A Page Kidney Case Report With Diastolic Flow Reversion in Doppler Ultrasonography

Abstract

The renal compartment syndrome, also known as Page kidney, is due to external compression of the kidney, generally caused by a subcapsular hematoma resulting in hypertension and sometimes renal failure. It was first described in an experimental model reported by Page in 1939 based on cellophane wrapping around canine kidneys (1, 2). We present a Page kidney novel cause associated with the placement of a percutaneous nephrostomy tube in a renal allograft. A 60-year-old hypertensive man, with chronic ischemic cardiopathy and antiplatelet therapy with aspirin, presented chronic kidney disease. He received a cadaver kidney transplant with immediate renal allograft function and was immunosuppressed with prednisone, tacrolimus, and mycophenolate mofetil. One month later patient’s renal function declined. An ultrasound scan detected urinary tract dilatation. A pyelography revealed stenosis of the ureterovesical anastomosis, thus requiring placement of a percutaneous nephrostomy tube with appropriate diuresis through nephrostomy and recovery of baseline creatinine. Forty-eight hours after nephrostomy, he developed oliguria and his serum creatinine increased to 8.6 mg/dL. Ultrasound scan showed a 12×4.4 cm renal graft with a 8×2.9 cm subcapsular hematoma. Doppler ultrasonography revealed a spectral tracing with diastolic flow reversion and an increase in the resistance indexes. Both main artery and main vein were patent. CT scan exposed a subcapsular hematoma with a longitudinal diameter larger than 14 cm, which compressed the graft in its entirety. Hematoma’s percutaneous drainage was initially attempted. Twenty-four hours later, the patient underwent surgery for hematoma’s removal and repair of the ureterovesical stenosis. Postsurgery development was successful, with progressive increase of the diuresis and decrease of serum creatinine to basal line. Ultrasound and Doppler studies confirmed the disappearance of the hematoma and the recovery of normal spectral tracings with a decrease in the resistance indexes (Fig. 1). The patient remained normotensive with his usual antihypertensive medication.FIGURE 1.: (A) Doppler ultrasonography spectral tracing with diastolic flow reversion and an increase of the resistance indexes up to 1. (B) Doppler ultrasonography after surgery with spectral tracing normalized 68×68 mm.Page kidney is most frequently due to a renal trauma that results in a hematoma (3, 4), but there have been case reports in which renal compression is secondary to a perirenal limphocele or retroperitoneal paraganglioma (5, 6). In our patient, Page kidney derives from a renal subcapsular hematoma secondary to placement of a percutaneous nephrostomy tube. This procedure in kidney allograft is a novel cause, which in our knowledge has not yet been reported. Antiplatelet therapy may have promoted development of a hematoma following the procedure (7). Usual clinical findings in this syndrome include hypertension, which develops immediately because of direct compression of the renal parenchyma and renal failure, which is more common in patients with a single native kidney or a renal graft (3). Blood pressure levels did not increase in our patient, although renal failure was observed. Reversion of the diastolic flow in Doppler ultrasonography is suggestive of allograft venous thrombosis or severe renal parenchymal damage (8, 9) and this fact has not previously been described in Page kidney. Normalization of spectral tracings after surgery and renal function recovery suggests that diastolic flow reversion is due to renal allograft compartment syndrome, in addition to other known conditions and it could be useful in the differential diagnosis of such processes. Silvia Caldés Ana Fernández Maite Rivera Jose L. Merino Department of Nephrology Ramón y Cajal Universitary Hospital Madrid, Spain Raquel González Department of Urology Ramón y Cajal Universitary Hospital Madrid, Spain Yesika Amezquita Roberto Marcén Department of Nephrology Ramón y Cajal Universitary Hospital Madrid, Spain F. Javier Burgos Department of Urology Ramón y Cajal Universitary Hospital Madrid, Spain Joaquin Ortuño Department of Nephrology Ramón y Cajal Universitary Hospital Madrid, Spain