A teenager presenting with anuric acute renal failure and metabolic acidosis with a high anion gap: Answers
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CLINICAL QUIZ
A teenager presenting with anuric acute renal failure and metabolic acidosis with a high anion gap: Answers Çağla Serpil Doğan 1 & Gülşah Kaya Aksoy 1 & Kadir Aras Demircan 1 & Şenay Yıldırım 2 Received: 20 March 2020 / Accepted: 23 March 2020 # IPNA 2020
Answers 1. When we repeatedly asked him about nephrotoxic medications, herbs, or drug abuse, he reported that he had sniffed one tube (150 g) of an industrial adhesive including toluene 2 days before his admission. However, he denied chronic toluene abuse. 2. In this case, we did not measure toluene concentration in blood or its metabolite hippuric acid in urine. However, there was a history of toluene exposure, and he had multiple organ injury on admission. In addition, histolopathological findings of proximal tubular injury, suggesting exposure to a toxic substance, were demonstrated. The diagnosis was considered toluene intoxication based on anamnesis and clinical and laboratory findings.
Discussion In recent years, inhalation of adhesives including toluene has gradually increased especially among adolescents. Toluene absorbed by the lungs is metabolized into hippuric acid in hepatic microsomes and excreted in urine. Toluene and its urinary metabolite hippuric acid may cause multiple organ failure and even lead to sudden death in both chronic and acute users [1, 2]. In this report, we presented an adolescent This refers to the article that can be found at https://doi.org/10.1007/ s00467-020-04549-9. * Çağla Serpil Doğan [email protected] 1
Department of Pediatrics, Division of Pediatric Nephrology, Antalya Training and Research Hospital, 07059 Antalya, Turkey
2
Department of Pathology, Antalya Training and Research Hospital, Antalya, Turkey
with acute toluene intoxication and reviewed its effects on renal function, acid-base, and electrolyte balance. Renal tubular dysfunction has been reported in most of the cases exposed to toluene. The hallmark of tubular dysfunctions associated with toluene is considered distal renal tubular acidosis (RTA); however, various types of metabolic acidosis can be caused by several different mechanisms. First, hippuric acid is dissociated in hippurate anions and protons. While protons are titrated by endogenous bicarbonate ( HC0 3 − ) to form C0 2 at collecting ducts, indirect loss of HC03− from distal nephron, hippurate anions are excreted with ammonium (NH4+) in the urine. When excretion rate of anions exceeds excretion rate of NH4+, anions are also combined with sodium and potassium. Resulting is distal RTA, characterized by hypokalemic, hyperchloremic metabolic acidosis with a normal anion gap as well as positive urinary anion gap. In addition, the obligatory excretion of sodium along with hippurate anions results in volume contraction of extracellular fluid. Second, Fanconi syndrome may occur due to direct toxicity of toluene on proximal tubule and accompany distal RTA, mixed-type acid-base disorder. Third, if hippuric acid accumulates in the plasma due to low GFR and/or high production rate that ex
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