Abstract: SA-PO289
Severe Drug-Induced Bilateral Obstructive Nephropathy in a Lung Transplant Recipient: A Case Report and Literature Review
Session Information
- Trainee Case Reports - VI
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 101 AKI: Epidemiology, Risk Factors, and Prevention
Authors
- Puri, Vidhit, University of Michigan, Ann Arbor, Michigan, United States
- Kandagatla, Pridvi, University of Michigan, Ann Arbor, Michigan, United States
- Puri, Nishant Krishan, University of Michigan, Ann Arbor, Michigan, United States
- Garg, Gunjan, University of Michigan, Ann Arbor, Michigan, United States
- Nigam, Tina, Michigan State University, Lansing, Michigan, United States
- Goranta, Sowmya, Hurley Medical Center, Flint, Michigan, United States
- Parasuraman, Raviprasenna K., University of Michigan, Ann Arbor, Michigan, United States
Introduction
Drug induced nephrolithiasis is rare and accounts for 1-2 % of all renal stone disease. Sulfamethoxazole mediated renal injury is mostly from interstitial nephritis and crystalluria with occasional renal stone formation. We present a rare case of Sulfamethoxazole induced acute bilateral ureteral stones causing hydronephrosis and severe AKI in a lung transplant recipient.
Case Description
A 59-year-old lung transplant recipient presented with a 3-day history of bilateral flank pain, weakness, anorexia, and decreased urine output after 4 weeks of high dose sulfamethoxazole-trimethoprim (Bactrim DS 2 TID) for cavitating Nocardia pneumonia. Examination was significant for moderate volume depletion, bilateral flank tenderness and oligo-anuria. Serum chemistry was significant for creatinine of 5.08 mg/dL (baseline 0.9), hyponatremia (130meq/L), and hyperkalemia (5.2meq/L) with a normal uric acid level. UA showed aciduria (pH=5.0). US and CT showed bilateral ureteral stones, hydronephrosis and bladder sediment layering (Fig.1a). Patient underwent bilateral ureteral stent placement and the urine (frank hematuria, unable to appreciate crystals) was strained and subjected for stone analysis. The infrared spectroscopy (IS) showed > 95% of absorbance pattern consistent with N4-acetylsulfamethoxazole, confirming the diagnosis of sulfamethoxazole stone (Fig.1b). Cessation of Bactrim therapy, urine alkalization, and volume replacement resulted in resolution of hydronephrosis and complete recovery of renal function.
Discussion
Bactrim induced interstitial nephritis, hyperkalemia and crystalluria is frequently seen. However, acute bilateral ureteral stone causing obstructive nephropathy is rare and to our knowledge not reported. The major risk factors include higher dose of medication, low urinary pH (poor solubility), and volume depletion. Our case exemplifies the importance of monitoring patient’s urine pH, crystalluria, renal function, and volume status when using high doses of Bactrim.
A. CT showing Distal Rt & Proximal Lt ureteral calculus with stone layering in bladder. B. IS showing stone composition matching metabolite of sulfamethoxazole.