A 48 y/o male patient with acute left flank pain and ... - 台中榮民總醫院

CASE CHALLENGE
A 48 YEAR-OLD MALE PATIENT WITH
ACUTE LEFT FLANK PAIN AND HYPERTENSION
臺 中 榮 民 總 醫 院
內 科 部 腎 臟 科
黃 士 婷 醫 師

病 史
• 主 訴 : 急 性 左 下 腰 痛 達 2 天
• 過 去 病 史 :
左 側 腎 結 石 , 一 年 前 於 外 院 診 斷
• 現 在 病 史 :
acute onset of dullness pain over left flank
No radiation pain, no fever, no dysuria,
no gross hematuria, no oliguria/anuria,
no nausea/vomiting, no diarrhea,

日 期
理 學 檢 查
體 溫 (BT)
脈 搏 (P)
呼 吸 (R)
血 壓 (BP)
身 高 (BH)
體 重 (BW)
2012/01/
11
36.2C 78 次 /min 20 次
/min
182/100
mmHg
161cm
74kg
General appearance: A well-nourished person, with acute ill looking.
Heart: Auscultation: Regular heart beats , No S3 , No S4 , No murmur
Abdomen: Soft
Back and spine: L’t flank knocking pain, no localized tender point
Extremities: No pitting edema, normal peripheral pulse

Q1: WHAT IS YOUR IMPRESSION
• 1. Renal or perinephric abscess
• 2. Renal cell carcinoma
• 3. Nephrolithiasis
• 4. Mesenteric ischemia
• 5. Renal infarction
• 6. None at all

DIFFERENTIAL DIAGNOSIS OF FLANK PAIN
Renal or perinephric abscess
症 狀 : 發 燒 , 腰 痛 腹 痛 dysuria frequency
Insidious in the elderly /autonomic neuropathy
Lab: WBC,ESR,CRP
Image: CT + contrast (extension)
Nephrolithiasis
症 狀 :
1. 排 出 結 石 !
2.pain: variable , waxes and wanes; by location;
疼 痛 來 源 : passing stone ,ureteral spasm,
阻 塞 ; 痛 持 續 約 20-60 分 鐘
3. 血 尿 痛 或 無 痛 性 , 微 觀 或 巨 觀
在 慢 性 下 背 痛 的 病 人 很 難 鑑 別 診 斷 , 需 影 像 檢 查
Image: IVP,SONO, non-contrast CT
Renal cell carcinoma
classic triad of RCC :
(flank pain, hematuria, and a
palpable abdominal renal mass);
Paraneoplastic symptoms
Image: SONO>CT>MRI
Mesenteric ischemia
症 狀 : intestinal angina 飯 後 痛
體 重 減 輕 噁 心 嘔 吐 腹 瀉
危 險 因 子 : 老 人 , CVD
診 斷 : Angiography, MRA

DIFFERENTIAL DIAGNOSIS OF FLANK PAIN
Renal infarction
症 狀 : 急 性 腰 痛 或 腹 痛 ; 少 見 : 發 燒 寡 尿
急 性 高 血 壓 , 其 他 器 官 栓 塞
Lab: ↑WBC, Cr, LDH X4 /GPT(-) U/R, U/C ,ECG
Renal vein thrombosis
症 狀 : loin pain, hematuria
診 斷 : MRI
Association: clotting disorder (protein C,s def.; NS)
Aortic dissection
誘 發 因 素 : 高 血 壓 , 之 前 有 aortic aneurysm, vasculitis, collagen disease
Post CBG, AVR , Cocaine
症 狀 :
Abrupt, tearing pain, hypertension
Variant of dissection : type A/B,
intimal tear without hematoma, intranural hematoma or penetrating atherosclerotic ulcer

“ RED FLAGS” FOR A POTENTIALLY SERIOUS
UNDERLYING CAUSE FOR LOW BACK PAIN
1. Recent significant trauma, or milder trauma age >50
2. Unexplained weight loss
3. Unexplained fever
4. Immunosuppression
5. History of cancer
6. Intravenous drug use
7. Osteoporosis, proloned use of glucocorticoids
8. Age>70
9. Focal neurologic deficit progressive or disabling symptoms
10. Duration greater then 6 weeks
Low back pain. American College of Radiology. ACR Appropriateness Criteria.

Sciatica
Simple
Complicated
Radiculopathy
Urgent
CT or MRI
Plain film
ESR

LABORATORY DATA
DATE WBC Hb Plt Neut Lym Mon
1010110 21000 16.6 304K 87 8 3
1010112 15100 14.9 293K 65.0 23.7 9.4
Alb TP Bil,T AlkP AST ALT LDH
1010110 4.5 7.4 0.5 78 49 64 399
1010114 23 48 740
1010116 281
NA K Cl Ca BUN Cr
1010110 140 3.9 107 8.7 16 1.3
Urine routine:
RBC: 0-2 /HP; WBC: 2-5/HP
SP. GR.: 1.016; pH: 6.5; Protein: +; OB: -; Nitrate: -
CRP: 0.29 mg/dL
Lipase: 54 U/L
D-Dimer: 0.58 mg/1 FEU

Q2: HOW TO APPROACH THIS PATIENT
1. Renal isotope scan
2. CT scan with contrast
3. MRI
4. Angiography

Q3. ADDITIONAL EVALUATION
• 1. Consult CV for cardiac echo and Holter’s monitor
• 2. Coagulation test
• 3. Evaluation for procoagulant state

COAGULATION TEST
• ACA IgG, IgM: (-)
• AphL Ab: (-) Ab2GP 1 Ab: (-)
• Protein C, S: (-)

DIAGNOSIS
1. Acute renal infarction, L’t kidney
2. Secondary hypertension , renin-mediated
3. Suspect old MI, with LV mural thrombus
4. Nephrolithiasis, R’t kidney

Renal Artery Embolism. J Gen Intern Med. 2008; 23(5):644–7

RISK FACTORS OF CLOT EMBOLI
• Atrial fibrillation
Incidence of renal thromboembolism in patients with atrial fibrillation : 2%
• Incident thromboembolism in the aorta and the renal, mesenteric, pelvic, and extremity
arteries after discharge from the hospital with a diagnosis of atrial fibrillation.
Arch Intern Med. 2001;161(2):272.
• Diffuse atherosclerosis
• Aortic dissection
• Antiphospholipid syndrome

Renal Artery Embolism. J Gen Intern Med. 2008; 23(5):644–7

MAJOR SOURCE OF CLOT EMBOLISM
1. left atrium or left atrial appendage in atrial fibrillation
2. Left ventricular thrombus in patients with a myocardial infarction
3. Thromboembolic originating from complex plaque in the aorta
• Other potential embolic sources include valvular vegetations in infective
endocarditis
• Rarely tumor and fat emboli
• Paradoxical embolism through a patent foramen ovale

RENAL ARTERY THROMBOSIS
• Preexisting atherosclerotic renovascular disease ,
spontaneous or iatrogenic renal artery or aortic dissection, or as a complication following
endovascular (aortic or renal) intervention
• Other renal artery disease (secondary)
• Anti-phospholipid syndrome
• hypercoagulable states

More sensitive in Enhanced CT with submillimeter resolution and
multidetector CT technology (MDCT).
Vascular abnormalities are rarely identified in acute renal infarct, but both CT and
MR angiography (CTA and MRA) are well-established methods of evaluating the
renal vasculature.
Consider allergy, renal function
Renal Artery Embolism. J Gen Intern Med. 2008; 23(5):644–7

Oxford Textbook of Clinical Nephrology 10.6.5

ANTICOAGULATION
• With other indication : atrial fibrillation, left ventricular thrombus,
or a hypercoagulable state
• Intravenous heparin followed by oral warfarin.
• Goal INR: 2.0-3.0
• Higher goal of 2.5-3.5 is reasonable if
1. event occurred while on adequate warfarin therapy
2. high risk (eg, rheumatic heart disease, prosthetic heart valves).

REPERFUSION
• Systemic and local intraarterial thrombolysis
1. Local infusion preferred
2. Golden time (ischemic tolerance of kidney): 90-180 minutes
3. Prolonged occlusion: consider collateral circulation
4. Intraarterial thrombolysis in RAE: no consensus !!
• Angioplasty
• 合 理 來 說 , 單 側 RAE, 症 狀 發 生 後 數 小 時 內 , 且 兩 側 腎 功 能 佳 的
病 患 較 有 益 處
• Surgical revascularization
Higher mortality rate and does not result in better outcomes

SUMMARY OF TREATMENT
• Anticoagulation therapy
• Indicated when warranted by the underlying disease
AFib, left ventricular thrombus, or a hypercoagulable state
• Reperfusion therapy (thrombolysis or angioplasty) should only be
considered in patients who :
1. Do not yet have atrophy of the affected kidney on imaging studies.
2. Do not have prolonged duration of occlusion
3. Facts: Time to diagnosis following presentation is often >2 days

RENAL OUTCOME AND PATIENT OUTCOME WITH
RAE
• Renal outcomes: favorable
• 當 影 響 到 腎 功 能 需 要 透 析 時 , 死 亡 率 上 升
• 常 見 死 因 :
Recurrent embolic disease or CVD 而 非 腎 臟 相 關

Renal Artery Embolism. J Gen Intern Med. 2008; 23(5):644–7

TAKE HOME MESSAGE
1. Renal infarction 少 見 , autopsy-proved incidence: 1.4%
2. 發 生 原 因 : Thromboemboli (heart,aorta) > in-situ thrombosis
3. 早 期 診 斷
任 何 病 人 有 flank pain, 心 臟 病 史 (arrythmia, MI, VHD),
LDH ↑↑ 都 要 懷 疑
4. 當 診 斷 延 誤 時 , 治 療 以 heparin IV then coumadin 為 主