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Case: Spontaneous Kidney Rupture

Case: Spontaneous Kidney Rupture. Santiago Ram ó n Leal-Noval. Patient. Male, age 71 Antecedents: Hypertension COPD Obesity Atrial fibrillation on oral anticoagulant prophylaxis with acenocumarol Admitted to hospital with severe pain in the upper left back area

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Case: Spontaneous Kidney Rupture

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  1. Case:Spontaneous Kidney Rupture Santiago Ramón Leal-Noval

  2. Patient • Male, age 71 • Antecedents: • Hypertension • COPD • Obesity • Atrial fibrillation • on oral anticoagulant prophylaxis with acenocumarol • Admitted to hospital with severe pain in the upper left back area • No associated fever or urinary symptoms

  3. Image Diagnosis • Ultrasound and CT showed: A left renal mass, suggesting abscess or haematoma extending through left perirenal area, affecting lateral fascia

  4. Diagnostic Puncture • CT-guided puncture/aspiration performed • Compatible with bleeding

  5. Lab Data at Admission Creatinine: 1.4 mg/dL Haemoglobin: 149 g/L Haematocrit: 0.43 L/L Platelets: 248 x 109/L Coagulation: PT: 25 (11 – 16 sec) INR: 2.02 (0.90 – 1.3) APTT: 30 (22 – 34 sec)

  6. Patient Management • Immediate withdrawal of oral anticoagulants (acenocumarol) • Vitamin K: 10 mg i.v. • Patient clinically stable • Further evolution observed

  7. Evolution24 Hours Later Renal function impairment: Creatinine: 3 mg/dL Anaemia: 100 g/L Haematocrit: 0.31 L/L Platelets: 264 x 109/L Coagulation: PT: 15 (11 – 16 sec) INR: 1.16 (0.90 – 1.3) APTT: 23 (22 – 34 sec)

  8. Evolution48 Hours Later • Patient suddenly presents severe pain in the upper left back area extending to left flank and back • No haemodynamic instability

  9. Lab Data Creatinine: 4.20 mg/dL Haemoglobin:6.5 g/L Hb Haematocrit: 0.19 L/L Platelets: 178 x 109/L Coagulation: PT: 12 (12 – 14 sec) INR: 1.06 (0.90 – 1.3) APTT: 26 (22 – 34 sec)

  10. Haematoma Treatment:Urgent Surgical Left Nephrectomy II Kidney, sectioned in two halves

  11. Transfusions Total transfusion required during surgery: • 4 RBC intraoperative • 5 RBC in ICU due to persistent anaemia

  12. Clinical Evolution Anaemia persists despite transfusion: Haemoglobin: 80 g/L Haematocrit: 0.25 L/L Platelets: 308 x 109/L Coagulation: PT: 11.6 (11 – 16 sec) INR: 1 APTT: 23 (22 – 34 sec)

  13. Possible Alternatives to Avoid Multi-transfusion • Recombinant activated FVII (rFVIIa) • Aprotinin

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