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A Rare Cause of Severe Flank Pain : Renal Infarction | OMICS International
ISSN: 2329-8790
Journal of Hematology & Thromboembolic Diseases
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A Rare Cause of Severe Flank Pain : Renal Infarction

Mehmet Can Ugur1*, Ercan Ersoy1, Merter Alanyali2, Hulya Colak3 and Harun Akar1
1Department of Internal Medicine, Izmir Tepecik Training and Research Hospital, Konak, Izmir, Turkey
2Department of Family Medicine, Izmir Tepecik Training and Research Hospital, Konak, Izmir, Turkey
3Department of Family Medicine, Izmir Tepecik Training and Research Hospital, Nephrology, Konak, Izmir, Turkey
Corresponding Author : Mehmet Can Ugur
Department of Internal Medicine
Izmir Tepecik Training and Research Hospital
5th floor, Konak, Izmir, Turkey
Tel: 905058861126
E-mail: [email protected]
Received January 29, 2015; Accepted February 08, 2015; Published February 20, 2015
Citation: Ugur MC, Ersoy E, Alanyali M, Colak H, Akar H (2015) A Rare Cause of Severe Flank Pain: Renal Infarction. J Hematol Thrombo Dis 3:189. doi: 10.4172/2329-8790.1000189
Copyright: © 2015 Ugur MC, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

Abstract
Renal infarction is a common clinical problem and often misdiagnosed because the symptoms are subtle. We are presented our patient who applicant with left flank pain and diagnosed renal infarction. 49-year-old male patient has come with 2 days of severe left flank. Pathologic were; left costovertebral angle tenderness, creatinine: 1.3 mg/dL, C reactive protein: 11.4 mg/dL. On Computed Tomography Angiography renal arteries there was no contrast matter transmission to left arcuat artery distale and there were ischemic regions. With renal infarction diagnose, patient was hospitalized. Organized thrombosis seen inside apical left ventricular aneurysm with transesophageal ecocardiography Patient was discharged from hospital with plannings of policlinic controls for INR follow-ups. We want to emphasize that it should be kept in mind that the diagnosis of renal infarction in the clinical management of patients with flank pain.
Keywords
Thromboembolism; Renal ─░nfarction; Angiography
Introduction
One of the most common cause of renal artery thrombosis is thromboembolic events originated from heart or aorta. Spontaneous renal artery thrombosis is quite rare. Renal artery thrombosis are generally due to blunt abdominal trauma and atherosclerotic lesions from renal arteries [1]. Case reports related with renal infarctions were reported in the literature such as possibly connected with polisitemia vera, pregnancy, hypercoagulability, renal transplants, intraabdominal balloon insertion, renal angiography, oral contraceptives, intravenosus cocain usage, nephrotic syndrome, systemic lupus erythematosus, renovascular hypertension, infective endocarditis, Ehler-Danlos syndrome and renal surgery [2-8]. The diagnosis of renal infarction as a rarely seen clinical problem can be difficult. Renal infarction must be kept in mind as a differantial diagnosis in the cases presented with severe flank pain. The most important issue is to think this entity. Herein, we are aimed for to present our case presented with severe flank pain and diagnosed as renal infarction.
Case Report
When 49-year-old male patient has been admitted to emergency room with 2 days of severe left flank pain and internal medicine clinic was consulted. There were no diabetes mellitus, hypertension, dyslipidemia, heart failure, atrial fibrillation or hypercoagulability syndrome in his history. Vital findings were normal in the physical examination except left costovertebral angle tenderness. Pathological laboratory findings were; creatinine: 1.3 mg/dL, C reactive protein: 11.4 mg/dL. There was no leucocytosis. Lactate dehydrogenase (LDH) levels and coagulation parameters were in normal ranges. In urinary tests, there were no haematuria or proteinuria. Electrocardiogram was in normal sinus rhythm. There were no renal stone or obstructive uropathy in abdominal ultrasonography. Posterior-anterior chest X-ray was normal. There were ischemic regions on upper pole of left kidney related to renal infarction in the contrasted abdominal computed tomography scan. Renal arteries were open in Computer Tomography Angiography but there was no contrast material transmission to distale part of the left arcuat artery (Figure 1).
Patient was hospitalized with the diagnosis of renal infarction. Searching the etiology and anticoagulant treatment were planned. Ceftriaxone antibiotheraphy, low molecule density heparine (LMDH) and warfarine had started. There was regional movement defect in left ventricul of anterior and septum with transthoracic echocardiogram. Left ventricul ejection fraction was %50. Other transthoracic echocardiographic findings were normal but there were an organized thrombosis inside the apical left ventricular aneurysm in the transesophageal echocardiography.
Anti nuclear antibody, perinuclear anti neutrophil and cythoplasmic anti neutrophilic antibody, protein C and protein S levels, Factor V Leiden mutation, anticardiolipine antibody IgM and IgG, antithrombine 3 activity, B12 vitamine, folic acid, homocysteine levels were all in normal ranges. Lower and upper extremities’ arteriovenosus Doppler ultrasonography had been found normal.
We aimed to be INR range 2.0 to 3.0 for treatment. LMDH was stopped when INR reached to effective levels in terms of consequent. Reperfusion was seen after 7 days of the treatment by computed tomographic angiography (CT angiography) on renal infaction regions (Figure 2). The patient had no pain and serum creatinine level was lower to 1.2 mg/dL at that time. Regular INR follow-ups were planned per week and patient was discharged.
Discussion
Renal artery thrombosis is usually seen at the age of 30-50’s. Incidence is 0.01% in Europe and Asia [9,10]. Atrial fibrillation, heart valve replacement, renal artery injury, mitrale stenosis and tobacco usage are common risk factors for renal infarction [11]. Patients are usually presented by rapidly started colic pain in upper abdomen or flank region. Leucocytosis, haematuria and proteinuria can be seen with symptoms like fever, nausea and vomiting. Although, laboratory findings such as LDH elevation and leucocytosis were not found in our case. renal infarction were still exist in our list of differantial diagnosis and we had tried to image the renal artery tree by CT angiography. This diagnose would be confirmed with Magnetic Resonance Imaging along with Computed Tomography [12]. Also, contrast-enhanced ultrasound (CEUS) would be used instead of CT angiography [13].
Severe acute abdominal or flank pain algorithm is seen on Schema 1 [14]. Computed tomography together with CT angiography can be useful in the diagnosis renal infarction presented with acute abdomen.
Our case was also different from the most cases in the literature which were usually seen with elevated LDH levels [15]. In our case despite of a large infarction area, LDH levels were not elevated Therefore, normal LDH levels may not exclude renal infarction.
We had a good result with a rapid diagnosis and treatment. Reperfusion was achieved by anticoagulant therapy.
In cases with renal infarction, it is important that diagnosis must be configured rapidly and treatment must be started as soon as possible to avoid irreversible renal damage [16]. Thrombolitic treatment is recommended to start within first 6 hours of the pain. In new treatment modalities, there are spesific treatment approaches like low dose of intraarterial streptokinase injection and percutane transluminale angioplasty [17,18]. If there is a delay on diagnosis and if thrombolitic/anticoagulant therapy is not started on time, there will be surgical options leading to nephrectomy [19].
For those cases presented with severe abdominal, lumbal or flank pain, renal infarction must be kept in mind in the differantial diagnosis.
References
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  2. Chagnac A, Zevin D, Weinstein T, Gafter U, Korzets A, et al. (1990) Erythrocytosis associated with renal artery thrombosis in a patient with polycystic kidney disease on hemodialysis. Acta Haematol 84: 40-42.

  3. Dimitroulis D, Bokos J, Zavos G, Nikiteas N, Karidis NP, et al. (2009) Vascular complications in renal transplantation: A single-center experience in 1367 renal transplantations and review of the literature. Transplant Proc 5: 1609-1614.

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  5. Golbus SM, Swerdlin AR, Mitas JA 2 nd , Rowley WR, James DR (1979) Renal artery thrombosis in a young woman taking oral contraceptives. Ann Intern Med 90: 939-940.

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  7. Tsugawa K, Tanaka H, Kudo M, Nakahata T, Ito E (2005) Renal artery thrombosis in a pediatric case of systemic lupus erythematosus without antiphospholipid antibodies. Pediatr Nephrol 20: 1648-1650.

  8. Liao WB, Bullard MJ, Liaw SJ (1995) Widespread embolism in a patient with infective endocarditis: A case report. Changgeng Yi Xue Za Zhi 18: 82-87.

  9. Domanovits H, Paulis M, Nikfardjam M, Meron G, Kürkciyan I, et al. (1999) Acute renal infarction. Clinical characteristics of 17 patients. Medicine (Baltimore) 78: 386-394.

  10. Huang CC, Lo HC, Huang HH, Kao WF, Yen DHT, et al. (2007) ED presentations of acute renal infarction. Am J Emerg Med 25: 164-169.

  11. Bolderman R, Oyen R, Verrijcken A, Knockaert D, Vanderschueren S (2006) Idiopathic renal infarction. Am J Med 119: 356 e9-12.

  12. Yamanouchi Y, Yamamoto K, Noda K, Tomori K, Kinoshita T (2008) Renal infarction in a patient with spontaneous dissection of segmental arteries: Diffusion-weighted magnetic resonance imaging. Am J Kidney Dis 52: 788-791.

  13. Ciccone MM (2011) The clinical role of contrast-enhanced ultrasound in the evaluation of renal artery stenosis and diagnostic superiority as compared to traditional echo-color-Doppler flow imaging. Int Angiol 30: 135-139.

  14. Laméris W, van Randen A, van Es HW, van Heesewijk JP, van Ramshorst B , et al. (2009) Imaging strategies for detection of urgent conditions in patients with acute abdominal pain:diagnostic accuracy study. BMJ 338: b2431.

  15. Huang CC, Kao WF, Yen DH, Huang HH, Huang CI, et al. (2006) Renal infarction without hematuria: two case reports. J Emerg Med 30: 57-61.

  16. Lessman RK, Johnson SF, Coburn JW (1978) Renal artery embolism: clinical features and long-term follow-up of 17 cases. Ann Intern Med 89: 477-482.

  17. Salam TA, Lumsden AB, Martin LG (1993) Local infusion of fibrinolytic agents for acute renal artery thromboembolism: report of ten cases. Ann Vasc Surg 7: 21-26.

  18. Boyer L , Ravel A, Boissier A (1994) Percutaneous recanalization of recent renal artery occlusions: report of 10 cases. Cardiovasc Intervent Radiol 17: 258-263.

  19. Singh S, Wang L, Yao QS, Jyotimallika J, Singh S1 (2014) Spontaneous renal artery thrombosis: an unusual cause of acute abdomen.  N Am J Med Sci 6: 234-236.

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