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ACUTE RENAL FAILURE PROGRESSING TO ESRD IN A PATIENT WITH UNTREATED HIGH GRADE HYPERTENSION – THE MALIGNANT NATURE OF “BENIGN’’ NEPHROSCLEROSIS

Objective: A 43 year old male with history of hypertension, non-adherence to medications, heavy smoking (since age 8) and alcohol abuse was admitted with epigastric pain, heartburn and upper GI bleeding (hematochezia) for which he had been recently taking PPI. On arrival his BP was 182/100 mmHg, HR-89, decreased breath sounds + wheezes. Design and method: Hemoglobin was 7.4 mg/dL, Creatinine 11.2 mg/dl (recent baseline 1.1 mg/dl) Urea- 200 mg/dl. He soon after needed HD which he continues a thrice weekly basis. Four months prior to this admission he was hospitalized with hemoptysis, BP up to 261/136mmHg, proteinuria (1.5 gram/gram) and microhematuria, mild creatinine elevation to 1.3 mg/dL and hypokalemia of 2.6 mg/dL. Fundus examination revealed high grade retinopathy with cotton wool spots and flame hemorrhages but no papilledema. Supine Renin was 41.37microunits/ml, aldosterone was 30ng/dl. Results: Since his renal function has not improved, and in parallel with HD treatments he undergone a kidney biopsy which revealed advanced benign nephrosclerosis (figure 1) with some FSGS, a single crescent and marked interstitial inflammation with eosinophils (figure 2) Conclusions: Untreated high-grade hypertension and severe “benign’’ nephrosclerosis represent a microvascular ischemic nephropathy (similar to critical bilateral RAS) in which a relatively minor insult can deteriorate the patient into ESRD. While being non-adherent to different anti hypertensive medications, patient did take omeprazole which triggered acute interstitial nephritis on the background of advanced ischemic nephropathy, leading to permanent loss of renal function.