Nephrol Dial Transplant (1996) 11: 1841-1842 Case Report Nephrology Dialysis Transplantation Acute renal failure and renal papillary necrosis following instillation of silver nitrate for treatment of chyluria S. C. Dash 1 , Y. Bhargav 1 , S. Saxena 1 , S. K. Agarwal 1 , S. C. Tiwari 1 and A. Dinda 2 Departments of 'Nephrology and 2 Pathology, All India Institute of Medical Sciences (AIIMS), New Delhi, India Key words: acute renal failure; chyluria; haematuria; silver nitrate instillation Introduction Chyluria is a common problem in South East Asia especially in India, Hong Kong, Japan, and Taiwan [1]. In endemic areas approximately 10% of population are infected with Wuchereria bancrofti, of whom 10% have chyluria. Although on most occasions chyluria is of parasitic origin, there could be non-parasitic causes (tuberculosis, malignancy, post-traumatic). Several therapeutic options are practised, one such method is instillation of sclerosing agents into the renal pelvis. We report a patient who developed severe acute renal failure following bilateral instillation of silver nitrate into the renal pelvis. She also developed gross haemat- uria due to renal papillary necrosis in the left kidney. Case report A 38-year-old woman developed anuria on 30.7.95 almost immediately after instillation of an unspecified quantity of 3% silver nitrate solution into each renal pelvis. Two days later she developed gross haematuria, and was transferred to the Nephrology Department, New Delhi. The procedure had been conducted in her home town under spinal anaesthesia in an attempt to treat a 10-year-old problem of chyluria. There was no hypotension during anaesthesia. She had no history suggestive of abdominal tuberculosis or filarial lymph- angitis, nor did she have a past history of abdominal surgery or trauma. Physical examination on admission revealed mild oedema and signs of circulatory overload. The patient had moderate anaemia and her temperature remained Correspondence and offprint requests to: Dr S. C. Dash, Professor of Nephrology, All India Institute of Medical Sciences, New Delhi, 110029 India. elevated between 37 and 38°C throughout the hospital stay. There was a soft systolic murmur at the apex, and bilateral crepitations at the lung base. Diagnosis of acute renal failure following silver nitrate instillation was made. The possibility of acute renal papillary necrosis was kept in mind in view of gross haematuria. The patient remained anuric for 10 days, and gross haematuria continued for 12 days. On investigation, the haemogram revealed Hb of 9.2 g% (92.0 g/1) with a TLC of 14600/mm 3 (14.6, 10 9/1) DLC-P 72%, L25%, E3%. Reticulocyte count, 1.5%; there was no evidence of intravascular haemo- lysis. Platelet counts varied between 1.2 and 2.3 lac/mm 3 , (120-230 x 10" 9 /l). The urine was grossly haemorrhagic; microscopy revealed fields densely packed with RBC. Renal function on admission: blood urea 180 mg%, serum creatinine 10.5 mg%, sodium 137 mmol/1, and potassium 4.5 mmol/1. Blood pH was 7.35, pCO 2 24.6 mmHg, pO 2 81.0 mmHg, HCO 3 13.4 mmol/1 with a base deficit of 9.5 mmol/1. Chest X-ray showed mild pleural effusion on the left side. Biochemistry of pleural fluid showed protein of 3.4 g% and 50 lymphocytes/mm 3 . Plain X-ray of kidneys showed a bilateral radio-opacity outlining the pel- vicalyceal system and upper ureters. Lower calyces on the left side showed damage and cavitation suggestive of necrosis of renal papillae (Figure 1). Ultrasonogram showed that right and left kidneys were 11.1 and 11.5 cm respectively, with splitting and distortion of left lower polar calyceal systems. The echogenicity of the pelvicalyceal system was increased. A large blood clot was found in the urinary bladder. On computed tomography, the above findings were confirmed in form of material of high attenuation outlining the bilateral pelvicalyceal system and ureters. In addition, multiple small retroperitoneal lymph nodes were seen in para-aortic and left renal hilar locations (Figure 2). The patient received three haemodialyses and other supportive treatment for her anuric state. Percutaneous renal biopsy revealed features of resolving acute tubu- lar necrosis (Figure 3). Ten days after admission she entered a diuretic phase and a month later blood urea and creatinine were 40 mg% and 1.6 mg% respectively, with a 24-h urine volume of 3.4 litres. © 1996 European Renal Association-European Dialysis and Transplant Association Downloaded from https://academic.oup.com/ndt/article/11/9/1841/1831104 by guest on 21 January 2024