Acute renal infarction in a heavy smoker

Predictors for Distinguishing Renal Infarction From Urolithiasis in the Emergency Department: A Randomly Matched Retrospective Case-Control Study

BACKGROUND

Emergency department (ED) clinicians may misdiagnose renal infarction (RI) as urolithiasis because RI is a rare disease with presenting symptoms similar to the symptoms of urolithiasis. However, earlier diagnosis of RI can improve patient prognosis.

OBJECTIVES

We investigated potential predictors for distinguishing RI from urolithiasis based on clinical findings and laboratory results.

METHODS

This randomly matched retrospective case-control study included patients who had been diagnosed with acute RI or acute urolithiasis between January 2016 and March 2020. Patients were excluded if they were aged under 18 years, had a history of trauma, or had incomplete medical records. Using a matching ratio of 1:4, RI patients were randomly matched to urolithiasis patients. Multivariable logistic regression was performed to identify factors that could distinguish RI from urolithiasis.

RESULTS

In total, 48 patients were included in the RI group and 192 patients were included in the urolithiasis group. Multivariable logistic regression showed that age ≥ 65 years (odds ratio [OR] 6.155; p = 0.022), atrial fibrillation (OR 18.472; p = 0.045), current smoking (OR 17.070; p = 0.001), costovertebral angle tenderness (OR 0.179; p = 0.037), aspartate aminotransferase level ≥ 27.5 U/L (OR 6.932; p = 0.009), sodium level ≥ 138.5 mEq/L (OR 0.079; p = 0.004), and hematuria (OR 0.042; p = 0.001) were significant predictors that could distinguish RI from urolithiasis. Based on these results, a nomogram was constructed.

CONCLUSION

Age ≥ 65 years, atrial fibrillation, current smoking, absence of costovertebral angle tenderness, aspartate aminotransferase level ≥ 27.5 U/L, sodium level < 138.5 mEq/L, and absence of hematuria were predictors that can distinguish between RI and urolithiasis.

Predictors of renal infarction in patients presenting to the emergency department with flank pain: A retrospective observational study

Objectives

Flank pain is a common symptom in the emergency department and can be caused by a variety of diseases. Renal infarction (RI) is a very rare disease, and many RI patients complain of flank pain. However, there is no definitive predictor of RI when patients complain of flank pain. This study aimed to identify the clinical factors for predicting RI in patients with flank pain.

Methods

This retrospective single-center study was conducted on patients complaining of flank pain from January 2016 to March 2020 at a South Korean tertiary care hospital. Exclusion criteria included patients who did not undergo contrast-enhanced computed tomography, age < 18 years, and trauma. Demographic and laboratory data were obtained from medical records. Logistic regression analysis was conducted to identify predictors of RI occurrence.

Results

In all, 2,131 patients were enrolled, and 39 (1.8%) had RI. From a multivariable logistic regression analysis, an age ≥ 65 years (odds ratio [OR], 3.249; 95% confidence interval [CI], 1.366–7.725; p = 0.008), male sex (OR, 2.846; 95% CI, 1.190–6.808; p = 0.019), atrial fibrillation (OR, 10.386; 95% CI, 3.724–28.961; p < 0.001), current smoker (OR, 10.022; 95% CI, 4.565–22.001; p < 0.001), and no hematuria (OR, 0.267; 95% CI, 0.114–0.628; p = 0.002) were significantly associated with the occurrence of RI.

Conclusions

Five clinical factors, i.e., age ≥ 65 years, male sex, atrial fibrillation, current smoker, and no hematuria, were significantly associated with the occurrence of RI in patients with flank pain.

Bilateral renal infarctions complicating fibromuscular dysplasia of renal arteries in a young male

Fibromuscular dysplasia (FMD) is an uncommon disorder, accounting for less than 10% of cases of renal artery stenosis, and typically presenting with hypertension in young women. This article reports the case of a previously healthy 37-year-old man presenting with acute-onset, severe, bilateral flank pain. Initially treated for ureteral colic and urinary tract infection, he was transferred to the nephrology clinic upon recognition of a rising serum creatinine. He was found to have FMD of bilateral renal arteries with a stenotic pattern on the right side and a dissecting aneurysm on the left side with resultant infarctions in both kidneys. On the basis of negative serological markers of vasculitis, a diagnosis of FMD complicated by bilateral renal infarctions was made. A stent was placed to the right stenotic renal artery, which resulted in sufficient lumen patency. No invasive procedure was performed on the other side owing to the complexity of the lesion. After 2.5 years of follow-up, the patient remained in good condition with normal renal function and adequate blood pressure control with dual antihypertensive therapy. Renal infarction complicating FMD of renal arteries is rare in the literature, with most of the cases having causative cardiovascular risk factors including coagulopathy, ischaemic heart disease, atrial fibrillation or structural cardiac abnormalities, none of which was present in this case. In conclusion, FMD may occur in atypical asymmetric presentations causing renal infarctions in both kidneys. Radiological interventions in such cases should focus on stabilizing renal lesions and renal function.

Renal Artery Thrombosis

The diagnosis of acute renal infarction is often delayed or failed due to the rarity of the disease and to its non-specific clinical presentation. Cigarette smoking, with its vasoconstrictive and prothrombotic effects, is a known and sure risk factor for the development of the atheroembolic artery disease.

Case study

This is the report of a case of acute renal infarction in a heavy-smoking patient, a 66-year-old man who arrived at our ward for right worsening backache with vomit and abdominal pain not reacting to the analgesic therapy. A urgent ultrasound showed excretory axes not dilated bilaterally. Therefore, we had to perform further diagnostic tests (CT and then angiography) which highlighted a case of a right massive renal infarction due to complete thrombotic obstruction of the renal artery with patent contralateral ramification. We performed a PTA and then a local infusion of thrombolytic (metalyse 2 mg in 10’). After this treatment the patient showed an immediate stop of the hurting symptomatology, an improvement of the flow and an opacification of the parenchyma. (lower and medium part) with persistence of vision concerning endoluminal thrombosis. A CT angiography 20 days later, after home therapy with LMWH at therapeutic doses, confirmed a restored and normalized vascularization of the lower and medium part of the right kidney.

Conclusions

In the light of these case results - good revascularization of the lower 2/3 of the right kidney, despite a prolonged time of ischemia from the beginning of the symptoms to the diagnosis and to the further thrombolytic therapy (about 14 hours) -, we assume that a wider use of the Doppler method can be of some usefulness, in case of recurring colics especially not reacting to analgesic therapy with negative ultrasonography check-up for the dilatation of the excretory routes, in order to considerably reduce the diagnosis time of renal diseases of vascular type.

Acute renal infarction from a cardiac thrombus

BACKGROUND

A 53-year-old man presented to hospital 2 hours after the abrupt onset of left upper abdominal pain. He was treated with analgesics and discharged after 4 hours of observation, but presented to another hospital 2 hours later with severe left abdominal pain. His past medical history included ischemic dilated cardiomyopathy due to recurrent myocardial infarction.

INVESTIGATIONS

Physical examination, electrocardiography, laboratory investigations, contrast-enhanced computed tomography, and transesophageal echocardiography.

DIAGNOSIS

Renal artery thromboembolism resulting from dilated cardiomyopathy, severely reduced cardiac function and an intracardiac thrombus.

MANAGEMENT

Anticoagulation with unfractionated heparin followed by enoxaparin and warfarin.