Acute kidney injury requiring hemodialysis in patients with anicteric leptospirosis

Leptospirosis is an infrequent disease in the US, with most cases reported in the state of Hawaii. Renal involvement is common (44 - 67%), ranging from a mild prerenal azotemia in anicteric disease to renal failure requiring dialysis in Weil's syndrome (severe leptospirosis with jaundice, renal failure, and hemorrhage).

To describe the pattern of leptospiral renal disease at our institution, we performed a retrospective analysis (1992 - 2004) of all hospitalized cases of laboratory confirmed leptospirosis presenting with acute kidney injury (AKI), defined as a presenting serum creatinine > 1.5 mg/dl.

During this time period, 18 patients were hospitalized with laboratory confirmed leptospirosis. Among these patients, 12 had AKI on presentation, and hemodialysis was required in 3 patients. Renal biopsies were performed in 2 of these patients, revealing acute tubulointerstitial nephritis. Interestingly, the patients who required dialysis did not have Weil's syndrome. They did not exhibit jaundice or hemorrhage, and serum AST (mean 51.7 U/l (range 36 - 60)), ALT (mean 51.0 U/l (range 38 - 64)), and total bilirubin (mean 1.2 mg/dl (range 0.8 - 1.8)) were either within normal limits or only slightly elevated, despite having the worst renal disease.

This series adds to other evidence that severe AKI (requiring dialysis) can complicate anicteric leptospirosis in contrast to the notion that the AKI in anicteric disease is typically mild and prerenal. Leptospirosis should be considered in all patients who present with fever and AKI, especially if associated with thrombocytopenia or travel to an endemic area.