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Kidney Week

Abstract: PO0187

Apparent AKI in a Patient with Ascites Following Laparoscopic Hysterectomy

Session Information

  • AKI Mechanisms - 2
    October 22, 2020 | Location: On-Demand
    Abstract Time: 10:00 AM - 12:00 PM

Category: Trainee Case Report

  • 103 AKI: Mechanisms

Authors

  • Cervantes, Carmen Elena, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
  • Menez, Steven, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
  • Hanouneh, Mohamad A., Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
Introduction

Bladder injury occurs following blunt or penetrating trauma. Gynecological and colorectal surgeries are the most common surgeries associated with bladder injury. Bladder injury can be classified as intra versus extra-peritoneal. Clinical manifestations include gross or microscopic hematuria, ascites, and/or difficulty voiding. Peritonitis and sepsis are common complications.

Case Description

A 39-year-old woman who underwent laparoscopic hysterectomy presented to ED 4 days following surgery with abdominal pain. Her vitals revealed hypotension and tachycardia. Initial laboratory values were as follows: WBCs 18.0x 109/L, Na 134 mmol/L, K 4.9 mmol/L, Cl 101 mmol/L, HCO3 17 mmol/L, BUN 45 mg/dL, serum Cr 7.4 mg/dL, lactate 2.4 mmol/L. UA was remarkable for hematuria with 25 isomorphic RBCs/HPF. Abdominal US revealed moderate ascites. An indwelling bladder catheter was placed, and she underwent diagnostic paracentesis, with WBC noted at 1288/μl (35% neutrophils) and ascites-to-serum Cr ratio of 2.14. CT abdomen with IV contrast confirmed a full-thickness tear of the superior wall of the urinary bladder, with the bulb of the indwelling catheter extending beyond the bladder and an associated urinoma surrounding the catheter (Figure 1). She was diagnosed with bladder perforation and underwent open bladder repair emergently. Her serum Cr improved to 0.5 mg/dL in 24 hours.

Discussion

Uroperitoneum can result in the reabsorption of urine into the systemic circulation, while sodium and chloride ions move in the opposite direction. This results in hyponatremia, metabolic acidosis, azotemia and rise in serum Cr. Uroperitoneum should be expected when ascites to serum Cr ratio is >1.0. It is essential to recognize that the rise in serum BUN and Cr is due to pseudo-azotemia from the reabsorption of urine and not from true kidney dysfunction. Bladder injury is diagnosed by CT cystography, which was deferred in our patient giving the clear evidence of bladder injury in the CT abdomen. Complex extraperitoneal and all intraperitoneal bladder injuries require surgical repair.