#2182 An unexpected life-threatening cause of kidney failure
Authors: Gliga Mirela Liana , Chirila Cristian , Cotoi Ovidiu , Gliga Mihail Gheorghe , Morariu Silviu , Chirila Paula 
Published: May 2024

Abstract

Background and Aims
Kidney failure can appear in acute clinical conditions and the cause cannot always be determined, as in approximately 40% of cases that require renal replacement therapy (RRT). In addition, there are other cases in which a patient with persistently low estimated glomerular filtration rate (eGFR) for 3 months is treated with RRT without a primary renal diagnosis. Systemic sclerosis (SSc) is a rare condition that can lead to RRT due to renal ”crisis”. Autopsy studies reveal kidney pathology in approximately 60 percent of patients with SSc. In addition, as many as 50 percent of patients with SSc have markers of kidney disease, as manifested by mild proteinuria, elevated serum creatinine concentration, and/or hypertension. The aim of our paper is to describe a case in which hemodialysis was initiated in emergency setting and the diagnosis was established after that. However clinical course was fatal and the final diagnosis was SSc.

Method
A 65-year-old male patient was admitted to the Nephrology department with a weight loss of 20 kg in 2 years, depression, low appetite and progressive decline of physical strength. He was previously diagnosed with diabetes mellitus (DM) and high blood pressure (HBP), the ponderal loss being attributed to DM. Insulin treatment was initiated together with antihypertensive medication. In the following 3 months, the kidney function deteriorated progressively and hemodialysis was started. Gray scale and CEUS US were performed to assess a possible cause of kidney failure. However, after the commencement of hemodialysis, the clinical condition did not improve and patient died in respiratory failure complicated by continuous pleural effusion. A skin biopsy from the right thigh was performed for the positive diagnosis.

Results
At clinical evaluation the patient was cachectic, with striking generalized parchment-like skin lesions which were suggestive both for ichthyosis or SSc.
Laboratory tests revealed hyperglycemia, anemia, hypoalbuminemia, increased lactate dehydrogenase and creatine kinase (CK), mild proteinuria and glomerular hematuria. On the other side, myositis antibodies (AB) panel, antinuclear AB, tumor markers for pancreas and gastro-intestinal carcinoma, AB for vasculitis and lupus were negative. Ultrasound (US) (grey scale and CEUS) described dilated bile ducts and gallbladder with massive sludge, without evidence of tumoral neovascularization, and shrunk kidneys with hypoechoic medulla. CT scan confirmed the US findings. Dialysis parameters indicated kt/V 1.4 and urea reduction ratio of 79%. Therefore, no metabolic disturbances could explain the severely altered medical status. The clinical condition of the patient made the kidney biopsy unfeasible. Nevertheless, we decided to perform a skin biopsy, which revealed gross collagen bands, absence of sebaceous glands or hair follicles, as well as rare capillaries with lymphocyte inflammatory infiltrate and absence of hypoderma, thus confirming the diagnosis of SSc.

Conclusion
SSc can present with obscure clinical signs, leading to multiple organ dysfunction and initially unapparent cause of kidney failure. However, clinicians must be aware of potentially suggestive etiological signs such as parchment-like skin lesions and high blood pressure in a patient with multiple comorbidities. One must differentiate a dehydrated skin from a pathognomonic skin lesion as it is in SSc.