Acute renal failure in severe leptospirosis

Ramón Peces

Service of Nephrology, Hospital Universitario La Paz, Madrid, Spain Email: cpeces{at}varnet.com

Sir,

Leptospirosis is considered a re-emerging infectious disease throughout the world, although the disease tends to be most frequently encountered in tropical and subtropical areas. The mortality of patients who develop acute renal failure as part of severe leptospiral infection remains high, despite the introduction of sophisticated support systems, including dialysis, plasma exchange and continuous renal replacement therapy [15]. In a retrospective study reported in a local journal [6], we analysed 24 patients with acute renal failure of severe leptospirosis associated with multiorgan involvement (Weil's syndrome), who were admitted over a 14 year period. The median patient age was 44.3 years (range 16–71 years) and the male/female ratio was 23:1. In six patients, the impairment of renal function was mild (pre-renal azotaemia) and resolved following intravenous fluid therapy. In 18 patients, the acute renal failure was moderate to severe, with 11 patients (46%) requiring dialysis. Nine of them were treated by continuous peritoneal dialysis and two patients by haemodialysis. Hyperbilirubinaemia occurred in 22 patients (92%), marked hypertriglyceridaemia in 24 (100%) and thrombocytopenia in 14 (58%). Serum urea, creatinine, bilirubin and triglyceride levels were higher in thrombocytopenic than in non-thrombocytopenic patients (Table 1Go). In addition, there was a significant inverse correlation between platelet count on the one hand and serum creatinine (r=-0.44, P<0.05) and bilirubin (r=-0.52, P<0.01) on the other. There were significant positive correlations when triglyceride levels were compared with bilirubin (r=0.65, P<0.005) and creatinine (r=0.51, P<0.02). Ten patients (42%) had evidence of a mild form of disseminated intravascular coagulation (thrombocytopenia and raised plasma levels of fibrinogen-degradation products). Eight patients (33%) had bleeding from the gastrointestinal tract. Seven patients (30%) presented respiratory failure and needed ventilatory support. Renal histopathology in four patients showed acute tubulointerstitial nephritis [7]. Liver histopathology in 12 patients was characteristic of leptospiral hepatitis with cholestasis and minimal inflammatory cell infiltration. Treatment was essentially supportive but antibiotics were administered to 19 of the 24 patients. General supportive measures included fluid and electrolyte reposition, vitamin K and transfusion of packed RBC, platelets and fresh-frozen plasma when necessary. Twenty-two patients (92%) recovered completely after 1–5 weeks. Triglyceride levels returned to normal after complete resolution of the picture. Two patients (8%), who had fulminant hepatorenal and haemorrhagic syndromes, died. We concluded that thrombocytopenia occurs frequently in acute renal failure from leptospirosis and bears a worse morbidity. Increase in triglyceride level in a suspected case of leptospirosis may be considered as a marker. It may be related to the severity of the acute renal failure and hepatitis seen during leptospirosis. A high degree of suspicion, early recognition and intensive supportive therapy, including the use of antibiotics and dialysis, could account for the low overall mortality observed in these patients.


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Table 1.  Characteristics of renal failure in thrombocytopenic and non-thrombocytopenic patients with leptospirosis

 

Conflict of interest statement. None declared.

References

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