The Turkish Journal of Pediatrics 2023 , Vol 65 , Num 5
Hemoglobin cast nephropathy: a rare but serious complication of hemolysis in a pediatric patient
Demet Baltu 1 ,Nihan Avcu Oral 2 ,Selman Kesici 3 ,Rezan Topaloğlu 1 ,Osman İlhami Özcebe 4 ,Tekin Aksu 5 ,Diclehan Orhan 6 ,Fatih Özaltın 1
1 Division of Pediatric Nephrology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara
2 Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara
3 Division of Pediatric Intensive Care Unit, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara
4 Department of Internal Medicine, Hematology Unit, Hacettepe University Faculty of Medicine, Ankara
5 Division of Pediatric Hematology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara
6 Department of Pathology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
DOI : 10.24953/turkjped.2022.1067 Background. Intravascular hemolysis is a serious and rare condition in children and causes the release of hemoglobin and heme into circulation, which have proinflammatory properties. These substances lead to inflammation, oxidative stress, apoptosis, and organelle dysfunction that lead to acute kidney injury (AKI). We report a pediatric case diagnosed with hemolysis-associated hemoglobin cast nephropathy due to autoimmune hemolytic anemia.

Case. A 4-year-old boy, who was admitted to another hospital with complaints of fever and dark urine for one day, developed anemia and kidney failure in the follow-up, was referred to our hospital. In physical examination, pallor and icterus on the sclera were noted. The patient had low hemoglobin and haptoglobin levels concomitant with high levels of serum lactate dehydrogenase, urea and creatinine. A peripheral blood smear showed marked spherocytes without schistocytes. A kidney biopsy was performed due to ongoing overt hemolysis and dialysis requirement, which showed findings consistent with hemoglobin cast nephropathy. Although the initial polyspecific direct antiglobulin test (DAT) was negative, due to persistent intravascular hemolysis DAT was studied monospecifically and showed IgM antibody positivity. Therefore, a diagnosis of autoimmune hemolytic anemia was made, and corticosteroid treatment was started. Hemolysis immediately ceased and the need for erythrocyte transfusion and dialysis disappeared.

Conclusions. Acute kidney injury associated with hemoglobin cast nephropathy is an extremely rare condition in childhood. Although the initial course is severe and potentially life-threatening, the prognosis is favorable with the treatment of the underlying cause and management of AKI. Therefore, pediatricians should be aware of this rare clinical entity during clinical practice. Keywords : acute kidney injury, autoimmune hemolytic anemia, intravascular hemolysis, hemoglobin cast nephropathy

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