Neonatal Renal Papillary and Cortical Necrosis

Keywords Renal failure · Sub-galeal hemorrhage · Neonate Sirs, Neonatal sub-galeal hemorrhage (SGH) is commonly associated with coagulopathies, intracranial hemorrhage, skull fracture, cerebral edema, and neonatal encephalopathy [1,2]. However, renal failure is not a frequent occurrence in children with SGH despite the loss of blood. Our neonatal intensive unit had successfully managed cases of SGH and did not encounter any infant with renal failure until the patient that is reported below.A full-term male baby weighing 2.8 kg was referred to our hospital at 72 h of age because of pallor (hematocrit 15%), progressive scalp swelling, and irritability lasting 24 h. The baby had been delivered to a 28-yearold para 1 +2 mother through vaginal delivery after a 4-h labor with oxytocin induction. The baby cried immediately after birth with Apgar scores of 7 and 10 at 1 and 5 min, respectively, and was discharged from the hospital at 35 h of age with caput succedaneum.Physical examination revealed a conscious but irritable child. He was very pale, afebrile, and had a blood pressure of 90/40 mmHg. The scalp was fluctuant with a positive transillumination test. Cerebrospinal fluid analysis excluded meningitis. A diagnosis of SGH was made and double-volume exchange blood transfusion (EBT) was carried out twice [first post EBT packed cell volume (PCV) 21%, second post EBT PCV 46%]. There was no clinical evidence of a blood transfusion reaction, such as jaundice, gross hematuria, or unexpected anemia after both EBT. The direct and indirect Coombs' tests were negative. Parenteral ceftriaxone and intravenous fluid were also administered. However, on the 2nd hospital day, he developed apnea and focal seizures, which became generalized. Seizures and apnea necessitated multiple resuscitation. Trans-fontanelle cranial ultrasonography suggested cerebral edema, but no intra-cranial collection. Three doses of parenteral 10% mannitol (1 g/kg) were administered. The initial serum biochemical tests indicated potassium (K + ) 7.5 mmol/l, sodium (Na + ) 146 mmol/l, and creatinine 1.9 mg/dl. Urinalysis showed hematuria and proteinuria.On the 4th hospital day, he became anuric with serum K + 6.0 mmol/l, Na + 134 mmol/l, and creatinine 4.9 mg/dl. Dialysis could not be performed due to lack of an appropriate catheter and dialysate. Bolus infusion of 0.9% saline (20 ml/kg), parenteral frusemide 1 mg/kg followed by fluid restriction were implemented, but urine output remained <0.1 ml/kg. Renal ultrasonography revealed a normal-sized kidney with loss of corticomedullary differentiation and no structural anomaly. The serum creatinine rose progressively from 1.9 mg/dl on the 2nd hospital day to 17.6 mg/dl on the 31st hospital day. The baby became virtually anuric with progressive weight gain and anasarca. The blood pressure and serum K + remained normal. He became unconscious and died 5 weeks after hospitalization. The parents did not consent to a post-mortem examination.

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“…Thrombocytopenia may also be present because of microvascular injury. The prognosis is much worse than that of ATN [5].…”

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confidence: 90%

Acute renal failure complicating neonatal sub-galeal hemorrhage

Adedoyin

Johnson

Mokuolu

et al. 2003

Pediatric Nephrology

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“…Evidence that chronic hyperbilirubinemia may play a contributory role in the development of RPN in liver disease is supported by the observation of in creased RPN that occurs in the Gunn rat with congenital hyperbilirubinemia, and the increased susceptibility of this strain of rats to analgesic nephropathy [86,87], Renal papillary necrosis occurs less commonly in chil dren. Several of the cases reported have been fatal and only a few well-documented cases of RPN have been diagnosed antimortem in children [88][89][90][91]. In cases that have survived, the RPN may be recognized as renal hypoplasia or pyelonephritis, while in others the presence of renal damage may not be appreciated until an intrave nous pyelogram is performed.…”

Section: Dr Eknoyanmentioning

confidence: 99%