Acute renal failure during acute fatty liver of pregnancy.

The patient, who was 28 years old and in her first pregnancy (34 weeks), was admitted to the obstetric ward because of jaundice. She complained of weakness, anorexia, and vomiting. No history of high blood pressure was reported. On the first day of hospitalization she spontaneously delivered a ‘mors in utero’. The immediate postpartum period was followed by a severe haemorrhage and it became necessary to perform a subtotal hysterectomy because of persistent atony of the uterus. However, jaundice advanced and the clinical situation worsened. Twenty-four hours after delivery the urinary output was 1.2 luday and laboratory tests showed a minimal proteinuria, pronounced anaemia but with a normal platelet count and bilirubin levels were 4.97 mg% (direct) and 6.63 mg% (indirect). There were moderately increased blood levels of urea and creatinine but a pronounced increase of uric acid (13.4 mg%). The glomerular filtration rate (GFR) was calculated to be 15 mlumin. SGOT was 102 U and SGPT was 55 U. On the second day of hospitalization, a moderate microscopic haematuria was observed. Plasma electrolytes levels were potassium 2.8 mequl and calcium 0.98 mequl. The platelet count was decreased (84 000uh.p.f.). On the third day the levels of urea (380 mgudl) and creatinine (5.6 mgudl) increased. Blood transfusions resulted in an improvement in anaemia and a normal urine output was observed. Direct bilirubinaemia predominated (5 mgudl) over indirect bilirubinaemia (1 mgudl). Some ascitic fluid was detected. On the ultrasound of the abdomen a brightness of the liver was noticed and both kidneys were of normal dimensions with a slightly hyperechogenic parenchyma. Despite intensive therapy, the patient’s conditions deteriorated 12 days after hospitalization. The Hct was 17%, haemoglobin 5.5 gudl, platelets 45 720, bleeding time 1.5 min, coagulation time 2 min, level of prothrombin 56%, alkaline phosphatase 194 U, and proteinaemia 4.8 gudl. Normal urinary output persisted but blood urea was 350 mgudl and creatinine 6.4 mg%, SGOT was 74 U, and SGPT was 61 U. Soon thereafter, the patient had profuse melena and haematemesis and she died on the 13th day after delivery.