Acute kidney injury following isotretinoin treatment

Abstract

Patient: Female, 17Final Diagnosis: Acute kidney injurySymptoms: Flank pain • nausea • vomitingMedication: IsotretinoinClinical Procedure: Acne treatmentSpecialty: NephrologyObjective: Unknown etiologyBackground:Isotretinoin is widely used for the treatment of acne that is unresponsive to topical therapy. Despite its efficacy, isotretinoin has various adverse effects, including cheilitis, increased risk of cutaneous Staphylococcus aureus infections, and liver function abnormalities.Case Report: A 17-years-old female was admitted to the hospital with a 5-day history of bilateral flank pain, nausea and vomiting. On physical examination, acne was observed over her face treated with Isotretinoin. Both vital signs and physical examination were normal apart from tenderness over both flanks. Initial laboratory results revealed serum creatinine of 2 mg/dl, blood urea nitrogen 20 mg/dl. Complete blood count, full chemistry panel, complements and urinalysis were all normal. Twenty four hours urine collection showed creatinine clearance test of 33 ml/min and urine protein of 390 mg/day. Chest X-ray and ultra sound of kidneys were normal. Acute kidney injury was suspected and she was treated with intravenous fluids. Despite these measures her kidney function steadily worsened. Her serum creatinine on days 2 and 3 were 2.16 and 2.24 mg/dl, respectively. Wright’s staining for eosinophils was positive. Fortunately her serum creatinine started to decrease and was 2 mg/dl and 1.4 mg/dl by day 4 and 5, respectively. A tentative diagnosis of acute interstitial nephritis due to Isotretinoin was made, with the recommendation to avoid this treatment in the future. Two weeks later her serum creatinine and urinary protein returned to normal values.Conclusions:Flank pain should raise suspicion of Isotretinoin-induced acute kidney injury, suggesting that a careful kidney function test besides testing for liver function is warranted in patients with these symptoms.

<p>Isotretinoin and the Kidney: Opportunities and Threats</p>

“…Two case reports have described the possible association between isotretinoin and acute interstitial nephritis. Armaly study group 14 in 2013 reported a case of previously healthy 17-year-old female, with a 5-day history of nausea, vomiting, and bilateral flank pain. Her past medical history only included the use of isotretinoin with a not-defined dose for acne treatment 2 months before admission.…”

“…The authors proposed that kidney function tests must be considered in routine follow up tests during the treatment course of isotretinoin. 14 …”

Isotretinoin Associated Rhabdomyolysis: Monitoring Creatine Kinase and Educating Patients

“…If patients develop AKI due to rhabdomyolysis, we suggest monitoring BUN, creatinine, and CK levels before initiating/restarting treatment as there have been 5 case reports of isotretinoin-induced AKI in the forms of acute interstitial nephritis, nephrotic syndrome, and hematuria with dysuria. All of these cases endorsed the resolution of AKI with the cessation of isotretinoin and appropriate resuscitation and management [16][17][18]. Although retinoids have been shown to reduce damage and inflammation in experimental models of glomerulonephritis and renal interstitial disease, paradoxically, isotretinoin's xerotic mucosal side effects have been described to cause hematuria [18].…”

“…All of these cases endorsed the resolution of AKI with the cessation of isotretinoin and appropriate resuscitation and management [16][17][18]. Although retinoids have been shown to reduce damage and inflammation in experimental models of glomerulonephritis and renal interstitial disease, paradoxically, isotretinoin's xerotic mucosal side effects have been described to cause hematuria [18].…”