menstrual History:

Normal 4-5/30 RMP

O/E

Pt Conscious

Oriented

Puffiness of face+

Anemia

Afebrile

Jaundice+

PR-82/MIN,BP-100/70 mm Hg,RR-15/min

CVS&RS-normal

P/A-soft

Epigastic tenderness

Minimal free fluid+

21/4/2010

Investigations

Hb - 6.48 g/dl

Pcv - 21 %

Urea - 149

Creatinine - 5.4

BT - 3.5

CT - 4

Investigations

DBR - 5.9

SBR - 9

SGOT - 433

SGPT - 177

SAP - 668

Platelets - 51000

22/4/10

Blood Urea - 135mg%

Creatinine - 5.4mg/dl

Total BR - 9.0mg/dl

DBR - 6.5mg/dl

Platelet - 85000

• Postpartum AKI for evaluation

• To r/o HUS / TTP / HELLP /

AFLP

Treatment given:

1.AKI- Haemodialysis started

2.Iv antibiotics- inj.meropenem 500 mg od

3.tab.ofloxacin 200 mg od

4.Supportive care

Laboratory criteria — HELLP syndrome

• Microangiopathic hemolytic anemia with characteristic

schistocytes (also called helmet cells) on blood

smear..

• Platelet count ≤100,000 cells/microL

• Serum LDH ≥600 IU/L or total bilirubin ≥1.2 mg/dL

• Serum AST ≥70 IU/L

Women who do not meet all of the above laboratory

abnormalities are considered to have partial HELLP

syndrome;

26/04/10

TC - 22900

PLT - 83000

DC - P78L12E10

Hb - 8.5 gm

Urea - 110

Creatinine - 4.63

Serum LDH- 2348U/L

Urine PH - 6.0

Protein - 1 +

Sugar - Neg

Blood - +

Ketone - Neg

BR - Neg

Urobilinogel - Neg

Nitrite - Neg

SG - 1.030

Microscopy

Leucocytes - Plenty

Epicells - Occasional

RBC - 3 – 5 /HPE

Urine C&S- Pseudomonas

HS to GM, Imipinem

Ofloxacin and

Netilmycin

Invesigaions:26/4/10

Investigations

23/4 26/4 27/4 29/4 4/5 5/5 6/5 7/5 9/5 10/5 11/5 13/5

HB% 9.5 8.5 9.0 7.4 9.8

PCV 26.0 26 22.9 30

TLC 14500 22900 6800 28800 6200 7400

DLC P83L13

E4

P78L12

E6

P66L32

E2

P84L7

E9

P55

L40E5

3.5

ESR

Platelet 85000 83000 1.O

lac

1.2 lac 1.1 lac 1.4 lac 1.5

lac

1.4

lac

1.4lac 1.5

lac

RBC 3.2 3.35 3.1

Urea 78 110.4 132 128 74 102 88 64 75 128 62 89

Creatine 6.0 4.63 6.2 5.6 7.1 4.5 3.3 4.2 3.8 5.3 3.2 3.0

Sugar 68 78 60 74 62 66 110 62 53 76 76

0

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/527

/5 2/6

10/6

11/6

Date

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Date

Liver function tests

23/4 26/4 29/4 4/5

T.BR 9.0 4.2 3.0 1.5

D.BR 6.5 2.3 1.8 1.0

SGOT 433IU 44IU 48IU 16IU

SGPT 177IU 33IU 45IU 28IU

SAP 668 714 432 87

PT/APTT 1.2/1.3 1.3/1.2 1.0

Peripheral smear study;

normocytic normochromic anemia with

few schistocytes < 1 %;WBC s normal in

morphology ;no premature cells ;platelets

adequate ;

Impression ;

s/o—hemolysis ;

Serum amylase – 46 IU /ml

Serum lipase –27 IU/ml

• HBsAg-neg

• antiHCV-neg

• HIV-neg

• VDRL-neg

07.05.2010

• USG ABDOMEN;

right kidney 12.5 6.5 cm

7.2 5.6 cm anechoic area within the

right renal capsule compressing the

parenchyma ;

left kidney 11.7 6.4 cm with

perinephric collection

Impression :

subcapsular collection right kidney

Urologist

opinion:Advised conservative management ;

To continue the antibiotics ;

Repeat USG on 21.05.2010;

Rt.kidney 11.46.4 cm echogenic collection within the right renal capsule

Lt.kidney 75 cm echogenic collection

free fluid present

s/o bilateral subcapsular collection –abscess

• Urine c&S-pseudomonas highly sensitive to

Amikacin

• During the course HD was done 14 times and 4

unis PC transfused.

• She developed hypertension and added

antihypertensives-PAGE kidney

04.06 .2010

Repeat USG;

11 7 cm sizes cystic lesion with internal

echoes in the subcapsular region compressing

the right renal parenchyma ;

11 5.7 sized collection in the subcapsular

region of left kidney;

Both kidneys show increased echoes & CMD is

lost ;free fluid +

------------------------------------------------------------------

Repeat urologist opinion

advised to continue the same

CT ABDOMEN 09.06.2010

• Bilateral subcapsular collection both

kidneys 10 7.2 cms and 8.1 7.1 cm

respectively with cystic density ;

• Free fluid present;

• Gallstones present ;

PAGE KIDNEY

Over a period of 2 months pt is having

persisent renal failure

Final diagnosis:Pospartum renal failure due

to sepsis-complicated UTI and cortical

necrosis

Surgical treatment

• Drainage is necessary whenever possible.

• When size is <5cm medical treatment for 2

weeks and review for reduction.

• When size is >5cm percutaneous drainage

has to be done.

Thank you