Malik Anas Rabbani, Syed Mansoor Ahmed Shah, Aasim Ahmad, Mahesh Moolani.
Acute Renal Cortical Necrosis - A Case Report and Review of Literature.
J Coll Physicians Surg Pak Jan ;11(5):337-9.

Acute renal cortical necrosis (ACN) is an uncommon, catastrophic and preventable disease but remains as a common cause of acute renal failure of obstetrical origin in developing countries. Obstetric complications responsible for ACN include septic abortions, severe pre-eclamsia, amniotic fluid embolism, retained fetus, abortion and placenta previa which account for more than half of all causes of acute cortical necrosis. We report a case of a 34-year-old female with acute diffuse renal cortical necrosis secondary to obstetric complication followed by review of possible pathogenesis, diagnosis and management.

Case Report: A 34-year-old female was admitted to a hospital with 7 months of gestation. She gave birth to a stillborn baby and subsequently underwent dilatation and evacuation. Forty-eight hours later her urine output declined, became anuric and developed signs and symptoms of uremia. She was shifted to our unit for further management. There was no prior history of hypertension or toxemia of pregnancy, nephritis, urinary tract infection, hematuria or any familial renal disease. This was her 5th pregnancy having had four previous uncomplicated pregnancies and deliveries. On physical examination she had a pulse rate of 88/min with blood pressure of 160/90 mmHg. She was afebrile and no edema or jugular venous distension was noted. Systemic examination was unremarkable. Laboratory investigations revealed Hb.10gms/dl, WBC 23.4X109/l with 88% left shifted neutrophils, platelet count 110X109/l, sodium 126mEq/l, potassium 4.1mEq/l, chloride 92mEq/l, bicarbonate 16.8mEq/l, serum creatinine 7.5 mg/dl, blood urea nitrogen 60 mg/dl, RBS 99 mg/dl. Liver function tests, PT and aPTT were within normal range. Urinalysis revealed mild proteinuria and hematuria. Ultrasound abdomen showed normal sized kidneys, preserved corticomedullary differentiation with a non-obstructing left renal calculus.

Over the next 48 hours she remained anuric. Keeping in view the history of obstetric complication with persistent anuria for 5 days and ultrasound showing no evidence of obstruction, clinical diagnosis of acute cortical necrosis was made. Renal biopsy was done which revealed large areas of coagulation necrosis of renal parenchyma characterized by presence of ghost appearing glomeruli and renal tubules. In the deeper parts of medulla some viable renal tubules were identified. These features were consistent with acute cortical necrosis. Considering diffuse nature of renal parenchymal involvement and negligible chance of recovery of renal function, an arterio-venous fistula was made in the left arm. She was started on hemodialysis and was finally discharged. Six months follow-up revealed no recovery of renal functions as she regularly requires chronic maintenance hemodialysis.

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