Effect of Focal Zone Size on Treatment Outcomes and Renal Injury Following Extracorporeal Shockwave Lithotripsy of Renal Calculi: A Prospective Randomized Study.

Background: The narrower focal zone (FZ) size of modern lithotripter was considered as one of the factors that resulted in suboptimal treatment result of extracorporeal shockwave lithotripsy (SWL). Therefore, we investigate the efficacy and safety of standard narrow or extended (FZ) sizes in SWL for patients with renal stones. Materials and Methods: In this prospective study conducted between April 2018 and October 2022, patients with renal stones were randomized to receive SWL with either standard or extended FZ. Treatment was delivered using a Modulith SLX-F2 lithotripter with a maximum of 3000 shocks at 1.5 Hz. The primary outcome was treatment success 12 weeks after a single SWL session, defined as the absence of a stone or stone fragment <4 mm on computed tomography. Secondary outcomes included the incidence of perinephric hematoma, stone-free rate (SFR), and changes in the urinary levels of acute renal injury markers. Results: A total of 320 patients were recruited, and 276 patients were randomized into the two groups. The two groups had similar baseline parameters. The treatment success rate was significantly better for standard FZ (74.3%) than the extended FZ group (59.3%) (p = 0.009). Standard FZ also had a significantly better SFR (Grade-A, 36.8% vs 23.0%, p = 0.013) and less pain after treatment. Both groups had similar perinephric hematoma formation rates, unplanned hospital admission rates, and changes in urinary acute renal injury markers. Conclusions: The standard narrow FZ has better treatment efficacy and similar safety compared with the extended FZ during SWL for renal stones. This clinical trial has been registered in the public domain (CCRBCTR) under trial number CUHK_CCRB00510.

A Rare Case of Page Kidney in a Young Man with Flank Pain.

BACKGROUND: Page kidney is a rare condition in which an external compression of the kidney as a result of a hematoma or mass causes renal ischemia and hypertension. In a patient with flank pain, elevated blood pressure, and recent trauma, this condition should be considered. Since this condition was first described in 1939, more than 100 case reports have surfaced. CASE REPORT: We describe the case of a 26-year-old man who presented to the Emergency Department with flank pain, vomiting, and elevated blood pressure. A computed tomography scan of the abdomen and pelvis confirmed the presence of a perinephric hematoma, and the interventional radiology team was consulted to resolve the Page kidney. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Symptoms seen in Page kidney may be similar to other more common diagnoses encountered in the emergency department. It is important to maintain a high suspicion and order imaging studies as needed, especially in the setting of trauma, or a recent procedure in the vicinity of the renal parenchyma.

Small Tumor, Major Complication: A Case of Spontaneous Perinephric Hematoma From a Small Renal Angiomyolipoma.

A renal angiomyolipoma is a benign kidney tumor composed of muscle, fat, and blood vessels. It is the most common benign kidney tumor, and it affects women more frequently than men. Angiomyolipomas can be small and asymptomatic, or they can be large, presenting with symptoms such as discomfort, hematuria, and hypertension. Occasionally, the rupture of an angiomyolipoma can cause a perinephric hematoma. This case report discusses a patient who developed a spontaneous large perinephric hematoma alongside a small renal angiomyolipoma. Aneurysm was seen on imaging. Angioembolization was successfully used for treatment. We explore the significance of the presence or absence of an aneurysm in predicting the risk of hemorrhage, particularly in association with small lesions. Angioembolization is an excellent choice for treating angiomyolipomas associated with significant hematomas.

A Subacute Presentation of Wunderlich Syndrome in a Young Woman: A Case Report.

Wunderlich syndrome (WS) is a rare, potentially life-threatening medical condition characterized by spontaneous renal or perinephric hemorrhage occurring in the absence of known trauma. WS usually presents as Lenk's triad: acute flank pain, flank mass sensation, and hypovolemic shock; however, the presentation of this condition can vary in terms of symptom type and duration. We present the case of a 23-year-old previously healthy woman who consulted our emergency department with an unusual subacute form of presentation of WS (eight days of pain) due to an angiomyolipoma. Considering that the patient was clinically stable, a conservative approach with strict follow-up with serial computed tomography scans was taken.

Double trouble - management of perinephric hematoma and renal vein thrombosis post percutaneous renal biopsy.

BACKGROUND: Performing percutaneous renal biopsy procedures in lupus nephritis (LN) and nephrotic syndrome presents a unique challenge to the nephrologist because of the risk of bleeding from the procedure and the hypercoagulable state in hypoalbuminemia. The management of a patient with venous thrombosis with perinephric hematoma post renal biopsy can be difficult if occurred. CASE PRESENTATION: We are presenting a case of perinephric hematoma following percutaneous renal biopsy in a 23-year-old man with lupus nephritis, nephrotic syndrome, and lower limbs deep vein thrombosis (DVT). The patient developed persistent frank haematuria, flank pain and acute urinary retention post-procedure. We have withheld his oral warfarin three days before the procedure, and no anticoagulation was given subsequently. Initial CT Angiography (CTA) renal showing stable hematoma and no visible evidence of vascular injury. Three weeks later, the patient still has persistent frank haematuria and a repeated CTA renal revealed new bilateral renal vein thrombosis. Considering the high risk of worsening symptomatic venous thrombosis, we gave subcutaneous enoxaparin sodium and restart oral warfarin despite ongoing haematuria. The frank haematuria resolved within two days of anticoagulation with no radiological evidence of worsening of the perinephric hematoma. The follow-up ultrasonography a month later showed resolution of the hematoma and renal vein thrombosis with no adverse effect. CONCLUSION: Our experience, in this case, highlighted the importance of case selection for percutaneous renal biopsy among high-risk patients. Additionally, a prolonged frank haematuria in post-renal biopsy with nephrotic syndrome warranted a reassessment, as a clinical presentation of post-procedure perinephric hematoma and renal vein thrombosis can overlap. We also demonstrated that restarting anticoagulation earlier than four weeks in a patient with renal vein thrombosis and post-renal biopsy perinephric hematoma can be safe in the selective case.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding.

BACKGROUND/AIMS: The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy. METHODS: In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed. RESULTS: Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120). CONCLUSIONS: We do not recommend desmopressin administration before kidney biopsy.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding / Ausencia de efecto de la administración de desmopresina antes de una biopsia renal sobre el riesgo de hemorragia mayor tras la biopsia

Background/Aims: The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy.MethodsIn this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed.ResultsBefore propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120).ConclusionsWe do not recommend desmopressin administration before kidney biopsy. (AU)

Antecedentes/objetivos: La complicación más importante de la biopsia renal es la hemorragia y no está claro si la desmopresina es eficaz en su prevención. Por lo tanto, el estudio se realizó para comparar la hemorragia tras una biopsia renal percutánea con o sin prescripción de desmopresina previa a esta.MétodosEn este estudio unicéntrico, retrospectivo y observacional se seleccionaron 3.018 pacientes adultos que se sometieron a una biopsia renal entre el 1 de enero de 2003 y el 31 de marzo de 2019 en nuestro instituto. De ellos, 776 pacientes recibieron desmopresina. Para comparar las diferencias en los acontecimientos de hemorragia mayor entre los pacientes que recibieron desmopresina y los que no, se realizó un emparejamiento por puntuación de propensión.ResultadosAntes del emparejamiento por puntuación de propensión, se observó que los pacientes del grupo con desmopresina tenían una edad significativamente mayor (p<0,001) y presentaban una presión arterial más alta (p<0,001), una creatinina sérica más alta (p<0,001), niveles de hemoglobina más bajos (p<0,001) y recuentos de plaquetas más bajos (p=0,001) que los del grupo sin desmopresina. Además, la incidencia de embolización de la arteria renal no fue significativamente diferente entre los 2 grupos (p=0,077); sin embargo, las transfusiones de sangre se produjeron con una frecuencia significativamente mayor en el grupo con desmopresina (p<0,001). Una comparación de los 2 grupos tras el emparejamiento por puntuación de propensión no reveló diferencias en la incidencia de embolización de la arteria renal (p=0,341), la transfusión de sangre (p=0,579) y los acontecimientos de hemorragia mayor totales (p=0,442). Además, no se observaron diferencias en la incidencia de hematomas perinéfricos en la tomografía computarizada o la ecografía (p=0,120).ConclusionesNo se recomienda la administración de desmopresina antes de una biopsia renal. (AU)

Spontaneous Page kidney from ruptured renal angiomyolipoma.

Renal angiomyolipomas are the most common benign tumors of the kidneys. They are prone to rupture, which may result in massive hemorrhage and often requires lifesaving nephrectomy. Delay in treatment is likely to result in death. We report two cases of ruptured angiomyolipoma compressing the renal parenchyma, causing secondary hypertension (Page kidney). Both patients presented with abdominal pain, hypertension, and reduced or dropping hemoglobin counts. The delay in diagnosis and treatment resulted in their adverse outcomes. We highlight the need to promptly diagnose and treat symptomatic renal hematomas to avoid subsequent morbidity and mortality.

Development of a Peri-renal Urinoma in a Follow-up Patient with History Posttraumatic Peri-nephric Hematoma: Role of Renal Scintigraphy.

A 7-year-old male with a history of blunt trauma to the abdomen and diagnosis of perinephric hematoma in contrast-enhanced computed tomography (CT) presented with increasing peri-nephric collection (after ~1.5 months) in the serial ultrasound examinations. The patient was referred to the department of nuclear medicine for the assessment of this collection as well as renal function. In 99mTc-diethylenetriamine pentaacetate renal scintigraphy, progressively increasing radiotracer activity was noted inferolaterally to the left kidney, separated from the same by a photopenic area. Single-photon emission computed tomography/CT revealed a peri-nephric urinoma in relation to the previously diagnosed hematoma at the lower pole; which was communicating with the pelvi-calyceal system (PCS). Not only did the renal scintigraphy aid in the diagnosis of urinoma but it was also able to show that it was communicating freely with the PCS and that the rest of the renal parenchyma was functioning adequately. This multi-faceted assessment in a single investigation allowed clinicians to opt for the conservative management despite the increasing size of urinoma in the early follow-up.

No effect of desmopressin administration before kidney biopsy on the risk of major post-biopsy bleeding.

BACKGROUND/AIMS: The most important complication of kidney biopsy is bleeding, and it is unclear whether desmopressin is effective in preventing it. Thus, the study was conducted to compare post-biopsy bleeding with or without desmopressin prescription prior to percutaneous kidney biopsy. METHODS: In this single-centered, retrospective, and observational study, 3,018 adult patients who underwent kidney biopsy between January 1, 2003 and March 31, 2019 at our institute were recruited. Of these, 776 patients received desmopressin. To compare the differences in major bleeding events between patients administered and not administered with desmopressin, propensity score matching was performed. RESULTS: Before propensity score (PS) matching, it was observed that patients in the desmopressin group were significantly older (p<0.001) and had a higher blood pressure (p<0.001), higher serum creatinine (p<0.001), lower hemoglobin levels (p<0.001), and lower platelet counts (p=0.001) than those in the no-desmopressin group. Furthermore, the incidence of renal artery embolization was not significantly different between the two groups (p=0.077); however, blood transfusions occurred significantly more frequently in the desmopressin group (p<0.001). A comparison of the two groups after PS matching did not reveal any differences in the incidence of renal artery embolization (p=0.341), blood transfusion (p=0.579), and total major bleeding events (p=0.442). Furthermore, there was no difference in the incidence of perinephric hematoma on computed tomography or ultrasound (p=0.120). CONCLUSIONS: We do not recommend desmopressin administration before kidney biopsy.

Retroperitoneal Hematoma as a Complication of Endovascular Embolization of Tumor Epistaxis: A Case Report.

Retroperitoneal hematomas are a rare and fatal complication of endovascular embolization. We report a case of an 89-year-old woman who was referred to interventional radiology for percutaneous embolization for intractable epistaxis as a result of a left nasal cavity mucosal melanoma. After successful embolization of the left sphenopalatine artery, the patient became hypotensive and was transferred to the intensive care unit. Post-operative CT abdomen and pelvis angiogram showed a large right perinephric hematoma, which is an extremely uncommon complication of endovascular embolization for epistaxis. Practitioners should be aware of this life-threatening complication in weighing the risks and benefits of embolization versus direct surgical ligation, and they should identify and intervene promptly if a retroperitoneal hematoma should occur.

A Renal Colic Mimic - Wunderlich Syndrome: A Case Report.

Wunderlich syndrome is a rare clinical syndrome characterized by the sudden onset of spontaneous, nontraumatic hemorrhage into renal subcapsular and retroperitoneal region. We present the case of a 24-year-old hypertensive who presented with acute flank pain and was found to have perinephric hematoma. He was managed conservatively and the follow-up revealed complete resolution of the hematoma with no structural abnormality of kidney. His connective tissue disorder/vasculitis work up was also normal.

Perinephric Hematoma Induced by Factor Xa Inhibitor in a Patient with a Vascular Renal Mass.

Perinephric hematomas are known to present in the form of Lenk's triad with acute flank pain, flank mass and hypovolemic shock. Here, we describe a case of perinephric hematoma occurring secondary to the use of anticoagulant therapy in the setting of a renal mass. To the best of our knowledge, this is the first reported case of a perinephric hematoma occurring secondary to the use of Apixaban. The patient was an 80 year old male with a history of the presence of a left sided vascular renal mass discovered seven years ago admitted from a peripheral health center with pneumonia and a dropping hemoglobin along with acute kidney injury. Evaluation of his course revealed the use of a Factor Xa inhibitor, namely Apixaban, for new onset atrial fibrillation. The patient was stabilized with multiple units of packed red blood cell transfusions. An abdominal computed tomography abdomen demonstrated a perinephric hematoma contained in the Gerotas fascia. Due to deranged renal function, the patient was managed conservatively and made a full recovery. This case highlights the challenges associated with the diagnosis of perinephric bleeds. The use of anticoagulation therapy in the setting of a pre-existing vascular lesion remains a dilemma.

Huge perinephric hematoma after ureteroscopy and pneumatic lithotripsy for ureteral stone; A life-threatening rare complication: Case report and review of literature.

INTRODUCTION: Ureteroscopy with pneumatic lithotripsy is a relatively safe procedure for the management of the ureteral stone disease. However; subcapsular hematoma and even huge perinephric hematoma are potentially serious events that may complicate this procedure and must be kept in mind. CASE PRESENTATION: We present a case of huge perinephric hematoma post ureteroscopy and pneumatic lithotripsy for an impacted ureteral stone. CONCLUSION: The occurrence of such a rare complication in a relatively safe procedure must be taken into consideration especially while dealing with patients with long-standing obstruction and thin renal cortex. Furthermore, the risk of bleeding should be included in risk-benefit counselling before ureteroscopic lithotripsy.

Percutaneous Renal Biopsy: Comparison of Blind and Real-time Ultrasound Guided Technique.

BACKGROUND: Percutaneous renal biopsy is performed for diagnosis and prediction of prognosis of renal diseases. Adequacy of tissue and clinically significant bleeding are the main issues of the procedure. We aimed to compare these issues in renal biopsy by blind and real time ultrasound guided technique. METHODS: It was a cross sectional, randomized study conducted between June 2016 to December 2016. In blind technique, marking for biopsy was done by ultrasound. Two attempts were performed for all and more if tissue was inadequate. Patients kept in bed rest for 24 hours, observed for post procedure hematuria and ultrasound done at 6 hours and 24 hours to diagnose perinephric hematoma. RESULTS: Total 75 biopsies (blind = 37 and Ultrasound -guided = 38) were evaluated. Blind and Ultrasound-guided technique had significant difference of number of attempt (mean±SD) 2.4±0.6 and 2.1±0.3 (p<0.01) respectively with no difference of number of glomeruli in light microscopy. Bleeding complications were macroscopic hematuria (11(30%)vs15(40%)) and perinephric hematoma ( 5(13.5%)vs3(7.9%)) in blind and Ultrasound-guided technique respectively with no significant difference. Those patients who developed perinephric hematoma was observed in all at 6 hours. CONCLUSIONS: Ultrasound-guided technique of percutaneous renal biopsy is superior with fewer attempts and equivalent in adequacy of tissue and bleeding complication than blind technique.

Spontaneous perinephric hematoma due to acquired factor X deficiency in AL amyloidosis.

Spontaneous perinephric hematoma (SPH) is a rare entity whose diagnosis is challenging because of its varied clinical presentation and lack of any specific etiology. We report a 34-year-old African-American male who presented with left flank pain and was found to have a large left perinephric hematoma, in the setting of undiagnosed AL amylodosis. The case illustrates that while a SPH due to the vascular angiopathy of amyloid is rare, when amyloidosis is associated with abnormal coagulation studies or bleeding at multiple sites, it should be considered because of its protean systemic manifestations and potential response to chemotherapy.

A Prospective Comparative Study Between Manual and Automated Renal Biopsy by Randomized Sampling / 대한신장학회잡지

OBJECTIVES: Percutaneous renal biopsy may be carried out in several ways. Recently, the use of a spring-loaded biopsy gun has become popularized. There have been much controversies on the tissue adequacy and the incidence of complications when compared to the manual biopsy. The present study was performed to compare tissue adequacy and the incidence of complications between manual biopsy and automated biopsy. METHODS: We have studied 108 patients in whom the method of renal biopsy was assigned to one of the two methods[14G Tru-cut needle manual bx (group I) and 18G automated gun biopsy(group II)] according to their national resident's identification number in a randomized and prospective manner. RESULTS: There were 50 patients in group I and 58 patients in group II. There was no difference in gender, age, hemoglobin, prothrombin time, partial thromboplastin time, diastolic and systolic blood pressure pre-biopsy in group I and II. Indications for biopsies were proteinuria accompained by hematuria (37%), proteinuria(34.3%), acute renal failure (9.3%), SLE (8.3%), chronic renal failure (5.6%), hematuria only (5.6%). In Group I the number of passes was 2.4+/-0.8, the glomeruli obtained were 25.3+/-13.2 and the number of glomeruli per pass were 11.6+/-6.5, and in Group II 3.4+/-1.1, 19.4+/-10.8, and 6.8+/-4.0, respectively. These showed a significant difference (p<0.05). In all cases pathological diagnosis were possible. The histology showed IgA nephropathy in 27.8%, MCNS in 14.8%, lupus nephritis in 11.1, MGN in 11.1%, MPGN in 7.4%, and others. The incidence and area of perinephric hematoma demonstrated on ultrasound 24 hours post-biopsy was increased in group I (24%, 937.7+/-640.0mm2 compared to 10.3%, 372.4+/-327.4mm2 in group II) although no statistically significant difference existed. There was no significant difference in gender, age, prothrombin time, partial thromboplastin time, systolic and diastolic blood pressure between the group with and without hematomas. Hematocrit levels before and after biopsy showed a significant difference (34.5+/-8.2, 33.5+/-8.1, p<0.05) in group I, but no significant difference was observed in group II (34.7+/-6.4, 34.8+/-6.4). CONCLUSION: Both techniques rendered adequate tissue sampling, but the extent of bleeding seems to be more severe with manual 14G Tru-cut needle biopsy.