Acute renal infarction from a cardiac thrombus

A Case of Bilateral Renal Infarct Due to Left Ventricular Thrombus

Renal infarction is an uncommon illness that can have serious side effects. Patients may be predisposed to the disease by factors including smoking, atrial fibrillation, thrombus, infective endocarditis, myocardial infarction, and prosthetic valves. Patients are most susceptible from 24 hours to 15 days after myocardial infarction, with an increased rate of left ventricular (LV) thrombus development, which raises the probability of thromboembolic events in the cerebrovascular system and might exacerbate morbidity and mortality rate. This can be diagnosed by two-dimensional echocardiography. Different risk factors can contribute to the development of an LV thrombus. Renal infarcts from LV clots are less common but can occur bilaterally in certain situations. A 30-year-old male diagnosed with anterior wall myocardial infarction presented at our hospital and was suspected to have bilateral renal infarcts, possibly due to the LV thrombi. The patient was managed on anti-thrombolytics and was reported to be doing well at a follow-up of one month.

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.

Use of point-of-care ultrasound to diagnose an alternate cause of flank pain in a patient with presumed renal colic

This is a case of a 34-year-old male patient who presented to the emergency department (ED) with severe left flank pain. Due to the patient's cardiac history, elevated troponin, lactic acidosis, and lack of renal calculi on a noncontrast CT, focused cardiac ultrasound was performed, which showed left ventricle thrombus. The patient was later found to have bi-interventricular thrombi causing both pulmonary embolism and renal infarction. This is an uncommon diagnosis in the ED, where point-of-care ultrasound helped in diagnosing and guiding the management and disposition of this case.

Keeping an Open Mind about Acute Flank Pain in Emergency Department: Acute Kidney Infarction

Differential diagnosis of the acute flank pain in a patient without nephrolithiasis is challenging in emergency department. Renal infarction should be suspected if accompanying cardiac arrhythmia, heart failure or valvular disease is present. Activated protein C resistance is the most common thrombophilia that triggers venous-obstructive conditions and rarely arterial thromboembolism. We described a young male with a history of non-ischemic dilated cardiomyopathy and coexisting activated protein C resistance presented with new onset acute flank pain due to acute renal infarction.

A Rare Cause of Acute Kidney Injury in a Female Patient with Breast Cancer Presenting as Renal Colic

Renal infarction is a rare cause of acute kidney injury which could lead to permanent loss of renal function. A prompt diagnosis is necessary in order to achieve a successful revascularization of the occluded artery. Given the rarity of the disease and the paucity of the reported cases in the previous literature a high index of suspicion must be maintained not only in the classical cardiac sources of systemic emboli (atrial fibrillation, dilated cardiomyopathy, or endocarditis), but also in the situations when a hypercoagulable state is presumed. The unspecific presenting symptoms often mask the true etiology of the patient’s complaints. We present here a rare case of renal infarction that occurred in the setting of a hypercoagulable state, in a female patient with a history of breast cancer and documented hepatic metastases.

Rupture and bleeding secondary to renal infarction in a patient with an abdominal aortic aneurysm

A 57-year-old man had been followed up for severe left ventricular dysfunction after acute myocardial infarction with a left ventricular thrombus. He had been treated with anticoagulant and antiplatelet therapy and was admitted to our hospital because of abdominal pain and shock. He had no prior episode of trauma. The electrocardiogram (ECG) showed no changes compared with the previous ECG. Enhanced abdominal computed tomography (CT) showed a retroperitoneal hematoma around an abdominal aortic aneurysm (AAA) and the right kidney. We suspected rupture of AAA or the right kidney, and we performed AAA replacement with a Y-shaped graft and nephrectomy of the right kidney. Pathological examination revealed hemorrhagic infarction of the lower part of the right kidney, with hemorrhage and rupture at the center of the infarct. In our case, enhanced CT showed extravasation from the lower part of the right kidney. In addition, postoperative echocardiography showed that the left ventricular thrombus had disappeared. We report a case of rupture and bleeding secondary to renal infarction in a patient with an AAA.

A case of renal artery thrombosis with renal infarction

Renal artery thrombosis is a rare, but serious and often misdiagnosed, condition. Emergency physicians and other physicians need to consider this diagnosis in unexplained flank pain, especially in patients with risk factors for this disease. In this case report, the authors review a case of renal infarction caused by renal artery thrombosis in a patient with risk factors for thrombosis but no previous history of thromboembolism. A review of scholarly articles was performed and the case is discussed in the context of the current knowledge of this condition. Common presenting symptoms, features of the history and risk factors will all be discussed herein. Diagnostic evaluation of flank pain in the setting of the suspicion of renal infarction will be discussed, including the modalities of high-resolution computed tomography, renal angiography, scintography and ultrasound. Acute management and prognosis will also be discussed.

A rare case of renal infarction caused by infective endocarditis

BACKGROUND

A 29-year-old man presented to the emergency department of a general hospital complaining of sudden onset left loin pain, radiating to the groin, which had started 48 h previously. He described no urological symptoms and had no medical history of note.

INVESTIGATIONS

Physical examination, electrocardiography, dipstick testing of urine, radiography of the chest and abdomen, blood tests (white blood cell count and serum urea, creatinine, sodium, potassium and C-reactive protein levels), CT of the renal tract, blood and urine cultures, renal angiography, thromboembolic blood panel, urine and blood tests for illicit drugs, transthoracic echocardiography, transesophageal echocardiography, renal ultrasonography.

DIAGNOSIS

Infective endocarditis resulting in thromboembolic unilateral renal infarction.

MANAGEMENT

The patient was started on anticoagulation therapy with low-molecular-weight heparin and treated with intravenous gentamicin and benzylpenicillin for 4 weeks. He was seen in an outpatient clinic 4 weeks after discharge, at which time serum urea and creatinine levels and repeat ultrasonography of the renal tract confirmed normal renal function. He will be followed up regularly by cardiologists and urologists, at 6 weeks initially, and every 6 months to 1 year thereafter by his family physician.

Considerations in the diagnosis and therapy for acute loin pain

The clinical presentation of acute onset of nausea, vomiting, and flank pain in combination with acute elevation of blood pressure should raise high suspicion of renal infarction. However, because of its nonspecific presentation, diagnosis may be delayed. We report the case of a 63-year-old man who presented with a 2-day history of right flank pain that was treated initially as a renal stone. He had a background history of atrial fibrillation. Further investigations confirmed this as a case of renal infarction. Renal infarction is underdiagnosed because of the similarity of its presentation to other renal pathology. Renal infarction should be considered in the differential diagnosis of loin pain, particularly in a patient with atrial fibrillation.

A lady with unresolved loin pain

A history of cardiac disease, especially atrial fibrillation, together with symptoms such as loin or abdominal pain, and accompanied by an elevated lactate dehydrogenase should prompt a computed tomography scan to exclude the diagnosis of acute renal infarction.