Wunderlich Syndrome Complicated by Page Kidney as the Initial Presentation of Polyarteritis Nodosa: A Rare Case Report

Page kidney secondary to subcapsular hematoma (SH) is a rare but serious complication in renal transplant recipients, typically occurring in the early postoperative period. This is caused by external graft compression, which impairs perfusion and leads to acute renal dysfunction. Prompt diagnosis and surgical intervention are essential for salvaging graft functions. This systematic review synthesizes available case-level evidence on Page kidney in transplant recipients, focusing on the timing of onset, clinical presentation, imaging characteristics, management strategies, and outcomes of Page kidney. A systematic search of the PubMed, Scopus, Embase, Web of Science, and Google Scholar databases was conducted until May 2024. Eligible studies included case reports and case series describing Page kidneys due to SH in renal transplant recipients. Data extraction included clinical features, imaging findings, interventions, and outcomes. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. This review was registered with PROSPERO (CRD42024547165; University of York, UK). Ten studies involving 15 patients were included in the analysis. Most patients (13/15) developed Page kidney within the first week after transplantation, while two cases presented > 6months after transplantation. Common features included oliguria or anuria (86.7%), elevated resistive indices (RI ≥ 0.9), and crescentic subcapsular hematomas on Doppler ultrasound. Surgical evacuation was performed in 93.3% of the cases, with favorable renal recovery in 11 patients (73.3%). Late or missed diagnoses are correlated with irreversible graft losses. The risk of bias was low in all included studies. Page kidney in transplant recipients, although rare, requires a high index of suspicion, particularly in the early postoperative period. Doppler ultrasonography remains central to diagnosis, while surgical decompression offers the best chance of graft salvage. Early recognition is critical given the narrow therapeutic window and high stakes of delayed intervention.

Case Report: Early Spontaneous Subcapsular Hematoma in a Transplanted Kidney: The Importance of High Suspicion and Timely Intervention.

The challenge of third and subsequents kidney transplantion in children.

Page kidney resulting from unilateral spontaneous subcapsular renal hematoma in mid-trimester pregnancy: A case report and literature review

Managing Page Kidney in a Patient With Underlying Renal Cell Carcinoma: A Case Report

Acute page kidney phenomenon following percutaneous transluminal renal angioplasty

G-030 Paging Nephrology: A Case of Page Kidney Caused by Spontaneous Rupture of a Hemorrhagic Cyst

Page kidney causes secondary hypertension due to external compression of the renal parenchyma and renal hypoperfusion. A 21-year-old healthy man was diagnosed with hypertension during a medical examination 3 months after he had gotten a bruise at the right lumbar region. The patient's blood pressure was 176/120 mmHg. Computed tomography showed a large encapsulated cystic lesion around the right kidney and severe external compression of the renal parenchyma. Dimercaptosuccinic acid renal scintigraphy revealed decreased right split renal function. Therefore, the patient was diagnosed with a Page kidney. Percutaneous drainage of the hematoma was performed. However, the hematoma enlarged again. Capsulectomy was subsequently performed. The pathological findings revealed capsule fibrosis and hyperplasia of the capillaries in the inner capsule layer. After capsulectomy, the patient's blood pressure normalized. Blood leakage from the fibrotic capsule likely maintained the hematoma. Capsulectomy is recommended in cases involving an encapsulated perineal hematoma.

Renovascular hypertension (RVHT) is an important cause of secondary hypertension, accounting for approximately 75% of cases. This pictorial review describes the imaging modalities used to diagnose RVHT, including ultrasound, computed tomography angiography, and magnetic resonance angiography, provides their benefits and limitations, and explores the imaging findings, diagnostic criteria, and management of multiple causes of RVHT. Atherosclerosis is the most common cause of RVHT, particularly in older individuals, while fibromuscular dysplasia is more prevalent in younger females. Less common discussed etiologies include polyarteritis nodosa, extrinsic compression, Page kidney, dissection, renal artery (RA) thrombus, and RA aneurysms. This paper also highlights the importance of recognizing anatomical variants and rare conditions that can impact diagnosis and management. While RVHT represents a minority of hypertension cases, its potential reversibility makes accurate diagnosis crucial. Treatment approaches vary based on etiology and may include medical management, angioplasty, stenting, or surgical intervention. This review aims to enhance radiologists' understanding of RVHT, facilitating improved diagnosis and patient care.

A Rare Case of Atraumatic Page Kidney in a Patient with EKRD

A Case of Page Kidney Secondary to Spontaneous Bilateral Retroperitoneal Hemorrhage

We sought to determine if genetically modified porcine kidneys used for xenotransplantation had sufficient tissue integrity to support long-term function in a human recipient. Kidney transplantation remains the best available treatment for patients with end-stage kidney disease. However, a shortage of available donor human kidneys prevents many patients from achieving the benefits of transplantation. Xenotransplantation is a potential solution to this shortage. Recent pre-clinical human studies have demonstrated kidneys from genetically modified pig donors can be transplanted without hyperacute rejection and are capable of providing creatinine and other solute clearance. It is unknown whether the porcine kidneys would tolerate the relatively higher resting blood pressure in an adult human recipient compared with the pig donor or non-human primate (NHP) recipients used in translational studies. Furthermore, previous experience in NHPs raised concerns about the tissue integrity of the porcine ureter and post-xenotransplant growth of the porcine kidney. Kidneys recovered from porcine donors with 10 gene edits were transplanted into decedent brain-dead recipients who were not eligible for organ donation. Decedents underwent bilateral native nephrectomy before transplant and were followed for 3 to 7 days. Standard induction and maintenance immunosuppression was used as previously reported. Vital signs, including blood pressure, were recorded frequently. Kidney xenografts were assessed daily, serially biopsied, and were measured at implantation and study completion. Three decedents underwent successful xenotransplantation. Subcapsular hematomas developed, requiring incision of the xenograft capsules to prevent Page kidney. Blood pressures were maintained in a physiologic range for adult humans (median arterial pressures (MAP) 108.5mmHg (Interquartile Range (IQR): 97-114mmHg), 74mmHg (IQR: 71-78mmHg), and 95mmHg (IQR: 88-99mmHg, respectively) and no bleeding complications or aneurysm formation was observed. Serial biopsies were taken from the xenografts without apparent loss of tissue integrity despite the lack of a capsule. Ureteroneocystotomies remained intact without evidence of urine leak. Xenograft growth was observed, but plateaued, in 1 decedent with increased volume of the left and right xenografts by 25% and 26%, respectively, and in the context of human growth hormone levels consistently less <0.1ng/ml and insulin-like growth factor 1 levels ranging from 34-50ng/ml. The findings of this study suggest kidneys from 10-gene edited porcine donors have sufficient tissue integrity to tolerate xenotransplantation into a living human recipient. There was no evidence of anastomotic complications, and the xenografts tolerated needle biopsy without issue. Xenograft growth occurred but plateaued by the study end; further observation and investigation will be required to confirm this finding and elucidate underlying mechanisms.

Page kidney is a condition where external compression of the renal artery and renal parenchyma leads to subsequent ischaemia and activation of renin-angiotensin-aldosterone axis. A 42-year-old female with hirsutism, hypertension and diabetes was diagnosed with a right adrenal mass and underwent laparoscopic adrenalectomy. Her hypertension worsened postoperatively and was managed medically. Subsequently she developed a right flank pain on the fifth postoperative day and died suddenly the next day. Autopsy revealed a pale body with cushingoid appearance. Surgical scars were healthy. Internal examination of the abdomen revealed a haemoperitoneum of 500ml together with a large subcapsular haematoma measuring 1000ml surrounding the right kidney, compressing the right renal artery. Kidneys were pale and the right kidney was soft and friable. Cortical surface of the right kidney demonstrated a possible surgical puncture site with an overlying thrombus together with a contused inferior vena cava. Other organs were pale but appeared otherwise normal. Histology revealed diffuse cortical necrosis of right kidney and features of adult respiratory distress syndrome in the lungs. Haemorrhagic shock following laparoscopic adrenalectomy for right adrenal tumor was declared as the cause of death, contributed by the development of the Page kidney. Trauma of several aetiologies including laparoscopic abdominal surgery may contribute to Page kidney. It presents with flank pain, hypertension and renal mass. Since postoperative blood loss usually manifests as hypotension, resulting hypertension may mislead the attending clinicians. Once diagnosed, it can be managed with surgical drainage and antihypertensives.

43 A Case of Apixaban-Induced Page Kidney

Page's kidney is a condition that occurs due to external renal compression, usually caused by a subcapsular haematoma, generating a renal compartmental syndrome with parenchymal damage and renal perfusion alteration. Classically associated with renal trauma, Page's kidney can also arise after invasive renal procedures, such as renal biopsies or percutaneous nephrostomies. Clinically, it can trigger hypertension due to activation of the renin-angiotensin system induced by hypoperfusion secondary to renal parenchymal compression and can also present with varying degrees of renal function impairment. Furthermore, severe acute renal failure may be found particularly in patients with solitary kidneys or renal transplants. We present two cases of Page's kidney after renal biopsy and their PoCUS ultrasound findings. We would like to highlight the reversed diastolic flow on Doppler ultrasound in this entity, a pattern we have found in all two cases.

A Rare Case of Page Kidney in a Young Man with Flank Pain

International Classification of Diseases, Ninth/Tenth revisions, clinical modification (ICD-9-CM, ICD-10-CM) are frequently used in the U.S. by health insurers and disease registries, and are often recorded in electronic medical records. Due to their widespread use, ICD-based codes are a valuable source of data for epidemiology studies, but there are challenges related to their accuracy and reliability. This study aims to 1) identify ICD-9/ICD-10-based codes reported in literature/web sources to identify three common diseases in elderly patients with cancer (anemia, hypertension, arthritis), 2) compare codes identified in the literature/web search to SEER-Medicare's 27 CCW Chronic Conditions Algorithm ("gold-standard") to determine their discordance, and 3) determine sensitivity of the literature/web search codes compared to the gold standard. A literature search was performed (Embase, Medline) to find sources reporting ICD codes for at least one disease of interest. Articles were screened in two levels (title/abstract; full text). Analysis was performed in SAS Version 9.4. Of 106 references identified, 29 were included that reported 884 codes (155 anemia, 80 hypertension, 649 arthritis). Overall discordance between the gold standard and literature/web search code list was 32.9% (22.2% for ICD-9; 35.7% for ICD-10). The gold standard contained codes not found in literature/web sources, including codes for hypertensive retinopathy/encephalopathy, Page Kidney, spondylosis/spondylitis, juvenile arthritis, thalassemia, sickle cell disorder, autoimmune anemias, and erythroblastopenia. Among a cohort of non-cancer patients (N=684,376), the gold standard identified an additional 129 patients with anemia, 33,683 with arthritis, and 510 with hypertension compared to the literature/web search. Among a cohort of breast cancer patients (N=303,103), the gold standard identified an additional 59 patients with anemia, 10,993 with arthritis, and 163 with hypertension. Sensitivity of the literature/web search code list was 91.38-99.96% for non-cancer patients, and 93.01-99.96% for breast cancer patients. Discrepancies in codes used to identify three common diseases resulted in variable differences in disease classification. In all cases, the gold standard captured patients missed using the literature/web search codes. Researchers should use standardized, validated coding algorithms when available to increase consistency in research and reduce risk of misclassification, which can significantly alter the findings of a study.

The patient presented with complaints of left flank pain and breathlessness. After stabilization, an emergency lower cesarean delivery was performed, and a percutaneous drainage procedure was carried out to alleviate the compression on the left kidney. The patient was treated with blood transfusion, methyldopa, and perindopril. Follow-up examinations performed 3 months later revealed a significant decrease in fluid volume surrounding the left kidney. Lenk's triad provides the primary description of the classical manifestations of this syndrome. Some instances have been connected to the Page kidney phenomenon. The relationship between pregnancy and Wunderlich syndrome has not been extensively studied, primarily because the symptoms can resemble other complications related to pregnancy. Due to the scarcity of evidence in the literature, there is no definitive guideline for managing Wunderlich syndrome during pregnancy. Consequently, each patient is treated on an individual basis. Conservative treatment is recommended once malignancy has been ruled out. The case highlights the importance of considering Wunderlich syndrome as a differential diagnosis in pregnant patients with abdominal or flank pain, a palpable mass, and hypovolemia. Furthermore, the case illustrates the successful management of Wunderlich syndrome during pregnancy.

Page kidney is a rare but potentially curable cause of secondary hypertension. While the pancreatic pseudocyst is a completely different and unrelated entity. Here, we report a case of a 45-year-old female, diagnosed with idiopathic acute pancreatitis with multiple pseudocysts. After successful ultrasound -guided drainage of her left subcapsular renal pseudocyst, she became normotensive again, confirming the diagnosis of page kidney. This case highlights dual reasons that prompted us to report the case. The first being such remotely located subcapsular renal pseudocyst as itself a rare entity and the second, its unusual presentation as page kidney. The case emphasizes on the early management of such patients so as to salvage renal function.