Acute renal infarction diagnosis can be missed. Unilateral flank pain in a patient with an increased risk for thromboembolism should raise the suspicion of renal infarction.
In such a setting, hematuria, leukocytosis, and an elevated lactate dehydrogenase LDH level are strongly supportive of the diagnosis. Korzets et al. The conclusion was that during the month observation period, the incidence of acute renal infarction was 0.
Acute renal infarction is not as rare as previously assumed because it can be missed [ 10 ]. The study found that time from admission to the emergency department to definitive diagnosis ranged from 24 hours to 6 days.
Obviously, this delay in diagnosis is much too long and points to a lack of physician awareness regarding the entity. This also applies to the radiologist, since in two cases the initial CT interpretation was incorrect.
Our overall incidence of 6. Since unenhanced CT is now used almost routinely in the investigation of acute flank pain, it is imperative to remember that contrast enhancement is essential for the diagnosis of acute renal infarction [ 10 ]. The clinical presentation of renal infarction can be misleading. The diagnosis of acute renal infarction is often missed or delayed due to both the rarity of the disease and its nonspecific clinical presentation [ 11 , 12 ]. Bolderman et al. This included the review of their CT scan.
Acute elevation of blood pressure can happen and this is explained by the fact that renal infarction can be renin-mediated [ 14 ]. Laboratory findings usually include elevated serum lactate dehydrogenase LDH , C-reactive protein, leukocytosis, microscopic hematuria, proteinuria, elevated serum creatinine, and creatinine kinase.
Oliguria can happen [ 13 , 15 ]. Our case was remarkable only for elevated serum LDH and leukocytosis. In case of diagnosing the renal infarction, exploring the precipitating etiology is the next step.
This includes ECG, transthoracic echocardiography, Holter monitoring, thrombophilia panel, homocysteinemia measurement, and magnetic resonance abdominal angiography [ 15 ]. In renal infarction patients, the CT angiography is the initial tool of choice, but definite diagnosis is made by renal angiography.
The classic finding is of a wedge-shaped zone of peripheral diminished density without enhancement. Conventional ultrasound imaging has been used to evaluate renal infarction, but it can neither diagnose nor exclude acute global renal infarction due to the fact that there is no specific change of the infarcted kidney. In segmental renal infarction, a time-sequence echogenicity change was described in animal experiment, whereas it is nonspecific in humans [ 16 — 19 ].
It is worthy to confirm that conventional ultrasound can be insensitive and that CT scan can even miss the diagnosis and can be misinterpreted as malignant disease for example [ 20 ]. Doppler evaluation of renal arterial and venous blood flow should be able to detect global or major segmental renal infarction by demonstrating the absence of blood flow.
Yet, segmental renal infarction has more risk to be missed by Doppler than global renal infarction [ 19 , 21 , 22 ]. Hazanov et al. CT scan of the kidney with intravenous contrast media is fast becoming the diagnostic technique of choice for renal embolism.
The classic finding is of a wedge-shaped zone of peripheral diminished density without enhancement [ 23 ]. The cortical rim nephrogram sign represents opacification of a rim of functioning nephrons, supplied by capsular collaterals, surrounding an otherwise nonfunctioning kidney [ 24 ].
Excretion urography IVP or a nuclear renal scan can be used for diagnosis of renal infarction but CT scan with IV contrast remains the best choice [ 24 ]. Unenhanced helical CT scan is now thought to be the investigation of choice for the diagnosis of renal colic, since it can be rapidly performed and can detect nearly all types of renal calculi. In addition it may detect extrarenal causes of abdominal pain including appendicitis, diverticulitis, biliary tract disease, leaking aortic aneurysm, and gynecologic disease.
However, it cannot easily detect renal artery thromboembolism. Since the clinical picture of renal artery embolism is similar to that of renal colic flank pain and microscopic hematuria , the widespread use of unenhanced CT scan needs to be reassessed. We suggest that in those patients with clinical characteristics suggesting renal embolus, such as atrial fibrillation without any or without appropriate anticoagulation, unenhanced CT scans of the abdomen should be followed by enhanced scans if no calculi are found [ 23 , 24 ].
Treatment is clear if the etiology is atrial fibrillation and it will be a conventional anticoagulation with favorable prognosis [ 25 ]. In our case, apixiban was used. On follow-up, patient was symptom free with no recurrence of abdominal pain. Laboratory work including kidney function tests , 3 months after initial presentation, was unremarkable. There are case reports and case series reporting the use of local intra-arterial thrombolytic therapy and thrombectomy.
These studies reported successful reperfusion in most patients without significant therapy-associated complications. However, renal outcomes were only improved in some patients [ 26 — 31 ]. Angioplasty is the used treatment among patients with renal infarction caused by an intrinsic abnormality of renal vessels, such as dissection, angioplasty with stent placement.
Surgery can be indicated in selected cases especially post-traumatic renal infarction after a blunt or penetrating trauma [ 32 , 33 ]. Renal infarction is a rare cause of acute abdominal pain. Incidence is rare and numbers vary according to different studies 0.
It has to be suspected and managed appropriately, especially in patients with risk factors like cardiac arrhythmias specifically atrial fibrillation. It has to be on the differential diagnosis of the admitting physician. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors. Read the winning articles. Journal overview. Academic Editor: Aristomenis K. Received 15 Oct Accepted 09 Dec Published 29 Dec Abstract We report an year-old female with known history of recurrent diverticulitis presented with abdominal pain.
Background Acute renal infarction is a rare cause of acute abdominal pain. Learning Objective We report a case with an acute renal infarction presenting only with abdominal pain.
Case Presentation An year-old Caucasian female presented to the emergency room ER with a three-day history of right lower quadrant and periumbilical abdominal pain. Figure 1. CT abdomen and pelvis with IV contrast. Findings: kidneys: both kidneys were not obstructed. A subcentimeter hypodense lesion is seen without calcification or septation in the upper pole of the left kidney.
A wedge-shaped hypodense lesion is seen in the upper pole of the right kidney, which may represent a perfusion abnormality. Additional hypodense regions are seen in the mid pole of the right kidney, which may represent the sequela of a perfusion abnormality.
Alternatively, these hypodense regions may represent lesions with soft tissue attenuation. In the lower pole of the right kidney, a 1. Figure 2. CT abdomen and pelvis with and without contrast renal protocol. Findings: multiple hypodense foci are present within the right kidney, on all 3 postcontrast series blue arrows. In addition, there is intraluminal thrombus within the mid to lower pole branch of the right renal artery on the arterial phase.
There is normal perfusion to the capsule surrounding these hypodense areas. Therefore, the findings are most consistent with multiple renal infarcts. The previous identified area of concern in the lower pole of the right kidney also likely represents a perfusion abnormality secondary to infarction.
There are multiple low-attenuation foci within the kidneys bilaterally which are too small to characterize as well. No fat retention was seen immediately after partial nephrectomy 4—8 days , but occurred 2—15 months after the surgery. Subsequently, intravesical fat retention disappeared in 3 patients 8, 24, and 16 months later , and it persisted from 19—22 months after surgery in the remaining 2 patients.
The association with intravesical fat retention was not significant for either tumor size, distance to the collecting system, or the R. Nephrometry Score. Abdom Radiol The diagnosis itself is typically made with computed tomography.
The image above is typical. A wedge shaped lesion that does not enhance with contrast is seen. The extent of the infarction depends on which renal artery was occluded and at what level. The disruption can result from an embolus arising in a distant location or from thrombosis of the renal artery.
Local renal arterythrombosis can be spontaneous or secondary to trauma. Once the diagnosis is made the reason for the infarction needs to be found. Treatment starts with anticoagulation. Duration of therapy and other treatments such as endovascular intervention depend on the cause, amount of renal damage and hypertension that may result.
We describe a new sign, flip-flop enhancement pattern, which we believe solidified the diagnosis of renal infarction in five of our cases. The authors recommend further investigations for association of flip-flop enhancement and renal infarction. The entity is often misdiagnosed. Unilateral flank pain in a patient with an increased risk for thromboembolism should raise the suspicion of renal infarction. In such a setting, hematuria, leucocytosis and an elevated LDH level are strongly supportive of the diagnosis.
Isr Med Assoc J Oct;4 10 Renal Infarction: Facts - Can be segmental or global in extent - Can be an isolated process or part of multisystem disease involvement - Acute and chronic renal infarction due occur - Symptoms may range from acute flank pain, to FUO to hematuria Renal Infarction: Causes - Trauma - Embolism - Arterial thrombosis - Vasculitis - Acute renal vein thrombosis "Underlying embolic and hemorrhagic complications are common in patients with acute nontraumatic abdominal pain in the setting of atrial fibrillation and can be accurately seen on CT.
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