Spontaneous Renal Hemorrhage Research Articles

Spontaneous renal hemorrhage: critical analysis of different lines of management in non-traumatic patients: a single tertiary center experience.

To assess clinical presentation and outcomes of different treatment strategies in cases of spontaneous renal hemorrhage (SRH). A retrospective analysis of patients with SRH between 2000 and 2018 was performed. Patients' demographics, clinical presentation, laboratory and radiological investigations, and different lines of treatment were retrieved. The primary outcome was to assess the predictors of the success of conservative treatment. The secondary outcome was to assess the long-term renal function outcome comparing serum creatinine, e GFF, and CT-assessed renal volume at last follow-up with baseline values. The study included 42 (23 males and 19 women) patients with mean ± SD age was 48.1 ± 17.8years. Conservative management was successful in 19 (46%) patients. Trans-arterial embolization (TAE) was performed in 13 patients (30%) to control active bleeding. Ten patients (25%) required surgical exploration and nephrectomy.Lower serum creatinine (P = 0.003), higher prothrombin concentration (P = 0.04), lower hematoma size (P = 0.02), and non-AML lesions (P = 0.03) were independent predictors of conservative management success. Unlike the TAE-treated group, serum creatinine increased significantly (P = 0.04) with a significant decrease in e-GFR (P = 0.02) and renal volume (P < 0.001) of affected kidneys at last follow-up after conservative treatment. Although SRH is a life-threatening condition, conservative treatment is successful in a certain subset of patients. However, it is associated with significant deterioration of the affected kidney function as well as renal volume.

Wunderlich syndrome.

Key Clinical MessageEnd‐stage renal disease (ESRD) patients are predisposed to bleeding diathesis in the setting of uremic platelet dysfunction and endothelial abnormalities. One should have high index of suspicion for spontaneous renal hemorrhage when these patients present with abdominal pain and/or unexplained drop in hemoglobin and appropriate imaging should be undertaken without delay.

Nephron-sparing management of Xanthogranulomatous pyelonephritis presenting as spontaneous renal hemorrhage: a case report and literature review

BackgroundXanthogranulomatous pyelonephritis (XGP) is an uncommon infectious disease of the kidney known to mimic other renal maladies. A rare presentation of this uncommon disease is spontaneous renal hemorrhage (SRH).Case presentationWe report a case of XGP in a 58 year old woman who presented with abdominal pain, hematuria, and radiating left flank pain. CT scan was felt to be consistent with perirenal hemorrhage abutting a fat-containing renal mass. The patient was eventually taken to surgery for left partial nephrectomy. Pathology report returned as XGP, and the patient has no complications from this disease process at 8 month follow up.ConclusionOur search of the literature shows XGP presenting as SRH to be a rare clinical entity. Furthermore, this is the first such case managed with a nephron-sparing approach. The “great imitator” XGP should be added to the differential for patients presenting with spontaneous renal hemorrhage.

Spontaneous renal hemorrhage secondary to choriocarcinoma in a man with congenital hypospadias and cryptorchidism: a case report and literature review

BackgroundChoriocarcinoma is a rare malignant germ-cell tumour, most commonly found in adult women. It infrequently presents as spontaneous renal haemorrhage (SRH). Genital malformation and SRH secondary to choriocarcinoma has previously been only reported in females. We present what we believe to be the first case of a male patient with genital malformation (hypospadias and cryptorchidism) and SRH at presentation of choriocarcinoma.Case presentationA 25-year-old man presented to the department with intense pain in the right flank region and lower back. Initial investigations showed spontaneous renal haemorrhage, for which an emergency partial nephrectomy was performed. Clinical, radiological, and pathological investigations suggested a diagnosis of testicular choriocarcinoma with metastases to the right kidney, both lungs, and brain. Initial treatment was with a chemotherapy regimen of cisplatin, etoposide and bleomycin and whole brain radiotherapy; however, 6 months after diagnosis the patient developed liver metastasis, after which time the BEP protocol was switched to ITP with oral apatinib. Despite best efforts, the liver and lung metastasis continued to grow and a decision was made to discontinue active treatment and provide only palliative care until the patient passed away.ConclusionChoriocarcinoma is a difficult cancer to diagnose pre-operatively. In male patients with early metastasis, prognosis may be much poorer than in the commoner gestational choriocarcinoma. A multidisciplinary with comprehensive post-surgical intervention is of great importance in the treatment of these patients.

Wunder-women: Systematic review of causes, treatment and outcomes of Wunderlich syndrome during pregnancy

Objective: The objective of this article is to conduct a contemporary literature review on Wunderlich syndrome, or spontaneous renal haemorrhage (SRH), among pregnant women to describe contemporary aetiology, investigations and management patterns. Methods: A systematic review of MEDLINE and CENTRAL in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. All articles, including case reports and case series on SRH published from 2000 to 2016, were included. Full-text manuscripts describing SRH among pregnant women were reviewed for clinical parameters, which were collated and analysed. Results: Twenty cases of SRH in pregnant women were identified. The median age and gestation were 32.1 years and 26.5 weeks, respectively, with SRH most commonly occurring in the third trimester (nine patients; 45%) and due to renal neoplasm, specifically angiomyolipoma (AML; 12 patients; 60%), followed by renal artery aneurysm (RAA; five patients; 25%). Surgical intervention (55%) was most commonly used for acute SRH. Foetal demise was not uncommon (15%). Conclusions: SRH in pregnant women is an uncommon but complex urological and obstetric emergency with potentially catastrophic consequences. A multidisciplinary approach is key to timely diagnosis and appropriate management considering the well-being both of mother and foetus. Pre-emptive diagnosis and intervention may reduce complications. Level of evidence: 4

Changing etiology and management patterns for spontaneous renal hemorrhage: a systematic review of contemporary series.

To conduct a systematic literature review on spontaneous renal hemorrhage (SRH) in a contemporary cohort describing patterns in etiology and treatment. A systematic search of MEDLINE and CENTRAL databases was conducted to include articles, including case reports and case series on SRH published from 2000 to 2016. Full-text manuscripts were reviewed for clinical parameters which were collated and analyzed with univariate methods. Seventy-nine publications met inclusion criteria, reporting on 102 cases. Renal neoplasms (56.9%) and polyarteritis nodosa (PAN) (11.8%) remained as the most common overall and vascular causes of SRH, respectively. Angiomyolipoma (AML) was the most common causative renal neoplasm (74.1%), and patients were more likely to be female and present with macroscopic hematuria than those with vasculitis, while malignant neoplasms were more common in men. Proportions of SRH due to malignant neoplasms (specifically renal cell carcinoma, RCC) were reported less than PAN. Among this contemporary series, transarterial embolization (TAE) was most commonly used for acute SRH (42.2%). Renal neoplasms remain as the most common cause of SRH, of which AML predominates, while PAN is currently the second most common etiology in acute SRH, replacing RCC. Minimally invasive approaches, such as TAE and conservative/medical management, were preferred to initial surgery. PROSPERO registration number CRD42017069222.

Acute Flank Pain in the Emergency Room: Rare Case and Review of the Literature

Wunderlich syndrome is defined as spontaneous renal hemorrhage. Generally, the kidney mass may be due to secondary causes such as vascular pathologies.Wunderlich syndrome is rarely idiopathic.Wunderlich syndrome is a classical clinical symptom of Lenk's triad, characterized by flank pain, mass, and hypotension. Wunderlich syndrome can be life threatening due to gross hemorrhage. Our patient applied with the complaint of abdominal pain.

Diagnostic Evaluation of Wunderlich Syndrome in Chronic Kidney Disease by Point-of-Care Ultrasonography

Wunderlich syndrome is a rare condition, which means spontaneous non-traumatic renal hemorrhage confined to the subcapsular or perirenal space. It usually presents as acute flank or abdominal pain. Computed tomography (CT) is currently the best method for diagnosis and further survey of possible etiology. We report a bed-ridden patient with right urothelial carcinoma who had unexpectedly rapid deterioration of renal function after admission. Bedside point-of-care ultrasonography provides excellent diagnostic performance. Case report and literature review. A 84-year-old female who had right urothelial carcinoma complicated with right hydronephrosis status post right double J catheter implantation was admitted due to urinary tract infection. During hospitalization, acute deterioration of renal function in the presence of chronic kidney disease developed. Point-of-care ultrasonography showed a hypoechoic lesion surrounding the cortical surface of right kidney. Further abdominal CT disclosed right perirenal hematoma, consistent with Wunderlich syndrome. Ultrasound is a non-invasive, convenient and reliable tool for expeditious evaluation of perirenal hematoma/hemorrhage. In terms of CT scan-related contrast-induced nephropathy, this approach provides comparative effectiveness and safety in early diagnosis of Wunderlich syndrome.

Letter to the editor: spontaneous renal haemorrhage in end-stage renal disease.

Letter to the editor: spontaneous renal haemorrhage in end-stage renal disease.

Spontaneous Bilateral Subcapsular Hematoma of the Kidneys: A Case Report

Spontaneous subcapsular renal or perirenal hemorrhage is uncommon and is seldom suspected clinically. Bilateral spontaneous renal hemorrhage and cases in which a causal etiology fails to be identified are even rarer. A 32-year-old man without the history of trauma, a fall, or any invasive renal procedure experienced progressive bilateral flank pain and abdominal pain for 10 days. Detailed imaging modalities demonstrated the presence of bilateral subcapsular renal hematoma with no identifiable underlying pathological conditions. The patient was treated conservatively and followedup by ultrasonographic and computed tomographic scans until the hematoma had almost completely been reabsorbed. No surgical intervention was needed, and the patient recovered well.

Wünderlich Syndrome From Lupus-Associated Vasculitis

Spontaneous perinephric hemorrhage is a clinically rare life-threatening condition, also known as Wünderlich syndrome. Presentations can be variable, but patients typically display symptoms and signs including flank or abdominal pain, abdominal mass, and hypovolemia. It is important to diagnose the syndrome early because untreated cases carry a high mortality risk, and prompt intervention with an endovascular procedure or surgery is life saving. Causes range from anatomical anomalies, including vascular diseases (vasculitides and aneurysms) and renal tumors, to functional coagulation defect (bleeding tendency). The most common causes of Wünderlich syndrome are renal angiomyolipoma and renal cell carcinoma, constituting 60%~70% of cases. Vascular causes of Wünderlich syndrome are infrequent, and the culprit most frequently is vasculitis resulting from polyarteritis nodosa. Other vasculitides presenting as Wünderlich syndrome are infrequent. We describe a 39-year-old woman with end-stage renal disease from lupus nephritis and spontaneous renal hemorrhage, ascribed to lupus-related vasculitis after serologic testing, computed tomography, and angiographic studies.

Metastatic gestational trophoblastic neoplasm presenting as spontaneous renal and cerebral hemorrhage with low titer of HCG: A case report of an unusual case

Gestational trophoblastic neoplasm includes tumor spectrum of four entities: hydatidiform mole (complete and partial), invasive mole, choriocarcinoma and placental site trophoblastic tumor. The hydatidiform mole is usually benign, but it is regarded as a pre-malignant disease. The other three conditions are malignant and are termed gestational trophoblastic tumor. Although most molar pregnancies behave in a benign fashion, metastatic tumors develop after complete molar pregnancy in 4% of patients. However, even when the disease is spread to many distal organs, it is highly curable with chemotherapy in most cases. We recently encountered an unusual case of metastatic gestational trophoblastic neoplasm following complete mole, presenting as spontaneous renal and cerebral hemorrhage with a fatal course.

Bilateral Subcapsular and Perinephric Hemorrhage as the Initial Presentation of Polyarteritis Nodosa

Polyarteritis nodosa is a systemic vasculitis of medium and small-sized arteries associated with aneurysm formation. Aneurysms may be complicated by thrombosis, rupture and hemorrhage. Kidney involvement in polyarteritis nodosa can rarely be complicated by Wunderlich syndrome which is characterized by acute onset of spontaneous, nontraumatic subcapsular and perirenal hematomas. A 22-year-old woman with mental retardation due to childhood cytomegalovirus infection presented with flank pain, weight loss and fever, and was found to have bilateral subcapsular and perinephric hematomas. Spontaneous bilateral renal hemorrhage as the initial manifestation of polyarteritis nodosa is rare, and it can be associated with delays in diagnosis and treatment.

MAJOR SPONTANEOUS RENAL HAEMORRHAGE AS AN UNUSUAL COMPLICATION OF SYSTEMIC AMYLOIDOSIS

We report the case of a patient with systemic amyloidosis who developed a life-threatening spontaneous haemorrhage from an amyloid kidney. A review of the literature suggests that this is a rare complication of renal amyloidosis. However, the grossly abnormal renal angiography observed in our patient has previously been described in the literature. Therefore, spontaneous renal haemorrhage should be considered a risk in any systemic amyloid patient, especially in the differential diagnosis for those patients with the condition who present with an acute abdomen.

Wunderlich's syndrome in spontaneous angiomyolipoma bleeding.

A 57-year-old female presented to the emergency department with progressive right flank pain for 2 days. She denied recent traumatic events. Initial vital signs were stable with blood pressure 125/80 mmHg. Physical examination revealed right flank knocking tenderness. Laboratory data showed leukocytosis 20 180/μL and normal haemoglobin 10.5 g/dL. The routine urine analysis was normal. After clinical evaluation, an abdominal computer tomography (CT) revealed a huge fat-containing tumor with active contrast extravasation and hematoma formation over the right perirenal space (Figure 1A). A diagnosis of renal angiomyolipoma with spontaneous bleeding was made. Transarterial angiography of the right kidney was emergently performed with coil embolization of the hypervascular tumor with intralesional aneurysmal formations (Figure 1B). The patient’s symptoms resolved shortly after embolization and she was scheduled for further renal-sparing surgery. Fig. 1. Renal angiomyolipoma are generally benign mesenchymal hamartoma composed of adipose tissue, tortuous blood vessels and smooth muscle. About 80% of renal angiomyolipoma occurs sporadically and 20% associated with tuberous sclerosis complex [1, 2]. Sporadic angiomyolipoma usually with a solitary nodule in middle-aged women; tuberous sclerosis complex with angiomyolipoma are usually bilateral and multiple, frequently with larger tumor size [2]. Clinical presentations of angiomyolipoma are usually subclinical until tumor size becomes progressively larger with mass effect or tumor rupture. Wunderlich’s syndrome (spontaneous renal hemorrhage) is a rare but potentially life-threatening complication of renal angiomyolipoma in the setting of tumors >4 cm. Clinical manifestations usually include flank pain, a palpable mass, gross hematuria and hypovolemic shock. CT is a good choice of imaging modalities because it is sensitive to demonstrating a fat-containing renal mass with perirenal and retroperitoneal hemorrhage, which is characteristic of Wunderlich’s syndrome due to spontaneous angiomyolipoma rupture. In addition, intralesional aneurysmal formations on the CT scan can lead to a greater possibility of tumor rupture [3]. Optimal treatment plans of angiomyolipoma depend on the tumor size and clinical manifestations. Conservative follow-up with imaging modality is recommended if tumor size is <4 cm in diameter. In acute tumor rupture, urgent transarterial superselective embolization can stop bleeding and save the life of patient. In symptomatic or larger angiomyolipoma with a high risk of bleeding, optimal treatment including elective preoperative transarterial superselective embolization prevention of and sequential renal-sparing surgery [4].

Wunderlich's Syndrome in a Tuberous Sclerosis Patient

Spontaneous non-traumatic renal hemorrhage known as Wunderlich's syndrome is known to occur in renal angiomyolipoma and may be the first manifestation of the disease. Angiomyolipomas in tuberous sclerosis are usually bilateral and multicentric. A 25yr old female, a case of Tuberous sclerosis with bilateral renal angiomyolipomas presented with right loin pain of increasing severity. On evaluation she had acute abdomen with increasing abdominal distension. Investigations revealed large right perinephric hematoma with bilateral renal angiomyolipomas. Exploratory laparotomy and right nephrectomy was done. Spontaneous hemorrhage in renal angiomyolipoma in a case of tuberous sclerosis and management are discussed. The online version of this article (doi:10.1007/s12262-010-0231-0) contains supplementary material, which is available to authorized users.

Spontaneous Bilateral Renal Subcapsular Hematoma as a Possible Complication of Myeloproliferative Disorders

A 64-year-old male had bilateral renal subcapsular fluid accumulation evident on abdominal sonography performed during postoperative follow-up after surgery for a hepatoma. There were no clinical symptoms, and he had no history of trauma or receiving anticoagulant medication. Spontaneous bilateral renal subcapsular hemorrhage was diagnosed after a series of examinations. He did have an underlying myeloproliferative disorder (MPD), and had received incomplete cytoreductive treatment. Platelet aggregation in MPD is often abnormal, and both bleeding and hypercoagulation complications have been reported. Here we report a rare case of MPD with possible thrombohemorrhagic complications presenting as spontaneous bilateral renal subcapsular hematomas.

Wunderlich Syndrome during antiplatelet drug therapy

Spontaneous hemorrhage in the kidney, also known as Wunderlich Syndrome, is a rare clinical problem. The most common cause of spontaneous renal hemorrhage is tumor. Other causes are rupture of a renal cyst, vasculitis, hydronephrosis, preeclampsia, and kidney infections. A 67-year-old man was admitted complaining left flank colic pain. A contrast CT scan showed the presence of a subcapsular hematoma of the left kidney extending from the upper to the lower pole. He had no history of trauma and immunological screening tests for vasculitis were normal. His current therapy included acetylsalicylic acid (100 mg/daily) and lisinopril (20 mg/ daily). The patient was hospitalized for 4 days and his circulatory state remained stable. Nine months later an ultrasound examination showed complete resolution of the hematoma. One year later the patient was admitted again because of a spontaneous right calf hematoma and a thoroughly investigation of his coagulation pattern was carried out. Laboratory finding revealed a platelet defect, as the number of adenine nucleotides and other marker related to platelet activation were increased: ADP 1 mcM lack 2 masculine wave, ADP 2 mcM lack 2 masculine wave, Adrenalina 5 mcM lack 2 masculine wave, Adrenalina 10 mcM lack 2 masculine wave. Platelet activation markers: Gp53 in lysosomal membrane 0.48 Dpar (0 - 0.26). Our case describes the recurrence of spontaneous hemorrhages (perirenal and intramuscular hematoma) as a result of an underlying platelet aggregation defect worsened by administration of acetylsalicylic acid. In patients on antiplatelet treatment with a history of excessive bleeding a thorough investigation of coagulation status appears beneficial.

Bilateral renal and jejunal metastasis of choriocarcinoma presenting as spontaneous renal hemorrhage

Spontaneous renal hemorrhage (SRH) is a difficult diagnostic problem with various causes. We report a case of SRH and episodic gross hematuria in a patient with metastatic choriocarcinoma involving both kidneys for which successful angioembolization was carried out for control of hemorrhage. There was no evidence of primary uterine tumor and pulmonary or liver involvement. The patient developed gastrointestinal bleeding due to jejunal metastasis while on chemotherapy and surgical resection of the involved segment was carried. However, the patient acquired nosocomial pneumonia and succumbed to sepsis in the postoperative period.

Wunderlich’s syndrome due to spontaneous rupture of large bilateral angiomyolipomas

Spontaneous renal haemorrhage, or Wunderlich’s syndrome, is an unusual cause of acute abdomen. It is a rare disease, usually secondary to tumours, and is an emergency and life-threatening condition. CT...