Acute renal failure in a case of unilateral contracted kidney after extracorporeal shock-wave lithotripsy

1.Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University

2.Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

3.Department of Internal Medicine , Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University

4.Department of Internal Medicine and 5. Urology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University

6.Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

  Acute renal failure is a relatively less common complication of extracorporeal shock-wave lithotripsy (ESWL), as compared to renal colic and perinephric haematoma. We report a patient who experienced acute renal failure following ESWL therapy undertaken three times in consecutive two months. Computed tomography showed a perinephric hematoma compressing the right kidney, calculi in the mid right middle ureter with hydronephrosis, and an atrophic left kidney. He received temporary hemodialysis twice, and then was treated with ureteroscopy and intracorporeal lithotripsy for the ureteric calculi. His serum creatinine recovered to his baseline value after one month. Follow-up imaging 6 months later showed resolution of the hematoma. The risk of acute renal failure, although rare, should be considered in patients with an atrophic kidney who have undergone ESWL.

Extracorporeal shock-wave lithotripsy (ESWL) is currently the non-invasive treatment of choice for people with renal stones. However, this non-invasive procedure can result in complications such as loss of corticomedullary differentiation, perinephric fluid, subcapsular hematoma, and hemorrhage into a renal cyst.[1-4] Acute renal failure (ARF) related to ESWL has rarely been reported.[5-7] Here, we report ARF following ESWL in a patient in whom one kidney show atrophic changes. The cause of ARF may be related to perinephric hematoma with hydronephrosis and a contralateral atrophic kidney.

A 60-year-old man with history of chronic kidney disease and hypertension presented to the emergency room with right flank pain. The patient’s pain was intermittent and he had taken diclofenac (25mg) twice daily for 3 days. He had undergone ESWL three times, with a total of 10,200 shock waves (15kv), for right renal stones in the preceding two months. Blood tests revealed a hemoglobin level of 4.9 g/dL (compared with a baseline of 10.0 g/dL recorded previously), and raised serum blood urea nitrogen and creatinine levels of 127.5 mg/dL and 15.26 mg/dl respectively (with a baseline creatinine of 4.2 mg/dL recorded previously) and a high anion gap metabolic acidosis. Urinalysis revealed hematuria (occult blood, 3+; red blood cells, 10-25/high-powered field). The patient’s coagulation test results, including platelet count, prothrombin time, partial thromboplastin time, and bleeding time, showed were normal. Non-contrast abdominal computed tomography revealed a large perinephric hematoma compressing right kidney, with an atrophic left kidney, and several right mid ureteric calculi with  hydronephrosis (Figure 1).

 

 

The patient’s daily urine output was 1480ml/day. He received temporary hemodialysis twice due to severe azotemia and anemia, and then underwent ureteroscopy and intracorporeal lithotripsy for the ureteric calculi. His postrenal obstruction was then relieved. After six months, follow-up computed tomography showed resolution of the hematoma. His serum creatinine decreased to 4.0 mg/dL.

We report an unusual case of a patient who developed ARF after ESWL, with the contralateral kidney showing atrophic changes. ESWL is effective and relatively noninvasive with low morbidity, and is the first choice of treatment for calculi in the kidney. Major complications of ESWL include pain, ureteric obstruction, and sepsis induced by the destruction of infected calculi.[8] Moreover, hemorrhagic complications such as hematuria and hematoma had also been reported.[9-10] ARF after ESWL has rarely been described. Lifuori et al.[5] reported a 68-year-old male who experienced an elevation of his creatinine from 1.2mg/dl to 9.1mg/dl after ESWL. His renal function recovered within 4 weeks with conservative treatment. The postulated the mechanism of his ARF was a reduction in renal blood flow due to elevation of the intrarenal resistance index. Lipski et al. [11] reported ARF in a 43 year-old man with a solitary kidney. As a consequence of a perinephric hematoma developing after ESWL, anuria and renal failure occurred. After 4 units of packed red blood cells were transfused to maintain a hematocrit of 30%, a, ureteral stent was placed to ensure renal drainage and the patient’s serum creatinine decreased from 7.6mg/dl to 2.8 mg/dl. Tuteja et al.[12] reported a 72-year-old white man who received a total of  2,200 shocks (19kv) bilaterally with 1,200 to the right kidney and 1,000 to the left. Anuric ARF caused by bilateral perinephric hematoma occurred with elevation of creatinine up to 4.3 mg/dl from a baseline value of 1.5 mg/dl. Over the ensuing 48 hours, 8U of packed red blood cells were administered to maintain his hematocrit. Renal function improved after supportive care, with hemodialysis undertaken two weeks later. An overview of these reports shows that the risk factors for ARF after ESWL include solitary functioning kidney, hypertension, perinephric hematoma after ESWL, and old age. Whether chronic kidney disease is also a risk factor for ARF post ESWL is still uncertain. Our patient was 60 years of age, with hypertension, chronic kidney disease and one atrophic kidney. Perinephric hematoma post ESWL affecting his conbtralateral normal sized kidney, may be one of causes of the deterioration in his renal function. The partial obstruction of his right ureter, due to the presence of stones, also affected his renal function.

 Reports of perinephric hematoma complicating ESWL are rare.[5, 8, 13] Treatment with ESWL induces changes in the kidney similar to that of renal trauma, consisting primarily of intraparenchymal and perinephric hemorrhage and edema[5]. The acute effects of ESWL are well tolerated by most patients, but the long-term sequelae of this therapy are not well established. In cases with post ESWL-related hematoma, underlying coagulopathy[14-15], hypertension[11] and hydrocalyx[16] are statistically associated with their incidence. Pastor Navarro H. et al.[17-18] reviewed 4,815 patients undergoing ESWL and concluded that renal and perinephric bleeding are related to the power of energy used and patient’s age. Our patient, who had chronic kidney disease, received serial ESWL (a total of 10,200 shocks) three times in two months. That he had poor platelet dysfunction related to the impaired renal function, may also be the cause of his bleeding. He was not prescribed any anticoagulant or hemostatic medications. Several previous  reports suggest that hemorrhage post ESWL could be detected in 15% to 30% of patients by computed tomography or magnetic resonance imaging, and that the incidence of clinically significant hemorrhage is less than 1%[19-20]. Chronic kidney disease may give clinicians a warning sign of high risk of post ESWL-bleeding.

The management of this patient is challenging. Should we arrange operation first to relieve the perinephric hematoma? Most patients recover from intrarenal or perinephric hematoma without blood transfusion or surgical intervention [5, 12-13]. In most cases of death due to haemarrhage following a medical procedure, the measurement of blood pressure and hemoglobin concentration are usually not well performed [13]. Although deaths from  hemorrhage post ESWL are rare, it has been reported recently[13]. The guidelines of surgical management of post ESWL need further evaluation. For this patient, we arranged hemodialysis first instead of operation due to severe uremic symptoms and signs, metabolic acidosis and severe anemia. Ureteroscopy one week-later relieved the ureteric obstruction. The patient’s renal function recovered back to its initial level after one month and he was withdrawn from dialysis.

In summary, we report a patient with a unilateral atrophic kidney who developed ARF with hematoma formation after ESWL. After emergency hemodialysis and ureteroscopy, his renal function recovered. Patients with chronic kidney disease, especially if only one of the kidneys is functioning, may be at high risk of ARF post ESWL. To prevent ARF and hematoma formation post ESWL, pre treatment work up including assessment of kidney size and coagulation profile particularly in patients with chronic renal failure case is advised.

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