Acute Page kidney following renal allograft biopsy: a complication requiring early recognition and treatment

A fatal misdiagnosis of page kidney - case report

Page kidney is a condition where external compression of the renal artery and renal parenchyma leads to subsequent ischaemia and activation of renin-angiotensin-aldosterone axis. A 42-year-old female with hirsutism, hypertension and diabetes was diagnosed with a right adrenal mass and underwent laparoscopic adrenalectomy. Her hypertension worsened postoperatively and was managed medically. Subsequently she developed a right flank pain on the fifth postoperative day and died suddenly the next day. Autopsy revealed a pale body with cushingoid appearance. Surgical scars were healthy. Internal examination of the abdomen revealed a haemoperitoneum of 500 ml together with a large subcapsular haematoma measuring 1000 ml surrounding the right kidney, compressing the right renal artery. Kidneys were pale and the right kidney was soft and friable. Cortical surface of the right kidney demonstrated a possible surgical puncture site with an overlying thrombus together with a contused inferior vena cava. Other organs were pale but appeared otherwise normal. Histology revealed diffuse cortical necrosis of right kidney and features of adult respiratory distress syndrome in the lungs. Haemorrhagic shock following laparoscopic adrenalectomy for right adrenal tumor was declared as the cause of death, contributed by the development of the Page kidney. Trauma of several aetiologies including laparoscopic abdominal surgery may contribute to Page kidney. It presents with flank pain, hypertension and renal mass. Since postoperative blood loss usually manifests as hypotension, resulting hypertension may mislead the attending clinicians. Once diagnosed, it can be managed with surgical drainage and antihypertensives.

A Rare Case of Page Kidney With Superimposed Infection

Page kidney (PK) is a rare renal condition characterized by external compression of the kidney, typically by a subcapsular hematoma, leading to resistant secondary hypertension due to hypoperfusion and ischemia. This hypertension is caused by the external compression of the kidney by a chronic subcapsular hematoma that activates the renin-angiotensin-aldosterone system (RAAS) system. Hematoma formation can result from external or internal trauma. The resolution of the hematoma can take months, and, in some cases, may necessitate a nephrectomy. Unresolved subcapsular hematomas can be complicated by infection, leading to sepsis, hospitalization, and the need for surgical drainage. This report presents a unique case of a 67-year-old female with a spontaneous left renal subcapsular hematoma that did not resolve with conservative measures and was complicated by superimposed infection requiring percutaneous drainage.

Renal tamponade in a patient with hydronephrosis-related Page kidney

A 48-year-old woman presented with hyperreninemic hypertension and renal dysfunction and was diagnosed with hydronephrosis-related Page kidney. The pathophysiology was "renal tamponade", in which the kidney was compressed by the renal pelvis and Gerota's fascia, resulting in intrarenal microvascular ischemia. Ureteral stent placement promptly improved the hyperreninemic hypertension and renal dysfunction, and additional perirenal fluid drainage gradually improved these conditions. These observations indicated the following three points. First, renal compression-induced renin-angiotensin-aldosterone system upregulation plays an important role in the pathogenesis of Page kidney. Second, physicians should consider perirenal fluid drainage as a therapeutic option in addition to ureteral stenting in patients with hydronephrosis-related Page kidney. Third, bilateral perirenal subcapsular hematomas in this case could be caused by hydronephrosis. Hydronephrosis-induced intrarenal pressure elevation possibly caused chronic perirenal subcapsular hemorrhage at the vulnerable sites of the renal cortex and peeling of the renal capsule from the cortex, resulting in the bilateral massive subcapsular hematomas and Page kidney.

Page kidney following spontaneous subcapsular hematoma immediately after kidney transplantation: a case report

BACKGROUND

Page kidney (PK) is the occurrence of kidney hypoperfusion and ischemia due to pressure on the kidney by a subcapsular hematoma (SH), a mass, or fluid collection. SH after renal transplantation may result in kidney ischemia and graft loss.

CASE PRESENTATION

We present a rare case of early spontaneous SH in an allograft kidney that led to a decrease in renal function. A 56-year-old male patient underwent deceased donor kidney transplantation. After declamping, appropriate renal perfusion and immediate diuresis were observed, with no evidence of SH. However, his urinary output abruptly decreased 6 h postoperatively. Abdominal ultrasonography showed 28 mm deep SH on transplant and the resistive index (RI) increased to 0.98-1 and diastolic flow reversal was observed. Surgical interventions were performed 2 days after transplantation, following a further decrease in urinary output. Serum creatinine decreased to 2.2 mg/dL, urinary output increased to an average of 200 cc per hour and the RI value was decreased to 0.7 on POD 7.

CONCLUSION

In patients with abrupt decreased renal function after transplantation, SH should be suspected and the presence of PK should be determined using Doppler USG. In these cases, surgical intervention may avoid allograft dysfunction.

Acute Page kidney after angioplasty in kidney transplant allografts

Acute Page kidney (APK) in kidney transplantation is a rare entity often related to interventional techniques. Percutaneous angioplasty remains an exceptional cause of APK. Herein we describe the clinical course and outcome of APK following percutaneous angioplasty for transplant renal artery stenosis in four kidney transplant recipients, where external compression of the graft was caused by subcapsular haematomas. All patients were treated with surgical drainage, after which two cases recovered baseline kidney function, one developed advanced chronic kidney disease and one remained dialysis-dependent. To our knowledge, the present series is the largest to describe APK in kidney allografts after percutaneous angioplasty.

The Double-Edged Sword of Immunosuppressive Therapy in Kidney Transplantation: A Rare Case Report of Pulmonary Mucormycosis Post-Transplant and Literature Review

Immunosuppressive therapy is improving the graft survival of kidney transplant recipients and increasing the potential risk of infection. Pulmonary mucormycosis is a rare post-operative infection complication characterized with rapid deterioration and high mortality. In this case, a 33-year-old patient underwent a kidney transplantation with regular immunosuppressive therapy. Soon, 38 days post-transplant, pulmonary patchy shadows can be seen in the radiological examination and rounded into a large cavity formation with splenic rupture 25 days later. The diagnosis of mucormycosis was confirmed by lung biopsy and spleen histopathology. This case is a reminder that early diagnosis is imperative, meanwhile, rational antifungal therapy, timely elimination of immunosuppressants, and alternatively, abandoning the graft should be prudently assessed in the treatment of mucormycosis.

Subcapsular Renal Hematoma in Simultaneous Pancreas Kidney Transplantation

Subcapsular renal hematoma (SRH) is a challenging condition, which may jeopardize kidney function or constitute a life-threatening event. This is particularly true in single-kidney patients, such as kidney-transplant recipients. SRH may exert an excessive pressure on the surrounding parenchyma, thus resulting in hypoperfusion and ischemia, with high risk of acute kidney failure and graft loss. Moreover, SRH may precede an overt renal rupture with subsequent hemorrhage and hemodynamic instability. The indication to an interventional management for this condition is still a matter of debate, with some authors advocating the high possibilities of spontaneous resolution and others advocating the high-risk of graft loss and even internal bleeding in case of overt renal rupture. Herein, we report the case of a 51-year-old simultaneous pancreas-kidney transplantation recipient who presented a SRH following a mild trauma. The therapeutic choices were carefully balanced on the specific case, and the conservative management proved successful.

Elevated C-peptide Levels Are Associated With Acute Rejection in Kidney Pancreas Transplantation

BACKGROUND

We assessed whether allograft rejection or failure can be predicted by an acute increase in C-peptide production from the transplanted pancreas.

METHODS

Patients with a minimum of 5 years of follow-up post simultaneous pancreas-kidney transplant were identified. C-peptide levels were obtained during clinic visits routinely. Graft failure was defined as return to dependence on insulin therapy or return to dialysis for pancreas and kidney grafts, respectively. Protocol kidney allograft biopsies were performed at 3 and 12 months. For-cause biopsies were also performed.

RESULTS

Acute rejections were detected in 11 patients on biopsy results of the renal allograft. C-peptide levels drawn prior to documented rejections were significantly higher in patients with acute rejection than patients with borderline or no rejection (P = .006). Receiver operating characteristics curves for C-peptide indicated greater accuracy in predicting rejection than simultaneously drawn serum creatinine or lipase.

CONCLUSIONS

Higher C-peptide levels in simultaneous pancreas-kidney recipients is associated with acute rejection vs nonrejection.

Bleeding Complications and Adverse Events After Desmopressin Acetate for Percutaneous Renal Transplant Biopsy

Introduction: Percutaneous renal biopsy remains critical for the workup of renal allograft dysfunction but is associated with the risk of bleeding. Prophylactic intravenous desmopressin has been proposed to reduce bleeding risk in native renal biopsies, but its efficacy in the renal transplant population is unclear and adverse events such as severe hyponatraemia have been reported. Materials and Methods: We conducted a single-centre retrospective cohort study involving adult (≥21 years old) renal transplant recipients with impaired renal function (serum creatinine ≥150 μmol/L) who underwent ultrasound-guided renal allograft biopsies from 2011‒2015 to investigate the effect of prebiopsy desmopressin on the risk of bleeding and adverse events. Results: Desmopressin was administered to 98 of 195 cases who had lower renal function, lower haemoglobin and more diuretic use.Postbiopsy bleeding was not significantly different between the 2 groups (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.26‒2.43, P = 0.68) but desmopressin increased the risk of postbiopsy hyponatraemia (sodium [Na] <135 mmol/L) (adjusted OR 2.24, 95% CI 1.10‒4.59, P = 0.03). Seven cases of severe hyponatraemia (Na <125 mmol/L) developed in the desmopressin group, while none did in the non-desmopressin group. Amongst those who received desmopressin, risk of hyponatraemia was lower (OR 0.26, 95% CI 0.09‒0.72, P = 0.01) if fluid intake was <1 L on the day of biopsy. Conclusion: Prophylactic desmopressin for renal allograft biopsy may be associated with significant hyponatraemia but its effect on bleeding risk is unclear. Fluid restriction (where feasible) should be recommended when desmopressin is used during renal allograft biopsy. A randomised controlled trial is needed to clarify these outcomes. Key words: Adverse effects, Deamino arginine vasopressin, Haematoma, Haemorrhage, Hyponatraemia

Acute Renal Failure in Kidney Transplantation Due to Subcapsular Hematoma After a Renal Allograft Biopsy: Report of Two Cases and Literature Review

The compression of the renal parenchyma due to a subcapsular hematoma, also known as the "Page kidney," is a potentially serious but treatable complication of renal biopsy. Hypertension is very common and, in some cases, renal failure may be present. In kidney transplantation, it is a not well-described entity. Rapid intervention is essential to avoid irreversible damage of the graft and preserve its function. We report 2 cases of acute renal failure due to Page kidney in patients with renal transplant after a percutaneous biopsy with successful recovery after surgical treatment. In addition, we conducted a literature review in order to describe the clinical characteristics of this infrequent complication in patients with a history of renal transplant.

Page Kidney: An Unusual Complication of a Renal Transplant Biopsy

Page kidney, a rare phenomenon whereby external compression of renal parenchyma can induce hypertension, can be caused by subcapsular hematoma following renal transplant biopsy. Surgical intervention is often warranted to salvage the transplant kidney. This is a case report of a patient with acute T-cell-mediated rejection and no other risk factors for postprocedural bleeding that developed Page kidney. The patient had no signs or symptoms for >24 hours from the time of biopsy, underscoring the need for awareness of this rare but potentially catastrophic complication of renal transplant biopsies.

Page kidney secondary to subcapsular hematoma following percutaneous renal allograft biopsy

Percutaneous renal biopsy with ultrasound guidance is a helpful procedure regularly performed to obtain renal tissue diagnosis for rejection in the postrenal transplant setting; however, it is not without risks. We report the case of a 42-year-old male with end stage renal disease who developed a subcapsular hematoma, with subsequent hypertension and renal failure, compatible with acute page kidney as a complication of the renal biopsy. The ultrasound images demonstrated classic imaging appearances which all diagnostic and interventional radiologists should be aware of. The patient was managed successfully with conventional open surgical evacuation of the hematoma with return to baseline laboratories and vital signs after the procedure.

Unexpected presentation of allograft dysfunction triggered by page kidney phenomenon immediately after kidney transplantation: a case report

Background

Page kidney phenomenon is caused by strong renal parenchymal compression and leads to renal hypoperfusion and microvascular ischemia, resulting in renal dysfunction and hypertension. Although the development of Page kidney phenomenon in allograft is rare, most of its cases are induced by allograft biopsy or trauma. We observed a case of Page kidney phenomenon that was induced by unusual causes immediately after kidney transplantation.

Case presentation

A 66-year-old man, whose wife donated a kidney, underwent ABO-compatible living kidney transplantation. The allograft had three renal arteries that were trimmed and formed into one piece on the back table, and subsequently, it was anastomosed to the internal iliac artery. Intraoperative Doppler ultrasonography (US) revealed adequate blood flow of each renal artery. Urine output was also observed as soon as allograft blood flow was reperfused. After the surgery, the urine output decreased, and serum creatinine level increased to 6.0 mg/dL. Doppler US did not show evidence of acute rejection, ureteral obstruction, or anastomotic stenosis of the renal arteries. On postoperative day 7, surgical exploration was performed and revealed that the blood flow of each renal artery was adequate but subcapsular hematoma was detected at the upper pole of the allograft. Capsulotomy and hematoma evacuation were performed. Subsequently, urine output increased and serum creatinine level decreased up to 1.7 mg/dL. Allograft sample was obtained 1 h after the transplantation from the lower pole of the allograft. Although the cause of subcapsular bleeding was unclear in this case, a small cyst of the allograft, which might have ruptured during donor nephrectomy, was located in the middle of the hematoma, and oozing around the cyst was observed.

Conclusions

Our case indicated that the small ruptured cyst of the allograft could be the cause of subcapsular hematoma and Page kidney phenomenon. Subcapsular hematoma caused by oozing over time could be difficult to diagnose using Doppler US, and thus, other imaging modalities, such as computed tomography, should be considered. Knowledge of the Page kidney phenomenon in the allograft can lead to early diagnosis and intervention, resulting in better outcomes for recipients with allograft dysfunction.

Postrenal Transplant Allograft "Page Kidney" Identified and Salvaged using 99mTc-diethylenetriaminepentaacetic acid Renogram and Single-photon Emission-computed Tomography

^99mTc diethylenetriaminepentaacetic acid (DTPA) renogram is a commonly performed evaluation postrenal transplant to assess graft function and for early detection of suspected immediate and late transplant-associated complications. Although several modalities can be utilized to detect perinephric collection in posttransplant period, the utility of ^99mTc DTPA single-photon emission-computed tomography (SPECT-CT) is not recognized. Herein, we discuss the incremental role of seldom considered SPECT-CT in early detection, leading to timely appropriate management and graft salvage in a case of posttransplant deteriorating renal allograft as a result of subcapsular hematoma.

Diffuse Renal Cortical Hemorrhage in the Setting of Subcapsular Hematoma: Diagnosis and Treatment with Embolization

PURPOSE

To describe radiologic findings, embolization technique, and clinical outcomes in patients with renal subcapsular hematoma and diffuse cortical hemorrhage.

MATERIALS AND METHODS

Ten patients with renal subcapsular hematoma and diffuse cortical hemorrhage were reviewed. Nine of the 10 had undergone procedures (nephrostomy, n = 4; biopsy, n = 4; embolization of a cerebral aneurysm, n = 1) and 1 patient was receiving oral anticoagulation. Computed tomography (CT), angiography, and embolization of bleeding sites were performed in all patients.

RESULTS

CT and angiography revealed subcapsular hematoma with diffuse cortical hemorrhage at the level of the interlobar and/or arcuate branches. Total embolization of intrarenal arterial branches was required in 3 patients. Partial embolization, which also resulted in permanent functional loss, was required in 4. The functional loss was likely caused by the embolization procedure and the underlying renal disease. In these 4 patients, renal failure was demonstrated by scintigraphy in 3 cases and based on the need to start chronic hemodialysis in 1 case. In the remaining three patients, embolization did not compromise renal function.

CONCLUSIONS

Diffuse cortical hemorrhage unrelated to the site of puncture may be seen in some cases of subcapsular hematoma. The cause is likely the laceration of transcortical capsular arteries secondary to enlargement of the subcapsular hematoma. In the present case series, embolization achieved hemorrhage control, but loss of renal function was observed in patients with underlying renal disease.

Allograft loss from acute Page kidney secondary to trauma after kidney transplantation

We report a rare case of allograft loss from acute Page kidney secondary to trauma that occurred 12 years after kidney transplantation. A 67-year-old Caucasian male with a past surgical history of kidney transplant presented to the emergency department at a local hospital with left lower abdominal tenderness. He recalled that his cat, which weighs 15 lbs, jumped on his abdomen 7 d prior. On physical examination, a small tender mass was noticed at the incisional site of the kidney transplant. He was producing a normal amount of urine without hematuria. His serum creatinine level was slightly elevated from his baseline. Computer tomography revealed a large subscapular hematoma around the transplant kidney. The patient was observed to have renal trauma grade II at the hospital over a period of three days, and he was finally transferred to a transplant center after his urine output significantly decreased. Doppler ultrasound demonstrated an extensive peri-allograft hypoechoic area and abnormal waveforms with absent arterial diastolic flow and a patent renal vein. Despite surgical decompression, the allograft failed to respond appropriately due to the delay in surgical intervention. This is the third reported case of allograft loss from acute Page kidney following kidney transplantation. This case reinforces that kidney care differs if the kidney is solitary or a transplant. Early recognition and aggressive treatments are mandatory, especially in a case with Doppler signs that are suggestive of compression.

Recurrence of Acute Page Kidney in a Renal Transplant Allograft

Acute Page Kidney (APK) phenomenon is a rare cause of secondary hypertension, mediated by activation of renin-angiotensin-aldosterone system (RAAS). Timely intervention is of great importance to prevent any end organ damage from hypertension. We present a unique case of three episodes of APK in the same renal transplant allograft.

Acute renal failure and arterial hypertension due to subcapsular haematoma: is percutaneous drainage a feasible treatment?

Percutaneous drainage proved to be successful in managing a renal subcapsular haematoma that was causing acute renal failure and hypertension in a 74-year-old woman. The patient presented with oliguria, nausea and malaise 2 days after a ureteronephroscopic procedure with biopsies of a suspected urothelial neoplasm in the right renal pelvis. The left kidney had recently been removed due to renal cell carcinoma. At admission, the patient's blood pressure and plasma creatinine levels were massively elevated. Ultrasonography revealed a moderate right-sided renal subcapsular haematoma. When the patient did not respond to antihypertensive treatment, Page kidney was suspected. A pigtail catheter was placed in the haematoma and, shortly after drainage, the diuresis resumed and plasma creatinine together with blood pressure decreased. This condition had previously been managed by open surgery, but recent case reports have described successful management by laparoscopy-assisted and radiology-assisted drainage, as described in this case report.

Rupture of a Subcapsular Hematoma After Kidney Transplant: Case Report

Subcapsular hematoma after kidney transplant may result in kidney ischemia and graft loss. In this report, we present a patient who had a subcapsular hematoma that had no intraoperative enlargement but ruptured after surgery. A man who had chronic kidney disease secondary to hypertension had a preemptive living-donor kidney transplant from his wife. After declamping, appropriate renal perfusion and urinary output were observed. At perfusion, a subcapsular hematoma (diameter, 3 cm) was observed at the upper pole of the kidney. The hematoma did not enlarge during the surgery. Capsulotomy was not performed due to possible risks, and transplant surgery was completed with the plan for close postoperative ultrasonography and hemodynamic follow-up. Decreased urinary output was observed early after surgery. Renal Doppler ultrasonography showed decreased diastolic flow and a hematoma (width, 9 mm) that completely surrounded the transplanted kidney. The patient had emergency reoperation due to active hemorrhage from his surgical drain at 40 hours after surgery. Rupture of the capsule and hemorrhage from the surface of the kidney were observed. Extended capsulotomy and hemostasis of the kidney were performed. After surgery, urinary flow increased and renal Doppler ultrasonography findings improved. In summary, intervention for a subcapsular hematoma after kidney transplant is controversial. Capsulotomy should be considered for treatment of increased pressure to the graft, risk of permanent damage, and risk of graft loss.

The Native Kidney Biopsy: Update and Evidence for Best Practice

The kidney biopsy is the gold standard in the diagnosis and management of many diseases. Since its introduction in the 1950s, advancements have been made in biopsy technique to improve diagnostic yield while minimizing complications. Here, we review kidney biopsy indications, techniques, and complications in the modern era. We also discuss patient populations in whom special consideration must be given when considering a kidney biopsy and the important role that the kidney biopsy plays in nephrology training. These data are presented to develop best practice strategies for this essential procedure.

Posterior lumbar fixation in a kidney transplant recipient: logistics and perioperative challenges

BACKGROUND

Kidney transplantation has become the ideal and successful treatment for medically suitable patients with established kidney disease. This results in increased likelihood of these patients developing unrelated conditions requiring surgery, including spinal surgery. There are only a few publications available regarding spinal patients with renal transplants.

CASE REPORT

A 67-year-old patient presented with recurrent sciatica. Four years prior to this, he received a living donor kidney transplant. He was diagnosed with right L4 radiculopathy due to recurrent foraminal stenosis as a result of the grade I L4/5 spondylolisthesis. He was offered a reoperation including microdecompression and postero-lateral fixation and fusion. The renal transplant necessitated specific pre- and intraoperative considerations. The knee-chest position with extra padding was used to maintain the region of the renal transplant free from any pressure. The renal care was planned in detail by the transplant surgeons and nephrologists and shared with the ward doctors and on-call teams. The procedure was uneventful; there were no signs of intraoperative or postoperative acute renal injury. The patient was discharged 5 days postoperatively; all renal parameters remained within normal ranges and the postoperative plain films demonstrated satisfactory surgical results.

CONCLUSIONS

The key to success was a multidisciplinary approach and detailed planning regarding pre-, intra- and postoperative care. The presented scheme of care might be useful when considering the posterior approach and prone positioning in kidney transplant recipients with spinal pathologies requiring surgical treatment.

Page kidney of renal allograft following blunt trauma

We report a case of the Page kidney phenomenon which occurred in a patient with a renal allograft following blunt trauma. The injury occurred following an accidental trip resulting in a trivial fall. The patient presented with acute graft dysfunction with no localizing symptoms or signs. His renal function deteriorated further and he also became hypertensive. Serial ultrasounds showed an increase in the size of perinephric hematoma and evidence of renal compression. Prompt surgical evacuation of the hematoma was performed and renal function returned to baseline. Serial ultrasound examinations and timely surgical intervention can prevent graft loss in this unusual situation.

Transplant renal artery stenosis: clinical manifestations, diagnosis and therapy

Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after kidney transplant. It occurs most frequently in the first 6 months after kidney transplant, and is one of the major causes of graft loss and premature death in transplant recipients. Renal hypoperfusion occurring in TRAS results in activation of the renin–angiotensin–aldosterone system; patients usually present with worsening or refractory hypertension, fluid retention and often allograft dysfunction. Flash pulmonary edema can develop in patients with critical bilateral renal artery stenosis or renal artery stenosis in a solitary kidney, and this unique clinical entity has been named Pickering Syndrome. Prompt diagnosis and treatment of TRAS can prevent allograft damage and systemic sequelae. Duplex sonography is the most commonly used screening tool, whereas angiography provides the definitive diagnosis. Percutaneous transluminal angioplasty with stent placement can be performed during angiography if a lesion is identified, and it is generally the first-line therapy for TRAS. However, there is no randomized controlled trial examining the efficacy and safety of percutaneous transluminal angioplasty compared with medical therapy alone or surgical intervention.

Page kidney secondary to large splenic artery aneurysm bleeding and its management by angioembolization

Introduction:

The Page kidney is a rare phenomenon that refers to hypertension resulting from any external compression of a kidney by a hematoma, tumor, lymphocele, or urinoma. The activation of the renin-angiotensin-aldosterone system is believed to be the main mechanism responsible for development of resistant hypertension in Page kidney.

Case Presentation:

We reported a patient with chronic pancreatitis who presented with hypotension due to splenic artery aneurysmal bleed; following the resuscitation, accelerated hypertension secondary to Page kidney caused by perinephric hematoma presented. Early diagnosis by contrast-enhanced computed tomography of the abdomen and renal angiogram was followed by therapeutic angioembolization. However, ultrasound guided aspiration was not done because of denial by the patient for further treatment. Follow-up showed normalization of blood pressure and resolution of hematoma on subsequent abdomen ultrasound evaluation.

Discussion:

Splenic artery aneurysm is a very uncommon cause of Page kidney and to our knowledge, it was the first case of its kind ever reported in the literature.

Traumatic page kidney induced hypertension in critical care: immediately resolved or long-term resistant problem

Page kidney is a well-known phenomenon causing hypertension, due to compression of renal parenchyma by a subcapsular hematoma, of either traumatic or non-traumatic origin. The main therapeutic approach is based on surgical approach (nephrectomy or hematoma evacuation) and antihypertensive treatment. In this paper we present a post-traumatic case of Page Kidney in a Critical Care unit. We discuss different therapeutical opportunities to extremely elevated systemic blood pressure resistant to traditional drug therapy.

Hypertension and hydronephrosis: rapid resolution of high blood pressure following relief of bilateral ureteric obstruction

Hypertension secondary to hydronephrosis is not commonly reported in the medical literature. Tubuloglomerular feedback and the renin-angiotensin-aldosterone axis are thought to mediate this process. We describe a patient presenting with acute kidney injury and bilateral hydronephrosis secondary to pelvic malignancy in which peripheral venous renin and aldosterone were elevated. Her blood pressure improved rapidly following insertion of bilateral nephrostomies. The speed of resolution of hypertension following relief of obstruction suggests that humorally mediated vasoconstriction can play an important role in the mechanism by which hydronephrosis causes hypertension. We also discuss other causes of renal parenchymal compression that may lead to the development of hypertension.

Page kidney in a 17-year-old renal allograft

Page kidney is a condition where extrinsic renal compression from a haematoma or mass results in hypertension and loss of renal function. Most cases are caused by a subcapsular haematoma following blunt trauma or invasive procedures (eg, renal biopsy). We report a patient who spontaneously developed Page kidney 17 years after renal transplantation. This case represents the oldest renal allograft to develop non-traumatic Page kidney.

Page kidney: etiology, renal function outcomes and risk for future hypertension

The initial description of Page kidney, a form of renin-mediated hypertension, included athletes with renal subcapsular hematoma after flank trauma. Subsequently, nontraumatic etiologies were identified. In this study, the authors compare traumatic and nontraumatic causes of Page kidney. All cases with hypertension attributable to renal hematoma at our institution from 1960 to 2010 were reviewed. Twenty-six patients (9 trauma, 17 nontrauma), with a mean age of 36.7 years, were included. Trauma patients were younger (P<.001), had lower systolic blood pressures (P=.011), and higher baseline estimated glomerular filtration rate (eGFR), (P=.027) at presentation. No differences in presenting features, imaging, urinalysis, or pathology are noted. Nontrauma cases required more antihypertensive medications (P=.001) and had higher nephrectomy rates. eGFR improved in all, but more in, trauma cases (P=.05). Through the analysis of 26 cases of Page kidney, two distinct groups were identified. Trauma patients tended to be younger, male, have less renal impairment and lower systolic blood pressure. Nontrauma patients required more antihypertensive medications and had a higher nephrectomy rate. New-onset hypertension occurred independent of etiology, calling for close surveillance of blood pressures.

Post-biopsy renal allograft compartment syndrome: Addressing the problem, illustrated with a case report

INTRODUCTION

Renal allograft compartment syndrome (RACS) has recently been coined to describe early allograft dysfunction secondary to raised pressure in the retroperitoneal space. This may be caused by direct compression of the renal vessels or by a diffuse renal parenchymal compression. Herein, we report a renal allograft compartment syndrome secondary to a needle core transplant biopsy and discuss the management strategies in line with an updated literature review.

PRESENTATION OF CASE

A retrospective case-note review was carried out where a 45-year-old male had a transplant renal biopsy at 4-weeks after transplant for raising creatinine. Following biopsy patient developed abdominal discomfort and had haematuria.

DISCUSSION

Doppler ultrasound scanning of graft demonstrated good perfusion but a small haematoma (2 × 2 × 2 cm) in the upper pole of the kidney at the site of the biopsy. Patient was thereafter assessed conservatively with serial ultrasound monitoring. After 24 h, significant deterioration of graft function was observed. The third scan, demonstrated reversed flow in diastole in the upper pole of the kidney with a resistive index of 1.0 in the main renal vessel. With the above findings the kidney transplant was explored immediately and the transplant released from a 300 ml of liquefied haematoma, which was under considerable pressure. In the next 24-h, the patient showed an immediate return of graft function.

CONCLUSION

We recommend sequential ultrasound Doppler scanning as an invaluable tool to help identify early RACS. The surgical exploration and adequate heamostasis with surgical glue should be sought out in all RACS.

An unusual presentation of a Page kidney 24 days after transplantation: case report

The Page kidney phenomenon is a well recognized entity where an extrinsically compressed kidney results in hypertension and loss of function. This compression is usually caused by a subcapsular hematoma secondary to blunt abdominal trauma or an invasive procedure such as a renal biopsy. We describe an unusual case involving the spontaneous development of a Page kidney 24 days after renal transplantation without any history of preceding trauma. The subcapsular hematoma was detected by a computerized tomographic scan performed as part of the work-up for acute allograft dysfunction. Prompt recognition and early intervention are essential if renal function is to be restored before irreversible damage occurs.

Recurrent Page kidney in a child with a congenital solitary kidney requiring capsular artery embolization

We report an unusual case of a child with a congenital solitary functional kidney complicated by a sports-related posttraumatic Page kidney. The child developed severe hypertension and renal insufficiency requiring percutaneous intervention to preserve renal function. The literature is sparse with no definitive guidelines for the treatment of Page kidney. Following the initial unsuccessful treatment with percutaneous drainage and sclerotherapy procedures, the child ultimately required catheter-directed particle embolization of the capsular arteries to resolve a recurrent subscapsular hematoma definitively. This was successful in preserving renal function and stabilization of the clinical manifestations of the Page kidney.

Bilateral renal hemorrhage due to polyarteritis nodosa wrongly attributed to blunt trauma

BACKGROUND

A 36-year-old, previously healthy man presented to an accident and emergency department with right-sided abdominal pain 7 days after he sustained a trauma to his right flank. He was using no medication other than over-the-counter analgesics since his injury.

INVESTIGATIONS

Complete blood count, serum creatinine measurement, liver function tests, hepatitis B and C screening, abdominal CT, renal angiography, surgical exploration and histology of kidney samples.

DIAGNOSIS

Polyarteritis nodosa with Page kidney causing bilateral perirenal hematoma, severe hypertension and renal failure.

MANAGEMENT

The patient was severely anemic, and his bleeding was investigated. A 15 x 13 x 12 cm retroperitoneal hematoma was found in the region of the right kidney and the patient underwent unilateral right nephrectomy. 3 weeks after discharge the patient was readmitted with a left-sided perirenal hematoma. Steel-coil embolization of the kidney stopped the bleeding but the patient developed hypertension and renal failure, and antihypertensive agents and dialysis were started. Microaneurysms and vessel-wall necrosis were discovered on re-examination of the angiogram and histology, respectively, so immunosuppressive therapy was started, comprising intravenous methylprednisolone daily for 3 days and oral prednisolone and intravenous cyclophosphamide for 4 weeks. Page kidney, resulting from the bleeding into the solitary kidney, caused stretching of the renal artery and deterioration of renal function, which required hemodialysis treatment.

Page kidney as a rare cause of hypertension: case report and review of the literature

Page kidney occurs by extrinsic compression of the renal parenchyma from a hematoma or a mass, leading to activation of the renin-angiotensin-aldosterone system and resulting in systemic hypertension. There have been about 100 cases of Page phenomenon reported in the literature. A review of cases published prior to 1991 revealed that football and nonsports-related trauma were the most common causes of Page kidney. Thereafter, 28 cases have been reported in the literature, including our case report presented here. These recent cases show that the etiology of Page kidney has shifted, perhaps because of the procedure-oriented current practice of medicine and the increased frequency of kidney transplant biopsies. In addition, management options have evolved, given the more frequent use of medications that block the renin-angiotensin-aldosterone system and the availability of less invasive procedures. Page kidney should be considered in the differential diagnosis of secondary hypertension.