Poster Presentation Australasian Diabetes in Pregnancy Society and Society of Obstetric Medicine Australia and New Zealand Joint Scientific Meeting 2021

HELLP me, I’m not aHUS, I’m AIN! Drug-Induced Acute Interstitial Nephritis mimicking Atypical Haemolytic Uraemic Syndrome (#125)

Michael Sullivan 1 , Emily Callaway 1 , Michelle Cole 2 , Siddharth Goswami 3 , Zaw Thet 1 4 5 , Leo Francis 2 , Leonie Callaway 1 2
  1. Univeristy of Queensland, Brisbane, Queensland, Australia
  2. Royal Brisbane and Women's Hospital, Herston, QLD, Australia
  3. Intensive Care Unit, Central Queensland Hospital and Health Service , Rockhampton, Queensland, Australia
  4. Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
  5. School of Medicine, Griffith University, Brisbane, Queensland, Australia

We present a case of a 32 year-old female with anaemia, thrombocytopenia and acute liver injury on day 1 following an uncomplicated spontaneous vaginal delivery. Alongside a nadir haemoglobin of 71g/L and platelets of 14 x109/L, she was clinically jaundiced with a peak total bilirubin of 246 (178 conjugated bilirubin), coagulopathy (INR 1.7) and hypoglycaemia (formal blood glucose 3.6mmol/L). Blood pressure was normal prior to delivery, but hypertension was noted in the Intensive Care Unit postpartum with blood pressures ranging between 146-170/94-117mmHg.

Following a normal liver screen, the acute liver failure improved, however she developed a progressive oliguric acute renal failure associated with microscopic haematuria and fluid overload. A blood film confirmed microangiopathic haemolytic anaemia accompanied by a low haptoglobin, normal ADAMTS13 and negative shiga-toxin producing E. Coli which, along with an acute kidney injury, fulfilled criteria for diagnosis of atypical haemolytic uraemic syndrome (aHUS).

Consensus opinion from Obstetric Medicine, Nephrology and Haematology was that of an active and progressive thrombotic microangiopathy with a severe acute kidney injury consistent with aHUS, presumably triggered by HELLP or acute fatty liver of pregnancy. Eculizumab was commenced following PBS approval.

A renal biopsy performed to further evaluate underlying aetiology demonstrated an eosinophilic acute interstitial nephritis (AIN). This was thought to be a drug-induced phenomenon, potentially from antibiotic or non-steroidal anti-inflammatory use in the peripartum period. A short course of prednisolone was given for AIN and eculizumab was ceased after the first dose. The patient’s renal and haematological parameters improved following temporary RRT on day 6 postpartum and she was discharged on day 17 of admission.

We present this diagnostic dilemma to encourage physicians to consider a renal biopsy in women with suspected aHUS and to consider medication induced acute kidney injury given the frequency of antibiotic and NSAID use in the postpartum setting.

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