Treatment of uncontrolled hypertension by therapeutic renal infarction

Acute renal infarction. Clinical characteristics of 17 patients

We analyzed the medical records of patients with an established diagnosis of acute renal infarction to identify predictive parameters of this rare disease. Seventeen patients (8 male) who were admitted to our emergency department between May 1994 and January 1998 were diagnosed by contrast-enhanced computed tomography (CT) as having acute renal infarction (0.007% of all patients). We screened the records of the 17 patients for a history with increased risk for thromboembolism, clinical symptoms, and urine and blood laboratory results known to be associated with acute renal infarction. A history with increased risk for thromboembolism with 1 or more risk factors was found in 14 of 17 patients (82%); risk factors were atrial fibrillation (n = 11), previous embolism (n = 6), mitral stenosis (n = 6), hypertension (n = 9), and ischemic cardiac disease (n = 7). All patients reported persisting pain predominantly from the flank (n = 11), abdomen (n = 4), and lower back (n = 2). On admission, elevated serum lactate dehydrogenase was found in 16 (94%) patients, and hematuria was found in 12 (71%) of 17 patients. After 24 hours all patients showed an elevated serum lactate dehydrogenase, and 14 (82%) had a positive test for hematuria. Our findings suggest that in all patients presenting with the triad--high risk of a thromboembolic event, persisting flank/abdominal/lower back pain, elevated serum levels of lactate dehydrogenase and/or hematuria within 24 hours after pain onset--contrast-enhanced CT should be performed as soon as possible to rule out or to prove acute renal infarction.

Iatrogenic renal vascular injury

Bilateral arteriovenous fistulas secondary to percutaneous needle biopsy of each kidney developed in a patient with malignant hypertension and chronic failure. The fistulas with aneurysmal formation and hematuria were of such magnitude that bilateral nephrectomy was required for control. The patient is now normotensive and is maintained on hemodialysis. The advisability of renal needle biopsy in uncontrolled hypertension is questioned. Cases of intrarenal arteriovenous fistulas resulting from percutaneous needle biopsy of the kidney are being reported with increasing frequency. The exact incidence of fistula formation after kidney biopsy is unknown, but several series based on arteriographic studies show an incidence as high as 18 per cent. Although many of these fistulas disappear spontaneously, approximately 4 per cent persist. A review of the literature failed to reveal the incidence of aneurysmal formation. Our case was complicated by formation of bilateral renal arteriovenous fistulas secondary to repeat bilateral percutaneous needle biopsy and right open renal biopsy. Subsequent gross hematuria from the right ureteral orifice also resulted which was proved by cystoscopy and required replacement with several units of blood. The likelihood of rupture led to bilateral nephrectomy.