Poombavai O. Nagappan M.D.              ST. LOUIS UNIVERSITY  
Acute renal failure due to acetaminophen toxicity   
         
 

A 19 year old white female with a past medical history of depression was hospitalized for acetaminophen toxicity. The patient had consumed 60 gm of acetaminophen and presented to the emergency room 20 hours thereafter. She had 15 to 20 episodes of vomiting prior to arrival at the emergency room. Vitals: BP 128/80 PR 105 RR22 Temp 99.2 HT 5’4" Wt 58.9K. The physical examination was significant for asterixis. The acetaminophen level 20 hours after ingestion was 56 mcg/ml (toxic range). Admission labs were as follows; SGOT 168 U/L, SGOT 171 U/L, Bilirubin 1.9, Alk 123 U/L, BUN 10 mg/dl Cr 0.7 mg/dl PT/INR 22.5/2 NH 119 umol/L. On day #2 (Peak values) SGOT 15130, SGPT 9470 PT/INR 3.2. The patient was started on N-acetyl cysteine on day #1 after acetaminophen ingestion. On day #3 acetaminophen levels were undetectable. The patient was started on loop diuretics. On day #6 urine output had decreased to 30 ml;/24 hours and creatinine had gradually increased to 6.3, chest x-ray showed pulmonary vascular congestion and right pleural effusion. Urinalysis: specific gravity 1.014, pH 5, protein 30, glucose 250 mg/dl, ketones negative, blood large, nitrite: neg, leukocyte esterase: trace, RBC 2, WBC 2, bacteria occ, eosinophils: neg. On day #8 liver function test had normalized. On day #11 the creatinine had peaked at 14.4 mg/dl. And the urine output had gradually increased to 4800ml. The patient did not need hemodialysis and there was spontaneous remission of kidney function by day #13 when the creatinine level improved to 6.1 mg/dl.

Review of literature showed that acute renal failure secondary to acetaminophen poisoning occurs alone or in combination with hepatic necrosis. Acute renal failure occurs in less than 2% of all acetaminophen poisonings and manifests as acute tubular necrosis. Thus, although liver failure remains the major cause of death from acetaminophen overdose, this case report emphasizes that acute renal failure is a source of considerable morbidity in these patients.