Rapid Anuric Acute Kidney Injury After the Administration of IV Anti-D in a Teenager

A 16 year old male developed dark brown urine and prolonged anuric renal failure requiring hemodialysis after receiving IV anti-D. He was diagnosed with idiopathic thrombocytopenia purpura (ITP) after presenting with diffuse petechiae and a platelet count of 7000/μl, about a week after onset of viral prodrome that had resolved 2 days before. The white cell count, hemoglobin, PT, PTT, INR, and direct Coomb’s screen (IgG and complement) values were normal/negative at initial presentation, as were plasma chemistries, including LDH and uric acid levels. Except for small ketones and small heme reactions, the initial urinalysis was also unremarkable. Following IV anti-D, the patient developed intravascular coagulation concurrent with hemolysis and renal failure.

In this case report we describe a teenager who presented with ITP and rapidly developed severe anuric acute kidney injury (AKI) associated with mild intravascular hemolysis and coagulopathy. We review previous reports of IV Anti-D associated AKI, in order to identify common risk factors that may be used as a pre-treatment screen.

Anuric renal failure following IV anti-D has previously been reported and is a profoundly rare complication associated with a high risk of death. There is no reliable screening test, as this case illustrates. The clinical and laboratory course in this teenager, as well as from other reported cases, lead us to speculate that while hemolysis following IV-anti D infusion is necessary for the development of acute renal failure, it is insufficient unless there is a concurrent or antecedent intravascular coagulopathy. We suggest that the D-dimers assay should be formally evaluated as a screen prior to IV anti-D therapy to identify those individuals at risk for this life-threatening adverse reaction.

IV anti-D is a good option for the treatment of ITP but the risks should be seriously considered prior to administration. A preliminary workup should be initiated prior to therapy. Other forms of treatment may be necessary in patients with evidence of renal insufficiency, hemolysis, recent EBV infection, known positive C-antigen or evidence of coagulopathy. We are planning a prospective study to evaluate the usefulness of obtaining a D-dimer in ITP patients prior to treatment. This will elicit information that is currently unavailable regarding the frequency of positive D-Dimers in patients with ITP prior to treatment.

No relevant conflicts of interest to declare.