ESPN 50th Annual Meeting

ESPN 2017


 
Another atypical case of Acute Kidney Injury-or not?
WERNER KEENSWIJK 1 Johan Vande Walle 1

1- GHENT UNIVERSITY
 
Introduction:

 A 12-year-old boy presented at the pediatric department with persistent non bilious vomiting since 3 days and anuria.

Material and methods:

 There was no diarrhea nor other symptoms. His medical history was negative besides episodes of vomiting during periods of stress from the age of 7 years. At physical examination moderate dehydration was seen.

Results:

His laboratory results showed metabolic alkalosis and elevated serum creatinine (1.7 mg/dl) and BUN (123 mg/dl) with hyperphosphataemia and hyperparathyroidism. Urinalysis was normal. Ultrasound showed enlarged kidneys with increased cortical echogenicity. After IV rehydration he recovered with normalization of diuresis and cessation of vomiting. Hyperphospataemia and hyperparathyroidism together typically are more associated with CKD than AKI and the ultrasound image was atypical for acute tubular necrosis. A renal biopsy was performed which showed normal glomeruli but tubules filled with amorphous material consistent with the microscopic presentation of Hyperoxaluria. 

 

Conclusions:

 He was suspected of primary Hyperoxaluria and treatment was commenced. Genetic testing for primary Hyperoxaluria was negative. We noticed that his growth chart showed stunted growth from the age of 9 years and he confirmed to having episodes of vomiting almost every night for the past 2 years. A hypotonic duodenography showed subobstruction at the duodeno-jejunal junction which was confirmed at gastroscopy where a complete torsion of the distal duodenum and stomach traction was seen. On laparascopy a malrotation with chronic volvulus without vascular compromise were seen and corrected. Hyperoxaluria was thought to be secondary to the chronic intermittent intestinal obstruction with malabsorption. Enteric hyperoxaluria is responsible for 5% of cases of hyperoxaluria and is seen secondary to (fat) malabsorption with increased enteric oxalate absorption. It is usually secondary to conditions such as intestinal surgery, bacterial overgrowth syndrome and Inflammatory Bowel Disease. After surgery his growth improved with cessation of vomiting and serum creatinine settling around 0.9 mg/dl (CKD stage 2).