Dengue-Associated Tubulopathy with Resultant AKI and Dialysis Dependence

Introduction: Dengue disease remains a prevalent mosquito transmitted viral infection worldwide. The incidence of dengue has increased 30-fold in the past 50 years. Acute kidney injury (AKI) is a serious complication of dengue with high morbidity and mortality. The available data regarding AKI in dengue is sparse and mostly originates from case series and case reports. We present a case of acute tubular injury secondary to dengue. Case Description: A 59-year-old male presented with AKI on CKD with proteinuria, shortness of breath and lower extremity swelling. He was diagnosed with dengue fever and thrombocytopenia 1 month prior to admission in Brazil, where nephrotic range proteinuria was also found. Labs were significant for a creatinine of 10.1mg/dL and albumin of 1.9gm/dL. Protein to creatinine ratio was 12g/day. Proteinuria work up included C3, C4, Hepatitis B, C panel, HIV screen, anti-PLA2R, P-ANCA, C-ANCA, kappa/lambda ratio, free kappa light chains, and free lambda light chains was non-diagnostic. With worsening renal function and development of volume overload, hemodialysis was initiated, and renal biopsy was obtained. Biopsy demonstrated acute tubular injury denoted by markedly dilated tubules lined by flattened epithelium. Ultrastructural findings support acute tubular injury with loss of brush border. Methylene blue stained section revealed increase in mesangial matrix and protein resorption vacuoles in podocytes with acute tubular injury noted in surrounding tubules. With no signs of renal recovery, patient was discharged on scheduled dialysis and follow up with renal function monitoring. Discussion: This case illustrates the potential long-term complications with dialysis dependence resulting from tubular injury caused by dengue infection. Dengue is an emerging source of global disease burden with limited data regarding cases complicated by AKI. Earlier recognition and management may lead to a significant reduction in dengue related renal complications in endemic areas.