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Abstract: TH-PO600

Spontaneous, Non-Traumatic Renal Hemorrhage: An Under-Recognized Entity

Session Information

  • Trainee Case Reports - II
    October 25, 2018 | Location: Exhibit Hall, San Diego Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Trainee Case Reports

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Chamarthi, Gajapathiraju, University of Flroida, Gainesville, Florida, United States
  • Koratala, Abhilash, University of Flroida, Gainesville, Florida, United States
Introduction

We present a case of spontaneous, non-traumatic renal hemorrhage in a patient with end-stage renal disease (ESRD), also known as Wunderlich syndrome.

Case Description

A 61-year-old man with ESRD, on hemodialysis for two years, left renal cell carcinoma status post nephrectomy 20 years ago, hypertension and 40 pack-years smoking history presented to our institution for sudden-onset right flank pain radiating to the right leg. His blood pressure at presentation was 130/90 mmHg, pulse 98 bpm and physical examination was significant for tenderness over the right flank without signs of peritonitis. Laboratory testing was significant for a drop in hemoglobin to 7.9 g/dL from a baseline value of ~11 g/dL. Platelet count and international normalized ratio were within normal limits. A computed tomography (CT) scan of the abdomen demonstrated acute hemorrhage throughout the right kidney extending into the anterior and posterior pararenal spaces. In addition, there was extravasation of contrast at the upper pole, indicating active bleeding [Figure 1]. There was no obvious underlying renal mass or evidence for acquired cystic kidney disease. He underwent renal artery angiogram and embolization using lipiodol-ethanol mixture and gelfoam. His blood count subsequently stabilized and was discharged in stable condition.

Discussion

Wunderlich syndrome, first described in 1856 is a rare condition characterized by acute spontaneous, non-traumatic renal hemorrhage into the subcapsular and perirenal spaces. Patients may present with the classic ‘Lenk's triad’ of symptoms consisting of acute flank or abdominal pain, a palpable flank mass, and hypovolemia but the presentation is variable and non-specific in most cases. CT scan is the imaging modality of choice and treatment often includes renal artery embolization or nephrectomy, depending on the severity. It is important to note that ESRD patients are predisposed to bleeding diathesis in the setting of uremic platelet dysfunction, anemia, increases in nitric monoxide, irregularities in von Willebrand factor and impaired platelet-vessel wall interaction.