Volume 3, Number 19;  November 15, 2004

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Resident Report 11/15/04 -- Shirine Allam

Left Flank Pain and Anuria

Case:  A 67 yo man presented with a 24 hour history of left sided flank pain that was dull, severe and constant.  It had started acutely the day prior to admission and was non- radiating.  It was associated with nausea and vomiting and decreased urinary output.  He had no hematuria, no constipation, no melena or hematochezia.  Past medical history was significant for dementia, paroxysmal atrial fibrillation, gout, poorly controlled hypertension, a right-sided nephrectomy in 1976 for a renal abscess and chronic kidney disease (baseline creatinine of 2.0).

            His medications included allopurinol, ASA and metoprolol.  He was taken off coumadin 3 weeks ago because of his risk of falls.

On admission his vitals were significant for a BP of 200/120.  His physical exam was unremarkable except for a mild left sided CVA tenderness. His EKG in the ER showed atrial fibrillation.  His labs showed a creatinine of 2.6.

A renal ultrasound was obtained and showed a normal left kidney.  A doppler view could not be done because of poor windows.  A CT scan of the abdomen without contrast revealed medullary calcifications (stones) but no signs of hydronephrosis or hydroureter.

The next day the patient was noted to be anuric and over the next two days his creatinine increased to 6.5, and he developed a transient fever and white count of 30,000.

An MRI/MRA was obtained 4 days after admission and showed an abrupt termination of the left renal artery consistent with thromboembolic disease, only 30% of the kidney was enhancing. The patient was put on heparin. It was decided not to perform embolectomy or thrombolysis because of the risks outweighing the benefits at this late point of the presentation. The patient was placed on permanent hemodialysis.

Clinical Question(s): 

1-     What is the sensitivity of Doppler ultrasound to detect renal artery thrombosis?

2-     What is the sensitivity of CT scan to detect urinary tract obstruction and hydronephrosis/hydroureter?

3-     What is the time frame and expected outcome of thrombolysis or embolectomy in renal artery stenosis?

4-     What are the risk factors associated with renal artery thrombosis?

Readings:

 Link Directly to Fulltext article in Ovid

<1>

Unique Identifier:15342973

Authors: Hazanov N. Somin M. Attali M. Beilinson N. Thaler M. Mouallem M. Maor Y. Zaks N. Malnick S.

Institution: Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel.

Title: Acute renal embolism. Forty-four cases of renal infarction in patients with atrial fibrillation.

Source: Medicine. 83(5):292-9, 2004 Sep.

Abstract: Acute renal embolus is rarely reported in the medical literature; thus, accurate data regarding presentation, laboratory tests, diagnostic techniques, and treatment are lacking. To better define this condition, we examined the medical records of all patients admitted to Kaplan Medical Center and Sheba Medical Center in central Israel from 1984 to 2002 who had a diagnosis of renal infarction and atrial fibrillation. We noted demographic, clinical, and laboratory parameters; method of diagnosis; treatment received; and patient outcome. We identified 44 cases of renal embolus: 23 females and 21 males, with an average age of 69.5 +/- 12.6 years. Thirty (68%) patients had abdominal pain, and 6 (14%) had a previous embolic event. Nine patients were being treated with warfarin on admission, 6 (66%) of whom had an international normalized ratio (INR) < 1.8. Hematuria was present in 21/39 (54%), and 41 (93%) patients had a serum lactate dehydrogenase (LDH) level > 400 U/dL. The mean LDH was 1100 +/- 985 U/dL. Diagnostic techniques included renal isotope scan, which was abnormal in 36/37 cases (97%); contrast-enhanced computed tomography (CT) scan, which was diagnostic in 12/15 cases (80%); and ultrasound, which was positive in only 3/27 cases (11%). Angiography was positive in 10/10 cases (100%). Twenty-three (61%) of 38 patients had normal renal function on follow-up. The 30-day mortality was 11.4%. Renal embolus was diagnosed mainly in patients aged more than 60 years, some of whom had a previous embolic event. Most of those receiving anticoagulant therapy had a subtherapeutic INR. Abdominal pain was common, as well as hematuria and an elevated LDH. These patients are at risk of subsequent embolic events to other organs. The most sensitive diagnostic technique in this population is a renal isotope scan, but contrast-enhanced CT scan requires further assessment.

<2>

Unique Identifier:1446864

Authors: Le Moine O. Adler M. Bourgeois N. Delhaye M. Deviere J. Gelin M. Vandermeeren A. Van Gossum A. Vereerstraeten A. Vereerstraeten P. et al.

Institution: Service Medico-Chirurgical d'Hepato-Gastroenterologie, Hopital Erasme, Bruxelles, Belgium.

Title: Factors related to early mortality in cirrhotic patients bleeding from varices and treated by urgent sclerotherapy.

Source: Gut. 33(10):1381-5, 1992 Oct.

Abstract: Variceal haemorrhage in cirrhotic patients carries a high early mortality even when balloon tamponade or emergency sclerotherapy are applied. The aim of this study to identify patients dying within six weeks of their first variceal haemorrhage. One hundred and twenty one patients with parenchymal cirrhosis presenting with the first variceal bleeding episode between June 1983 and December 1988 were studied. Nineteen patients were excluded for various reasons. Emergency sclerotherapy was carried out in cases of active bleeding or where there were endoscopic signs of recent bleeding, and then regularly repeated afterwards. Of the 24 variables studied and included in a multivariate analysis using a logistic regression model, three had an independent prognostic value: encephalopathy, prothrombin time, and the number of blood units transfused within the 72 hours of time zero. The subsequent regression equation was able to predict 89% of the patients who will die and 97% of the patients who will still be alive six weeks after their first variceal haemorrhage treated by sclerotherapy. Pugh score was less discriminatory than these last three variables in terms of accuracy of adjustment, goodness of fit to the model, receiver operating characteristic curves, and percentage correct prediction. To measure the accuracy of the prediction rule, our model was applied to another series of 28 cirrhotic patients admitted with their first variceal bleeding during the next period (January 1989 to May 1990). Death and survival were correctly predicted in respectively 82% and 94% of the cases. The use of this score is recommended for the selection of patients with high early mortality after variceal bleeding despite sclerotherapy, and for the design of new therapeutic trials.

Resident Report / Department of Medicine & Grady Branch Library

Emory University School of Medicine

2004 Edition

Participating Faculty:  Carlos Del Rio MD  / Joyce Doyle MD / Lorenzo Difrancesco MD /  Monica Adams MD  / Josh Larned MD

Contact: Karl Woodworth