NDT Advance Access originally published online on August 9, 2005
Nephrology Dialysis Transplantation 2005 20(11):2580-2581; doi:10.1093/ndt/gfi073
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Can rhabdomyolysis be the only cause of acute renal failure in leptospirosis?
Sir,Acute renal failure (ARF) is a well-known complication of leptospirosis in its severe form (Weil's syndrome). Generally, ARF is accompanied by jaundice and thrombocytopaenia, with only sporadic case descriptions of milder forms of ARF in anicteric patients (rarely requiring dialysis). Thrombocytopaenia is also closely correlated with ARF occurrence [1] and is described in all anicteric cases with ARF. The pathophysiology of ARF in leptospirosis evolves hypovolaemia, direct tubular toxicity and rhabdomyolysis. This case describes a patient with leptospirosis, severe rhabdomyolysis and ARF, with no jaundice or thrombocytopenia. Clinical and laboratory findings point to rhabdomyolysis as the major factor responsible for kidney injury.
A 38-year-old man, with no previous disease, had a history of myalgia 2 days previously and noticed reddish urine. Physical examination was unremarkable, except for extremely painful and tense calf muscles. Serum laboratory evaluation showed serum creatinine (sCr) 7.5 mg/dl, urea 280 mg/dl, sodium 139 mEq/l, potassium 6.8 mEq/l, calcium 0.98 mmol/l, phosphorus 8.6 mg/dl and creatine kinase 602 234 IU/l. Haematological examination showed the presence of leukocytosis (16.7x109/l) only, with no anaemia (haemoglobin 13.7 mg/dl) or thrombocytopaenia (456x109/l). Fractional excretion of sodium was 0.8% and the urinary excretion of potassium was 630 mmol/day. The patient needed dialysis support for 2 weeks (eight sessions) and evolved with a decrease in creatine-kinase levels and complete recovery of renal function (sCr, 1.2 mg/dl). Urine output was maintained during the entire hospital stay, with a mean output of 2.050 ml/day. Leptospirosis diagnosis was confirmed by positive serologic tests (ELISA IgM and microscopic agglutination test). Investigation for other infectious diseases (HIV, cytomegalovirus, toxoplasmosis and Coxsackie) was negative.
The pathophysiology of renal failure in leptospirosis involves proximal tubular dysfunction, augmenting distal sodium delivery and, consequently, potassium excretion by the intact distal tubule [2]. In the presented case, the presence of hyperkalaemia is explained by the rhabdomyolysis. However, the low fractional excretion of sodium and urinary potassium of the patient described is dissimilar to the findings described by Covic et al. [3]. These authors demonstrated, in a large series of ARF due to leptospirosis, a high fractional excretion of sodium (>1%) in all patients, even in those with volume depletion. Moreover, in the same series, 20/22 patients with hypokalaemia had a urinary excretion >1000 mmol/day.
On the other hand, the low urinary excretion of sodium and potassium observed in this case is in agreement with ARF due to rhabdomyolysis [4]. In conclusion, the absence of jaundice, normal platelet value and low renal excretion of sodium and potassium allowed us to conclude that the major renal lesion in this case was due to rhabdomyolysis, with no or minimal involvement of leptospirosis.
Conflict of interest statement. None declared.
Complexo Hospitalar do Mandaquil Department of Nephrology São Paulo SP, Brazil Email: alexandreliborio{at}yahoo.com.br
References
- Cousin D, Updike SJ, Maki DG. Massive rhabdomyolysis and multiple organ dysfunction syndrome caused by leptospirosis. Intensive Care Med 2000; 26: 808–812[CrossRef][Medline]
- Magaldi AJ, Yasuda PN, Kudo LH, Seguro AC, Rocha AS. Renal involvement in leptospirosis: a pathophysiologic study. Nephron 1992; 63: 332–339
- Covic A, Goldsmith DJ, Gusbeth-tatomir P, Seica A, Covic M. A retrospective 5-year study in Moldova of acute renal failure due to leptospirosis: 58 cases and a review of the literature. Nephrol Dial Transplant 2003; 18: 1128–1134
[Abstract/Free Full Text] - Corwin HL, Schreiber MJ, Fang LS. Low fractional excretion of sodium. Occurrence with hemoglobinuric- and myoglobinuric-induced acute renal failure. Arch Intern Med 1984; 144: 981–982
[Abstract/Free Full Text]
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