Acute Renal Failure Due to Leptospirosis in a Renal Transplant Patient

Roberto C. Manfro, MD, Hospital de Clínicas de Porto Alegre, Unidade de Transplante Renal, Porto Alegre, RS. 90210 (Brazil) Dear Sir, Acute renal dysfunction in the late course ofrenal transplantation is an unusual finding. The present report describes a case of acute renal failure (ARF), secondary to an episode of leptospirosis, in a renal transplant patient 20 years after transplantation. A 20-year-old man received a haplotype-matched kidney allograft in 1971. In September 1990, his serum creatinine was 97.3 μmol/ 1 (1.1 mg/dl) and he was receiving 150 mg of azathioprine q.d. since he had discontinued prednisone on his own 2 years before. Four months later, he presented to the emergency room with a 5-day history of muscle pain, fever, vomiting and diarrhea. He reported he had had contact with rat tissues 10 days prior to admission. The physical examination displayed an acutely ill patient with a blood pressure of 120/70 mm Hg, heart rate of 140 and a temperature of 38 °C. He also presented jaundice, bilateral conjunctival suffusion, a tender liver, splenomegaly and petechiae in the medial aspect of the right thigh. The allograft was not tender. Numerous warts were present in the patient’s hands. At that moment, his serum creatinine and BUN were 530.4 μmol/l (6.0 mg%) and 26 mmol/dl (73 mg%), respectively, SGOT 38 and SGPT 42 U/l. Total and direct bilirubin increased up to 9.8 and 7.0, respectively, 2 days later. Leukocytes were 15,600/mm3, and platelet count was 15,000/mm3. Urinalysis displayed 3 + proteinuria, and the urinary sediment had 5 erythrocytes and 20 leukocytes per high-power field with granular and hyaline casts. He was treated with intravenous fluids, penicillin, vitamin K, cimetidine and loperamide. The azathioprine dosage was halved in the next 2 days and discontinued by the 3 day when peritoneal dialysis was started due to worsening of uremia and continued for 48 h. Within 24 h. of admission, the urinary volume was 450 ml. Afterwards, he presented improvement of diuresis and renal function. Prednisone 10 mg/day was started by the 10th day and azathioprine 50 mg/day 2 weeks later. Antileptospira IgM antibodies tested positive (macroagglutination). The patient was discharged 14 days after admission with normal renal function. This report describes a case of ARF secondary to leptospirosis in a renal transplant patient 20 years after transplantation. We think that leptospira transmission may have occurred through