PMC5907419_01
Graph with patient's serum creatinine over time, before and after admission for AKI.
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Baseline serum creatinine was 0.7 mg/dl three months prior to this presentation (Figure 1) and eGFR was 91 ml/min by CKD-EPI creatinine equation.
(a) Kidney biopsy showing acute tubular necrosis (ATN) with globular cast material in the tubules and interstitial edema (hematoxylin and eosin stained 200x). (b) Special stain for hemoglobin highlights yellow staining in the globular cast material (200x). ((c) and (d)) Direct immunofluorescence staining for IgA and C3 shows granular mesangial staining, respectively (400x). (e) Ultrastructural examination shows osmophilic globular hemoglobin casts in tubular lumen (uranyl acetate and lead citrate fixation, 10,000x). (f) Ultrastructural examination shows small scattered paramesangial electron dense immune-type deposits (uranyl acetate and lead citrate fixation, 12,000x).
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The biopsy processed per routine protocol (light microscopy, direct immunofluorescence, and electron microscopy) had 23 glomeruli with mild focal mesangial hypercellularity, diffuse acute tubular necrosis (ATN), interstitial edema, and granular/globular casts in scattered tubules (Figure 2(a)). Immunoperoxidase stain for myoglobin was negative, but hemoglobin stain showed yellow-green staining in the globular tubular casts (Figure 2(b)). Direct immunofluorescence study showed mild (1+) mesangial IgA and complement C3 (Figures 2(c) and 2(d)). Electron microscopic examination showed tubules with globular casts and few scattered mesangial electron dense immune-type deposits (Figures 2(e) and 2(f)).