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Kidney Week

Abstract: PO0324

Page Kidney Secondary to Ruptured Mycotic Pseudoaneurysm of Renal Artery: An Unusual Complication of Infective Endocarditis

Session Information

Category: Acute Kidney Injury

  • 103 AKI: Mechanisms

Authors

  • Ezeh, Ebubechukwu, Marshall University Joan C Edwards School of Medicine, Huntington, West Virginia, United States
  • Malik, Saad Ullah, Marshall University Joan C Edwards School of Medicine, Huntington, West Virginia, United States
  • Higginbotham, Zachary Scott, Marshall University Joan C Edwards School of Medicine, Huntington, West Virginia, United States
  • Saylor, John L., Marshall University Joan C Edwards School of Medicine, Huntington, West Virginia, United States
  • Bandak, Ghassan, Marshall University Joan C Edwards School of Medicine, Huntington, West Virginia, United States
Introduction

Mycotic pseudoaneurysms of renal artery following infective endocarditis are uncommon and their rupture is the most feared complication. This can lead to subcapsular hematoma and development of Page kidney, an uncommon cause of secondary hypertension and renal dysfunction. We present a unique case of ruptured mycotic pseudoaneurysm of the renal artery that resulted in subcapsular hematoma and Page kidney in an intravenous (IV) drug user.

Case Description

A 36-year-old female IV drug user presented with fever and hemoptysis. She denied history of kidney disease or preceding trauma. Admission blood pressure was 116/61 millimeter of mercury. Initial serum creatinine was 1.6 milligrams per deciliter (mg/dl) and hemoglobin (Hb) was 12 grams per deciliter (g/dl). Renal ultrasound was unremarkable. She was found to have septic emboli on computed tomography (CT) of the chest, and methicillin-resistant Staphylococcus aureus (MRSA) grew in her blood cultures. Patient was diagnosed with infective endocarditis based on Duke’s criteria. She was started on IV antibiotics. On the third day of admission, she developed severe right flank pain and hematuria. She had worsening acute kidney injury and was started on hemodialysis. She was persistently hypertensive and progressively anemic. Hb dropped to 6.5 g/dl requiring transfusion of packed red cells. CT abdomen showed a new aneurysm and a large subcapsular hematoma of the right kidney. The bleeding pseudoaneurysm of the superior pole branch of the right renal artery was embolized by interventional radiology. She subsequently improved and no longer required hemodialysis. Plasma renin activity level returned elevated at 12.26 nanograms per milliliter per hour (reference 0.16-5.83).

Discussion

Renal artery aneurysm has a reported incidence of 0.1%. Subcapsular hematoma from rupture of mycotic pseudoaneurysm is a very rare complication of infective endocarditis. Page kidney is a hyperreninemic phenomenon that results from the renal ischemia secondary to external compressive forces from subcapsular hematoma. Elevated renin level and activation of the renin-angiotensin-aldosterone system usually occurs, as in our patient. For this reason, angiotensin converting enzyme inhibitors and relief of external compression are great treatment options in these patients.