A Case of Recurrent Renal Infarction Following Transient Resolution: Evidence From Serial Computed Tomography.

Quiz Page June 2014: A 45-Year-Old Woman With Acute Anuria

Case Reports1 September 1945HYPERTENSION CAUSED BY RENAL INFARCTIONS. BEN-ASHER, M.D.S. BEN-ASHER, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-23-3-431 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptOf the numerous experimental investigations as to the pathogenesis of essential hypertension, the work of Goldblatt1is beyond doubt the most outstanding. In a classical experiment he produced hypertension in the dog by constriction of one or both renal arteries with a silver clamp, with a resultant decrease in the blood flow through the kidney. These experiments have been repeated by other investigators with the same result. It is believed that the diminution in renal flow produces hypertension by the secretion of a pressor substance into the blood by the ischemic kidney. Since then a number of reports have appeared...Bibliography1. GOLDBLATTLYNCHHANZALSUMMERVILLE HJRFWW: Studies on experimental hypertension. I. The production of persistent elevation of systolic blood pressure by means of renal ischemia, Jr. Exper. Med., 1934, lix, 347-379. CrossrefGoogle Scholar2. BUTLER AM: Chronic pyelonephritis and arterial hypertension, Jr. Clin. Invest., 1937, xvi, 889-897. CrossrefGoogle Scholar3. BARKERWALTERS NWW: Hypertension and chronic pyelonephritis: results of nephrectomy, Jr. Am. Med. Assoc., 1940, cxv, 912-916. CrossrefGoogle Scholar4. RICHARDS GG: Unilateral renal tuberculosis associated with hypertension, Ann. Int. Med., 1941, xv, 324-328. Google Scholar5. BLATTPAGE EIH: Hypertension and constriction of renal arteries in man; report of case, Ann. Int. Med., 1939, xii, 1690-1699. Google Scholar6. HOWARDFORBESLIPSCOMB TLRPWR: Aneurysm of left renal artery in a child five years old with persistent hypertension, Jr. Urol., 1940, xliv, 808-815. CrossrefGoogle Scholar7. KOONSRUCH KMMK: Hypertension in a seven year girl with Wilms' tumor relieved by nephrectomy, Jr. Am. Med. Assoc., 1940, cxv, 1097-1098. CrossrefGoogle Scholar8. HOFFMAN BJ: Renal ischemia produced by aneurysm of abdominal aorta, Jr. Am. Med. Assoc., 1942, cxx, 1028-1030. CrossrefGoogle Scholar9. PRINZMETALHIATTTRAGERMAN MNLJ: Hypertension in a patient with bilateral renal infarction, Jr. Am. Med. Assoc., 1942, cxviii, 44-46. CrossrefGoogle Scholar10. FISHBERG AM: Hypertension due to renal embolism, Jr. Am. Med. Assoc., 1942, cxix, 551-553. CrossrefGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Jersey City, N. J.*Received for publication July 20, 1944.From the Medical Department of the Fairmount Hospital, Jersey City, N. J. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byBlood pressure and renal outcomes in patients with kidney infarction and hypertensionSegmental Renal Artery Infarction: A Case Report With Computerized Tomography Scan and Angiographic CorrelationNatural History of Hypertension in Renal Parenchymal DiseaseRenal Artery Thrombosis: A Cause of Reversible Acute Renal FailurePercutaneous arterial embolization in the kidneys of dogs: a comparative study of eight different materialsHypertension resulting from segmental renal artery infarction A reviewRenal Artery Changes in HypertensionVarious Organic DiseasesMitral Stenosis. Hypertension following Renal EmbolismAkuter ArterienverschlußAcute Renal InfarctionHypertonieHypertonieOcclusion of a Renal Artery as a Cause of HypertensionARTERIAL INFARCTION OF THE KIDNEY*J. GEORGE TEPLICK, M.D., M. WILLIAM YARROW, M.D.Case 38381A CASE OF MALIGNANT HYPERTENSION SECONDARY TO RENAL ISCHEMIA*WILLIAM H. BLAHD, M.D., RAYMOND MARCUS, M.D., DAVID M. WASSERMAN, M.D.Thrombosis of the inferior vena cava and renal veins with hemorrhagic renal infarction in infancyHYPERTENSION FOLLOWING RENAL INFARCTIONRenal Infarction: A Clinical and Possible Surgical EntityThrombosis of the Left Renal Artery with Hyper-Tension: Case Report 1 September 1945Volume 23, Issue 3Page: 431-436KeywordsBlood flowHypertensionInfarctionKidneysPathogenesisRenal arteriesRenal circulation ePublished: 1 December 2008 Issue Published: 1 September 1945 PDF downloadLoading ...

Renal Infarction: A Clinical and Possible Surgical Entity

Despite current recommendations by the Brain Trauma Foundation regarding the placement of intracranial pressure (ICP) monitoring devices, advances in computed tomographic (CT) scan technology have led to the suggestion that increased ICP may be predicted by findings on admission head CT scan and that patients without such findings do not require such monitoring. A linear relationship exists between characteristics of admission head CT scan and initial ICP level, allowing for selective placement of ICP monitoring devices. From 1997 to 2001, a retrospective review of patients admitted with a Glasgow Coma Scale (GCS) score < 8 and head CT scan who underwent ventriculostomy placement at our institution, was conducted. Patients undergoing craniotomy with evacuation of mass lesions before ventriculostomy placement were excluded. Age, sex, mechanism of injury, anoxia, osmotic treatment, presence of drugs/alcohol, initial mean arterial pressure, initial GCS score, and initial ICP were recorded. Initial head CT scans were reviewed independently by two neuroradiologists who were blinded to ICP measurements, neurosurgical treatment, patient outcome, and each other's interpretation. Initial CT scans were evaluated and scored on a 1 (normal) to 3 (abnormal) scale with respect to ventricle size, basilar cistern size, sulci size, degree of transfalcine herniation, and gray/white matter differentiation. Initial ICP readings and CT scan findings were compared to determine whether a significant linear relationship existed between the above CT scan findings and ICPs. Logistic and univariate linear regression were used to compare averaged radiologist score versus dichotomized ICP at baseline. Initial head CT scan characteristics show a linear relationship to baseline ICPs. These findings are associative, but are not uniformly predictive. Therefore, the current Brain Trauma Foundation recommendation of ICP monitoring in those patients presenting with a GCS score < 8 with an abnormal CT scan or a normal CT scan with age > 40 years, systolic blood pressure < 90 mm Hg, or exhibiting posturing should be followed.

In late December 2019, a series of unexplained cases of pneumonia were reported in Wuhan, China. On January 12, 2020, the World Health Organization temporarily named the virus responsible for the emerging cases of pneumonia as the 2019 coronavirus. Acute respiratory distress syndrome (ARDS) due to Covid-19 has rapidly spread around the world, and while no specific treatment or vaccine has been reported, mortality rates remain high. One of the suggested treatments for cellular damage in the pathogenesis of ARDS caused by the coronavirus is the administration of high doses of intravenous vitamin C. Considering the paucity of literature on the therapeutic effects of high doses of intravenous vitamin C in patients with ARDS resulting from the coronavirus, this study was conducted to assess this therapeutic supplement in these patients. This study was performed as a single-center clinical trial in patients with a documented diagnosis of COVID-19 pneumonia. 54 eligible patients with moderate to severe COVID-19 symptoms, based on specific inclusion and exclusion criteria, were included in the investigation and randomly divided into two groups. The control group consisted of 26 patients who received standard treatment, whereas the treatment group was comprised of 18 patients administered intravenous vitamin C at a dose of 2 g every 6 hours for 5 days in addition to standard treatment. Demographic characteristics, underlying diseases, length of hospital stay, and mortality rates were reviewed and collected. Oxygen saturation, respiratory rates, serum C Reactive Protein (CRP) levels, lymphopenia and lung parenchymal involvement on CT were investigated at the time of admission and on the sixth day after hospitalization. Finally, all variables were analyzed with IBM SPSS Statistics 23 software and a significant statistical difference was defined for all variables, P <0.05. Of these variables, the amount of oxygen saturation in the vitamin C group increased significantly from 86±5% on the first day of hospitalization to 90±3% on the sixth day of hospitalization (P value=0.02). Also, the respiratory rate in the vitamin C group decreased significantly from 27±3 on the first day of hospitalization to 24±3 on the sixth day of hospitalization (P value=0.03). Lung CT scans of patients in the two groups reported by two radiologists were also compared. Based on the report of the radiologists, the rate of lung involvement in the vitamin C group was significantly lower than in the control group at the end of treatment (P value=0.02). Due to the effectiveness of high doses of intravenous vitamin C on reducing lung involvement and improving clinical symptoms, further studies with a larger sample size are recommended to demonstrate the effects of this drug supplement.

Case Report A 67 years old Angolan woman was referred to our hospital for worsen dyspnea, palpitation and left flank pain while walking. She had no relevant medical history and her only cardiovascular (CV) risk factor was hypertension. For high suspicion of pulmonary embolism (PE), an abdominal–thoracic CT was performed, demonstrating the presence of bilateral PE with greater thrombotic burden of the right branch, right ventricle (RV) enlargement and left renal infarction. She was stratified in an intermediate–high risk class. The patient was hemodynamically stable (BP: 120/65 mmHg, HR: 115 bpm) with a calculated PESI class of III and elevated Hs–cTnI. Transthoracic echocardiography (TTE) showed RV dilation, McConnell sign, flattened intra–ventricle septum, mild pulmonary and severe tricuspid valve regurgitations. Therefore, we decided to start anticoagulation and to perform ultrasound–assisted thrombolysis (USAT) without procedural complications. A venous echo–doppler demonstrated the presence of thrombosis of the left popliteus veins. Moreover, screening for thrombophilia syndromes and neoplastic markers were negative. The day after, a partially–restored flow was noticed on renal artery US. The bubble test during transesophageal echocardiography revealed a patent foramen ovale (PFO) with a moderate right–to–left shunt. From these findings, a paradoxical embolism (PDE) through amoderate PFO was confirmed as the cause of her renal infarction. After 7 days of hospitalization, the patient was discharged on anticoagulant (apixaban) in good health status and with reduced serum creatinine levels. Discussion PE is the 3rd leading cause of CV mortality. A rare scenario in PE is PDE, manifesting in this case with acute kidney injury, with no other organ involvement. PDE occurs when a thrombus crosses an intracardiac defect into systemic circulation and it usually follows PE because elevated right–side pressure enhances right–to–left shunting. For patients with intermediate–risk PE, there is no clear consensus on 1st–line therapy. In our case, USAT has been effective in reversing RV dysfunction with early decrease of right–side pressures by TTE assessments. Compared with anticoagulation alone, USAT may quicker protect from PDE recurrence and potentially reduce the incidence of chronic thromboembolic pulmonary hypertension, a rare but serious long–term complication. Moreover, as we observed, thrombolytic local release can dissolve systemic clots when PDE occurs.

Portal-mesenteric pylephlebitis with hepatic abscesses in a patient with Crohn's disease treated successfully with anticoagulation and antibiotics.

The effect of early acyclovir therapy on the course of varicella pneumonia in previously healthy adults was assessed. Medical records from five university-affiliated medical centers were retrospectively reviewed; included were all immunocompetent adults with a clinical diagnosis of primary varicella, a chest radiograph consistent with varicella pneumonia, and an arterial blood gas measurement indicating significant hypoxia. Of the 38 patients who met the study criteria, 11 had had a course of intravenous acyclovir initiated within the first 36 hours of hospitalization; the mean time from admission to initiation of therapy in this early-treatment group was 9.6 hours. The group that received early acyclovir treatment had a lower mean temperature beginning on the fifth day of hospitalization (37.0 degrees C vs. 37.7 degrees C; P = .011) and a lower mean respiratory rate beginning on the sixth day of hospitalization (21 vs. 28 respirations per minute; P = .004). Early acyclovir therapy also resulted in a significant improvement in oxygenation beginning on the sixth day of hospitalization in patients with follow-up arterial blood gas measurements (P = .035). Thus, early institution of acyclovir therapy is associated with reduction in fever and tachypnea and improvement in oxygenation in otherwise healthy adults with varicella pneumonia.

Ex Vivo Repair and Renal Autotransplantation for Complex Renal Artery Aneurysms in a Solitary Kidney

To the Editor, Hyperthyroidism is associated with increased plasma levels of procoagulants and antifibrinolytic clotting factors such as fibrinogen and plasminogen activator inhibitor-1 [1,2]. Similarly, thyrotoxicosis is associated with the occurrence of arterial thrombosis that is primarily due to atrial arrhythmias; the overall incidence of thromboembolism varies from 8% to 40% [3]. Thrombosis is often observed in patients with thyrotoxicosis but there are few reports of arterial thrombosis in conjunction with thyrotoxicosis that are independent of atrial arrhythmias. The present study is a case report of a patient with Graves' disease who presented with a renal infarction without atrial fibrillation. A 54-year-old man visited our emergency department due to the sudden onset of left flank pain for 30 minutes that was accompanied by dysuria in the absence of other symptoms of pyelonephritis in conjunction with neck enlargement and eyeball protrusion. The patient did not have a medical history of diabetes, hypertension, or cardiovascular disease but he had a 10 pack-per-year history of smoking. An electrocardiogram (ECG) revealed sinus tachycardia but his chest X-ray was unremarkable. His vital signs were as follows: blood pressure of 140/90 mmHg, heart rate of 108 beats per minute, respiration rate of 22 breaths per minute, and body temperature of 36.5℃. His laboratory findings were as follows: urinary analysis of 5 to 9 red blood cells per high power field, +1 proteinuria, a thyroid stimulating hormone (TSH) level of 0.01 µU/mL (normal range, 0.55 to 4.78), a free thyroxine level of 28.33 pmol/L (normal range, 11.5 to 22.7), and a TSH-binding inhibitory immunoglobulin level of 40.00 IU/L (normal level, 1.75 or less). Coagulation tests, including prothrombin time and activated partial thromboplastin time, were performed while the patient was in the emergency room and were within normal ranges. In addition, the patient's levels of Factor VIII, von Willebrand factor, antithrombin III, fibrinogen, and plasminogen activator inhibitor-1 were also assessed to screen for coagulation and fibrinolytic system disorders. All levels were within normal ranges and further tests for antiphospholipid antibodies, cytoplasmic antineutrophil cytoplasmic antibodies, and perinuclear antineutrophil cytoplasmic antibodies, which are associated with vasculitis, were negative. Initial Holter monitoring (24 hours) revealed sinus tachycardia but the patient's echocardiogram findings were normal. An enhanced abdominal computed tomography (CT) scan revealed a hypoechoic lesion with a clear wedge-shaped margin on the left kidney and a thrombus in the left renal artery (Fig. 1A). The renal infarction was diagnosed based on the symptoms of the patient and typical CT findings and he was treated with intravenous unfractionated heparin infusions. A thyroid ultrasonography revealed increases in the size and vascularity of both thyroid glands (Fig. 1B) and a technetium-99m thyroid scan was compatible with a diagnosis of Graves' disease (Fig. 1C). The patient was initially treated with methimazole and was switched to warfarin therapy after 5 days of heparin infusions. A second round of Holter monitoring (24 hours) after 1 week showed nonspecific findings and a subsequent ECG showed a normal sinus rhythm. Figure 1 (A) An enhanced abdomen computed tomography scan showing a left renal infarction in the transverse view (left) and the coronal view (right). (B) Thyroid ultrasonography revealing increases in the size and vascularity of both lobes. (C) A technetium-99m ... Hyperthyroidism is associated with a hypercoagulable state and is thought to increase the risk of venous thrombosis [2]. However, the relationship between thyroid function and the risk of venous thrombosis has yet to be fully explored. Thyrotoxicosis shifts the haemostatic balance of an individual towards a hypercoagulable and hypofibrinolytic state [2], but unlike venous thrombosis, the arterial embolisms that are associated with thyrotoxicosis typically result from atrial arrhythmias. Patients with hyperthyroidism frequently present with atrial fibrillation, and its incidence is approximately 10% to 25% for all patients with thyrotoxicosis [3]. The overall rate of systemic embolisms is 8% to 40% in patients with thyrotoxic atrial fibrillation [3], but as in the present case, the presence of arterial thromboembolism in thyrotoxic patients without cardiac arrhythmia is very rare and not fully characterized. Only seven cases of acute cerebrovascular ischemic disease have been reported [1] and in some of these instances, including the present case, paroxysmal atrial fibrillation or vasculitis that may contribute to embolic phenomena could not be entirely excluded. In the present case, the patient presented with a renal infarction during the course of thyrotoxicosis that was caused by hyperthyroidism induced by Graves' disease. Although the relationship that likely exists between arterial embolisms, particularly renal infarctions, and hyperthyroidism needs to be clarified, the present case suggests that uncontrolled thyrotoxicosis is associated with a risk of renal infarction.

Confession and Some Lessons The PISA-PED study

Introduction: A 35 year old man presented with sudden onset left-sided chest pain and left flank pain. He had known non-ischemic cardiomyopathy (EF of 40-45%), non compliant with treatment. He was in severe pain with left costovertebral angle tenderness. Initial investigations showed a WBC count of 12,000, troponin of 3.72 and a urinalysis significant for 2+ proteins but no RBCs. Initial ECG showed &lt;1 mm ST segment elevations with T wave inversions in inferior leads. Cardiac catheterization, did not demonstrate any flow limiting disease. Serial ECGs demonstrated a resolution of the aforementioned changes and his troponins trended down. Further review revealed an extensive history of cocaine use confirmed with a positive urine drug screen. Due to worsening abdominal pain, a CT abdomen with contrast was done which showed an acute segmental infarct on the upper pole of left kidney, but a CT angiogram did not show any evidence of obstructing vascular lesion or dissection. He was discharged on oral oxycodone, diltiazem and lisinopril.The patient returned in one week with exertional chest pain that was relieved with sublingual nitroglycerin. ECG on admission showed diffuse T wave inversions which improved in 6 hours. A repeat urine drug screen was positive for cocaine. Troponins peaked at 5.03. He then complained of persistent right flank pain and a repeat CT angiogram showed a new moderate-sized segmental infarct in the mid-pole of the right kidney. His pain was managed with oxycodone and he was eventually discharged home with isosorbide mononitrate, amlodipine and lisinopril. Conclusions: Renal infarcts may be sometimes missed in the absence of imaging, but must be suspected in drug users with flank pain and inferior EKG changes. In this case, it was hypothesized that renal arterial vasospasm led to the infarct; an extension of the known effect of cocaine on coronary vessels. This case highlights the importance of ruling out renal infarction as a cause for persistent abdominal pain. Identification of the cause of infarction is important, so as not to subject patients to long term anticoagulation. Guidelines for the treatment of drug induced renal infarction are lacking and the approach to such patients, as with all substance abusers, is abstinence.

Renal artery infarction (RI) is the presence of blood clot in the main renal artery or its branches causing complete or partial obstruction of the blood supply. Its etiology is either related with disorders of the renal vasculature or with cardiovascular diseases. Recently, the SARSCoV- 2 virus is an emerging cause of thromboembolic events and the incidence of RI is anticipated to increase after the pandemic. A systematic review based on COVID-19 associated RI was conducted. A systematic review of the Medline/Pubmed and Scopus databases was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA statement). Search strategy and information sources: A hand-search was performed using the terms "SARS-Cov-2" OR "COVID-19" AND "renal thrombosis" OR "renal infarction" OR "renal "thromboembolism". all types of publications (case reports, case series, letters to the editor, short communications) were evaluated for relevance. Inclusion criteria were: confirmed SARS-Cov-2 infection irrespectively of the age, diagnosis of RI during or after the onset of viral infection, and exclusion of other potential causes of thromboembolic event except of SARS-Cov-2. Patients with renal transplantation were also considered. Study criteria selection: after checking for relevance based on the title and the abstract, the full texts of the selected papers were retrieved and were further evaluated. Duplicated and irrelevant cases were excluded. Any disagreement was resolved by consensus with the involvement of a third reviewer. Quality of studies: The assessment of the quality case reports was based on four different domains: selection, ascertainment, casualty and reporting. Each paper was classified as "Good", "Moderate" and "Poor" for any of the four domains. Data extractions: Crucial data for the conduct of the study were extracted including: age, sex, time from SARS-Cov-2 infection till RI development, medical history, previous or current antithrombotic protection or treatment, laterality and degree of obstruction, other sites of thromboembolism, treatment for thromboembolism and SARS-Cov-2 and final outcome. methods of descriptive statistics were implicated for analysis and presentation of the data. The systematic review retrieved 35 cases in 33 reports. In most cases, RI was diagnosed within a month from the SARSCov- 2 infection albeit 17 out of 35 patients were receiving or had recently received thromboprophylaxis. Right, left, bilateral and allograft obstruction was diagnosed in 7, 15, 8 and 5 patients respectively. 17 cases experienced additional extrarenal thromboembolism primarily in aorta, spleen, brain and lower limbs. Low molecular weight heparins (LMWH) (usually 60-80 mg enoxaparine bid) was the primary treatment, followed by combinations of unfractionated heparin and salicylic acid, apixaban and rivaraxaban, warfarin, acenocoumarol or clopidogrel. Kidney replacement therapy was offered to five patients while invasive therapies with thrombus aspiration or catheter directed thrombolysis were performed in two. Regarding the outcomes, five of the patients died. The total renal function was preserved in 17 cases and renal impairment with or without hemodialysis was recorded in 5 patients, two of them having lost their kidney allografts. The majority of included studies are of moderate quality. The results and the conclusions are based on case-reports only and crucial data are dissimilarly presented or missing through the relevant publications. Thromboprophylaxis may not offer adequate protection against SARS-Cov-2 induced thrombosis. Most patients could be effectively treated with conservative measures, while in more severe cases aggressive treatment could be recommended. Therapeutic doses of LMWH could be considered for protection against RI in SARS-Cov-2 cases. Interventional treatment could be offered in a minority of more severe cases after carful balancing the risks and benefits.

The role of bedside ultrasonography, urinalysis, and computed tomography in the diagnostic evaluation of flank pain

Background: Acute abdominal pain is a common reason for presentation and readmission to the emergency department (ED). It involves a broad range of differential diagnoses, posing a diagnostic challenge to treating physicians. Computerized tomography (CT) scans of the abdomen are commonly utilized for patients presenting with abdominal pain, providing established diagnostic value. However, exposure to ionizing radiation, intravenous contrast material, the financial burden, and the impact on ED wait times necessitate investigating the diagnostic utility of abdominal CT scans in the ED. This study aims to assess the indications for CT scans, explore the diagnostic yield, and examine the rate of diagnosis alteration pre- and post-CT, with the goal of providing insights into the trends associated with abdominal CT requests and guiding local CT ordering protocols. Methods: A retrospective review of patient medical records from January to March 2024 was conducted on adult (≥18 years) patients presenting to the ED with non-traumatic acute abdominal pain (&lt;7 days) who underwent CT scans. Data collected included demographics, medical history, location of abdominal pain, provisional diagnosis, and CT scan findings. Descriptive statistics were used for categorical and continuous variables, and multi-logistic regression models explored relationships between clinical variables and scan outcomes. Results: A total of 460 patients were enrolled in the study, 55% were male, with a mean age of 40 years. The most common comorbidities were hypertension and diabetes (10% each). Right iliac fossa pain was the most frequent presenting complaint (37%), followed by left flank (16%) and right flank pain (14%). Appendicitis was the most common pre-CT provisional diagnosis (40.8%), followed by renal stones (16.6%). Overall, 74.6% of scans were positive, with appendicitis (21.9%) and urinary tract stones (20.1%) being the most common findings. CT scans altered the provisional diagnosis in 48% of cases. Gender was the only significant clinical variable associated with positive scan results; females were 50% less likely to have a positive scan compared to males. Conclusion: Overall, our results provide valuable insights into local patterns associated with the use of CT for acute abdominal pain and align with regional and international studies regarding the common indications and CT findings. The results are also comparable with the ratio of positive CT scan findings and the rate of post-CT diagnosis alteration, which, as shown in the literature, can guide critical clinical decisions. However, apart from gender, no other clinical variable significantly predicted positive CT results, underscoring the inherent diagnostic uncertainty in evaluating acute abdominal pain in the ED. These findings highlight the need for optimized CT scan protocols that balance diagnostic accuracy with resource utilization.