Postpartum hemolytic uremic syndrome with multiple organ involvement in a severe case
Postpartum hemolytic uremic syndrome with multiple organ involvement in a severe case
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Here we report for the first time a severe case of PHUS complicated by pancreatic necrosis, bilateral visual loss due to central retinal artery occlusion (CRAO) and disseminated intravascular coagulation (DIC). </p><p class="elsevierStylePara">A 20-year-old primigravid was admitted for edema and headache when she was 34 weeks pregnant. On presentation her blood pressure (BP) was 180/115 mmHg and moderate edema on face was noted. Initial investigations showed 3+ proteinuria and normal serum creatinine (Scr) concentration. The diagnosis of preeclampsia was established and a cesarean section was performed in the 35th week of gestation.</p><p class="elsevierStylePara">Nine days later, the patient complained of oliguria, nausea with BP of 175/105 mmHg. Laboratory tests revealed hemolytic anemia, with hemoglobin of 81 g/L, serum haptoglobin <0.2 g/L, and schistocytes shown in peripheral blood smear. Platelets (Plt) were markedly reduced at 41×10<span class="elsevierStyleSup">9</span>/L and an acute rise of Scr to 463.2 μmol/L showed acute renal failure. The immunologic studies revealed negative anti nuclear antibody and Coomb’s tests. Under suspicion of PHUS, antihypertensives, aspirin and furosemide were commenced on the 1st day of presentation and renal biopsy was performed on day 2.</p><p class="elsevierStylePara">The patient complained of left-upper abdominal pain after renal biopsy and developed a sudden bilateral painless visual loss. The subcutaneous bleeding over her upper arms was noted and she rapidly developed anuria, dyspnea, confusion, hypotension with BP of 70/50 mmHg. The ultrasound scan excluded the existence of perinephric / subcapsular hematoma caused by renal biopsy. The fundus exam revealed bilateral CRAO. Laboratory tests on day 3 showed elevated serum amylase, lipase and Scr up to 625μmol/L, Plt down to 12.2×10<span class="elsevierStyleSup">9</span>/L. The level of fibrinogen decreased to 3.82μmol/L with delaying activated partial thromboplastin time and positive D-dimer. Computed tomography scan confirmed pancreatic necrosis. Renal pathology showed thickened glomerular capillary walls with subendothelial edematous expansion that forming double contouring and renal arteriolar intimal expansion with fibrin exudation on the arteriolar wall (Figure 1). Based on these findings, the diagnosis of PHUS complicated by pancreatic necrosis, CRAO and DIC was established.</p><p class="elsevierStylePara">She was treated with pulse methylprednisolone 500mg/d and intravenous immunoglobulin (IVIG) 20g/d for 3 days. Meanwhile, plasma exchange (PE) with fresh frozen plasma (FFP) infusion and CRRT were initiated. Anticoagulant therapy for DIC and CRAO were also carried out. On day 15, she was improved significantly and the urinary output increased whereas the bilateral vision improved only slightly and hyperglycemia became noted. On review after 6 months of onset, she remained bilateral visual loss, elevated blood glucose and Scr when hemodialysis and subcutaneous injection of insulin were suspended. These showed the irreversible visual impairment, secondary diabetes mellitus dependent on insulin and the progression to CRF.</p><p class="elsevierStylePara">HUS and thrombotic thrombocytopenic purpura (TTP), collectively referred to as TMAs, occur with increased frequency during pregnancy or the postpartum period. These two disorders are considered by many to be manifestations of the same disease process; however, others consider HUS and TTP to be distinct entities.<span class="elsevierStyleSup">3</span> Since TTP and HUS share many overlapping features, distinguishing the two disorders may be difficult.<span class="elsevierStyleSup">4</span> As in the case we showed, the patient developed TMA with disturbance of consciousness that seemed to suggest TTP; however, the prominent renal insufficiency and the lack of diffused thrombi in renal tissue might support PHUS rather than TTP. Another differential diagnosis should be included in this case is hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP syndrome). HELLP, usually associated with preeclampsia is more common in multiparous women and approximately 70% of HELLP occur prior to term, with the remainder usually occurring within 48 hours after delivery.<span class="elsevierStyleSup">5</span> Patients with HELLP frequently present with severe right upper quadrant pain. Based on these characteristics of HELLP, we prefer to diagnose our case as PHUS.</p><p class="elsevierStylePara">Although the pathogenesis of PHUS is unknown, the previous cases reported<span class="elsevierStyleSup">2,6,7</span> and the case presented here demonstrated preeclampsia could possibly trigger PHUS by causing platelet aggregation, deposition of microthrombi and occlusions in the microvasculature of the kidney, resulting in acute renal failure. The deficiency of ADAMTS-13, a metalloprotease that cleaves ultra-large von Willebrand factor (VWF) multimers observed in PHUS<span class="elsevierStyleSup">8</span> which suggest PHUS may be also associated with ADAMTS-13 deficiency. Recent studies revealed alternative complement 3 convertase dysregulation were detected in most PHUS patients suggesting PHUS was probably associated with complement gene mutation.<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">Multiple organ involvement such as pancreas and ocular structures were reported in non-pregnancy-related HSP,<span class="elsevierStyleSup">10,11</span> whereas PHUS involving extrarenal vascular beds has been less reported so far except central nervous system and liver damage.<span class="elsevierStyleSup">12,13</span> Does this mean PHUS have a better prognosis than non-pregnancy HUS? The case we described here developed multiple organ damage such as pancreatic necrosis, CRAO, DIC and progressed to secondary diabetes mellitus, bilateral visual loss and CRF eventually. The severe complications of pancreatic necrosis and CRAO might be the manifestations of TMA in PHUS, but might be more likely induced by DIC in this patient. Anyway, this case suggests PHUS could also involve multiple organ dysfunctions and result in bad outcomes even if the appropriate treatments have been given without delay.</p><p class="elsevierStylePara">The renal pathology in HUS is characterized by glomerular capillary subendothelial expansion, arteriolar fibrinoid necrosis, arterial edematous intimal expansion and vascular thrombosis. The preceding etiologic conditions of HUS and the histological findings appeared not to be related to each other.<span class="elsevierStyleSup">14</span> Our case showed typical subendothelial edematous expansion and renal arteriolar intimal expansion with fibrin exudation which supported renal microangiopathy, but without diffused thrombi and fibrinoid necrosis in renal tissue which seemed to be inconsistent with the following development of multiple organ complications and the progression to CRF. This was considered to be due to the early performance of renal biopsy after the attack and the early pathological findings in PHUS presented here may be difficult to predict the disease development and poor prognosis.</p><p class="elsevierStylePara">In conclusion, pancreatic necrosis, CRAO and DIC were observed in PHUS. Although renal replacement therapy and PE with FFP infusion have improved the survival of PHUS significantly, multiple organ complications such as pancreatic necrosis, CRAO and DIC may cause severe sequelae and lead to a poor prognosis of PHUS.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">The authors declare that there is no conflict of interest associated with this manuscript.</p><p class="elsevierStylePara"><a href="grande/11334_108_25509_en_11334_f1.jpg" class="elsevierStyleCrossRefs"><img src="11334_108_25509_en_11334_f1.jpg" alt="Renal biopsy findings in postpartum hemolytic uremic syndrome"></img></a></p><p class="elsevierStylePara">Figure 1. Renal biopsy findings in postpartum hemolytic uremic syndrome</p>" "pdfFichero" => "P1-E536-S3514-A11334.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Weiner CP. Thrombotic microangiopathy in pregnancy and the postpartum period. Semin Hematol 1987;24:119-29. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3299720" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Santos Nores J, Bravo López JJ, Borrajo Prol MP, Iglesias Forneiro A. HTA-pre-eclampsia-postpartum haemolytic-uraemic syndrome: good results can be achieved. Nefrologia 2010;30:593-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20882100" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Hosler GA, Cusumano AM, Hutchins GM. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are distinct pathologic entities. A review of 56 autopsy cases. Arch Pathol Lab Med 2003;127:834-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12823037" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "George JN. The thrombotic thrombocytopenic purpura and hemolytic uremic syndromes: overview of pathogenesis (Experience of The Oklahoma TTP-HUS Registry, 1989-2007). Kidney Int Suppl 2009;(112):S8-S10." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kirkpatrick CA. The HELLP syndrome. Acta Clin Belg 2010;65:91-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20491358" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Iannuzzi M, Siconolfi P, D'Angelillo A, Capuano M, Tufano L, Macri M. A post-partum hemolytic-uremic-like-syndrome in a patient with pre-eclampsia: description of a clinical case. Transfus Apher Sci 2006;34:11-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16427809" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Karam JS, Pitiranggon P, Wheat H, Stefanick B, Venuto RC. Postpartum hemolytic uremic syndrome in a patient with preexisting hypertension and resolving preeclampsia. Clin Nephrol 2007;68:38-41. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17703834" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Vesely SK, George JN, Lämmle B,\u{A0}Studt JD, Alberio L, El-Harake MA, et al. ADAMTS13 activity in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. Blood 2003;102:60-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12637323" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Fakhouri F, Roumenina L, Provot F,\u{A0}Sallée M, Caillard S, Couzi L, et al. Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. J Am Soc Nephrol 2010;21:859-67. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20203157" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Primhak RA, Taitz LS, Variend S, Webb DH, Cser A. Necrosis of the pancreas in the haemolytic uraemic syndrome. J Clin Pathol 1984;37:655-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/6373838" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sturm V, Menke MN, Landau K, Laube GF, Neuhaus TJ. Ocular involvement in paediatric haemolytic uraemic syndrome. Acta Ophthalmol 2010;88:804-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19604154" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lampinen K, Peltonen S, Pettilä V, Kaaja R. Treatment of postpartum thrombotic microangiopathy with plasma exchange using cryosupernatant as replacement. Acta Obstet Gynecol Scand 2004;83:175-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14756736" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mocan H, Mocan MZ. Postpartum hemolytic uremic syndrome with a more severe liver involvement. Clin Nephrol 1998;49:319-20. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9617497" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Matsumae T, Takebayashi S, Naito S. The clinico-pathological characteristics and outcome in hemolytic-uremic syndrome of adults. Clin Nephrol 1996;45:153-62. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8706355" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02116995/0000003200000003/v0_201502091350/X0211699512001101/v0_201502091351/en/main.assets" "Apartado" => array:4 [ "identificador" => "35346" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Director - Casos clínicos breves" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02116995/0000003200000003/v0_201502091350/X0211699512001101/v0_201502091351/en/P1-E536-S3514-A11334.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699512001101?idApp=UINPBA000064" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 4 | 9 | 13 |
| 2024 Octubre | 49 | 45 | 94 |
| 2024 Septiembre | 69 | 29 | 98 |
| 2024 Agosto | 94 | 63 | 157 |
| 2024 Julio | 55 | 34 | 89 |
| 2024 Junio | 91 | 46 | 137 |
| 2024 Mayo | 105 | 41 | 146 |
| 2024 Abril | 82 | 51 | 133 |
| 2024 Marzo | 51 | 28 | 79 |
| 2024 Febrero | 70 | 35 | 105 |
| 2024 Enero | 56 | 29 | 85 |
| 2023 Diciembre | 39 | 25 | 64 |
| 2023 Noviembre | 74 | 37 | 111 |
| 2023 Octubre | 65 | 14 | 79 |
| 2023 Septiembre | 70 | 37 | 107 |
| 2023 Agosto | 57 | 20 | 77 |
| 2023 Julio | 96 | 39 | 135 |
| 2023 Junio | 61 | 15 | 76 |
| 2023 Mayo | 71 | 33 | 104 |
| 2023 Abril | 51 | 13 | 64 |
| 2023 Marzo | 56 | 20 | 76 |
| 2023 Febrero | 60 | 27 | 87 |
| 2023 Enero | 48 | 16 | 64 |
| 2022 Diciembre | 56 | 32 | 88 |
| 2022 Noviembre | 105 | 29 | 134 |
| 2022 Octubre | 69 | 37 | 106 |
| 2022 Septiembre | 77 | 33 | 110 |
| 2022 Agosto | 87 | 37 | 124 |
| 2022 Julio | 59 | 45 | 104 |
| 2022 Junio | 84 | 31 | 115 |
| 2022 Mayo | 52 | 33 | 85 |
| 2022 Abril | 66 | 56 | 122 |
| 2022 Marzo | 61 | 43 | 104 |
| 2022 Febrero | 55 | 55 | 110 |
| 2022 Enero | 106 | 46 | 152 |
| 2021 Diciembre | 71 | 39 | 110 |
| 2021 Noviembre | 71 | 41 | 112 |
| 2021 Octubre | 77 | 50 | 127 |
| 2021 Septiembre | 52 | 24 | 76 |
| 2021 Agosto | 61 | 47 | 108 |
| 2021 Julio | 57 | 30 | 87 |
| 2021 Junio | 73 | 30 | 103 |
| 2021 Mayo | 78 | 39 | 117 |
| 2021 Abril | 178 | 22 | 200 |
| 2021 Marzo | 118 | 36 | 154 |
| 2021 Febrero | 89 | 28 | 117 |
| 2021 Enero | 69 | 28 | 97 |
| 2020 Diciembre | 43 | 20 | 63 |
| 2020 Noviembre | 42 | 14 | 56 |
| 2020 Octubre | 32 | 22 | 54 |
| 2020 Septiembre | 34 | 7 | 41 |
| 2020 Agosto | 44 | 10 | 54 |
| 2020 Julio | 23 | 15 | 38 |
| 2020 Junio | 28 | 12 | 40 |
| 2020 Mayo | 45 | 5 | 50 |
| 2020 Abril | 29 | 16 | 45 |
| 2020 Marzo | 36 | 13 | 49 |
| 2020 Febrero | 30 | 21 | 51 |
| 2020 Enero | 53 | 28 | 81 |
| 2019 Diciembre | 45 | 35 | 80 |
| 2019 Noviembre | 39 | 22 | 61 |
| 2019 Octubre | 25 | 7 | 32 |
| 2019 Septiembre | 26 | 22 | 48 |
| 2019 Agosto | 22 | 15 | 37 |
| 2019 Julio | 23 | 20 | 43 |
| 2019 Junio | 32 | 11 | 43 |
| 2019 Mayo | 42 | 15 | 57 |
| 2019 Abril | 61 | 32 | 93 |
| 2019 Marzo | 46 | 23 | 69 |
| 2019 Febrero | 26 | 19 | 45 |
| 2019 Enero | 26 | 17 | 43 |
| 2018 Diciembre | 68 | 41 | 109 |
| 2018 Noviembre | 84 | 18 | 102 |
| 2018 Octubre | 43 | 10 | 53 |
| 2018 Septiembre | 65 | 17 | 82 |
| 2018 Agosto | 50 | 24 | 74 |
| 2018 Julio | 45 | 20 | 65 |
| 2018 Junio | 55 | 19 | 74 |
| 2018 Mayo | 45 | 15 | 60 |
| 2018 Abril | 58 | 13 | 71 |
| 2018 Marzo | 54 | 9 | 63 |
| 2018 Febrero | 47 | 6 | 53 |
| 2018 Enero | 54 | 9 | 63 |
| 2017 Diciembre | 66 | 8 | 74 |
| 2017 Noviembre | 44 | 10 | 54 |
| 2017 Octubre | 34 | 9 | 43 |
| 2017 Septiembre | 53 | 16 | 69 |
| 2017 Agosto | 62 | 22 | 84 |
| 2017 Julio | 54 | 9 | 63 |
| 2017 Junio | 53 | 22 | 75 |
| 2017 Mayo | 67 | 11 | 78 |
| 2017 Abril | 63 | 7 | 70 |
| 2017 Marzo | 48 | 14 | 62 |
| 2017 Febrero | 40 | 16 | 56 |
| 2017 Enero | 22 | 17 | 39 |
| 2016 Diciembre | 81 | 8 | 89 |
| 2016 Noviembre | 76 | 20 | 96 |
| 2016 Octubre | 124 | 17 | 141 |
| 2016 Septiembre | 142 | 3 | 145 |
| 2016 Agosto | 238 | 7 | 245 |
| 2016 Julio | 245 | 10 | 255 |
| 2016 Junio | 113 | 0 | 113 |
| 2016 Mayo | 142 | 0 | 142 |
| 2016 Abril | 103 | 0 | 103 |
| 2016 Marzo | 108 | 0 | 108 |
| 2016 Febrero | 148 | 0 | 148 |
| 2016 Enero | 156 | 0 | 156 |
| 2015 Diciembre | 143 | 0 | 143 |
| 2015 Noviembre | 122 | 0 | 122 |
| 2015 Octubre | 101 | 0 | 101 |
| 2015 Septiembre | 83 | 0 | 83 |
| 2015 Agosto | 85 | 0 | 85 |
| 2015 Julio | 89 | 0 | 89 |
| 2015 Junio | 55 | 0 | 55 |
| 2015 Mayo | 91 | 0 | 91 |
| 2015 Abril | 18 | 0 | 18 |
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