A CASE OF RENAL-LIMITED THROMBOTIC MICROANGIOPATHY WITH COLLAPSING GLOMERULOPATHY IN A PATIENT TAKING UNLABELLED BODYBUILDING SUPPLEMENTS
Dr HARSHA SURESH1, Dr AISHA YASEEN1, Dr JING JING LI2, Dr MICHAEL SURANYI1
1Department of Renal Medicine, Liverpool Hospital, Liverpool , Australia, 2Department of Anatomical Pathology, Liverpool Hospital, Liverpool, Australia
Background: Renal-limited thrombotic microangiopathy (TMA) is a rare condition described in case reports, often under-recognised without systemic features of TMA. This poses a challenge as the mainstay of treatment is addressing the underlying aetiology. Here, we describe a case of an acute kidney injury (AKI) secondary to renal limited TMA with features of collapsing glomerulopathy due to a decade of unlabelled, illicit bodybuilding supplement use.
Case Report: A 28-year-old man with a 10-year history of growth supplement use, including various formulations of testosterone, presents with malignant hypertension, AKI and proteinuria. Renal tract imaging did not demonstrate an infarct or structural abnormalities. He had abnormal complement levels demonstrating low C3 of 0.76 g/L and high C4 of 0.49 g/L raising the question of atypical haemolytic uraemic syndrome, however, this was not supported by other biochemical parameters. He had an otherwise negative glomerulonephritis screen. A renal biopsy demonstrated glomerular arterioles with vascular thrombosis consistent with TMA, with additional evidence of widespread tubular atrophy, interstitial fibrosis and global sclerosis. There was evidence of regenerative changes in tubules and active inflammation, with few crescents.
The patient was approved for eculizumab for suspected immune mediated renal-limited TMA with 900mg weekly for 4 doses, and concurrently treated with 4-week tapering course of prednisone commencing at 50mg daily for concurrent interstitial nephritis. Despite treatment, his renal function continued to deteriorate with a creatinine of 742 µmol/L, becoming symptomatic requiring initiation of peritoneal dialysis.
Conclusions: This is a case that demonstrates bodybuilding supplement use as an underlying cause for renal limited TMA, resulting in substantial irreversible kidney injury necessitating the commencement of renal replacement therapy despite treatment with eculizumab or corticosteroids.
Biography:
Dr Harsha Suresh is a Basic Physician Trainee at Liverpool Hospital, New South Wales, Australia.