Page Kidney: An Unusual Complication of a Renal Transplant Biopsy

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.

Reversed diastolic intrarenal flow in page kidney following renal biopsy

Page's kidney is a condition that occurs due to external renal compression, usually caused by a subcapsular haematoma, generating a renal compartmental syndrome with parenchymal damage and renal perfusion alteration. Classically associated with renal trauma, Page's kidney can also arise after invasive renal procedures, such as renal biopsies or percutaneous nephrostomies. Clinically, it can trigger hypertension due to activation of the renin-angiotensin system induced by hypoperfusion secondary to renal parenchymal compression and can also present with varying degrees of renal function impairment. Furthermore, severe acute renal failure may be found particularly in patients with solitary kidneys or renal transplants. We present two cases of Page's kidney after renal biopsy and their PoCUS ultrasound findings. We would like to highlight the reversed diastolic flow on Doppler ultrasound in this entity, a pattern we have found in all two cases.

Surgically managed acute Page kidney following renal biopsy-A case report

Introduction and importance

Case presentation

Clinical discussion

Conclusion

A case report of post-surgical page kidney due to extensive renal hematoma following percutaneous nephrolithotomy

INTRODUCTION AND IMPORTANCE

Post-surgical Page kidney due to large renal hematoma following percutaneous nephrolithotomy (PCNL) is a rare significant complication that may lead to loss of a kidney.

CASE PRESENTATION

A 50-year-old lady underwent elective left side PCNL for a 3 cm renal pelvis stone, and one week later, she presented back with a massive renal hematoma with high blood pressure.

CLINICAL DISCUSSION

The ultrasound abdomen and computed tomography diagnosed a page kidney due to massive intrarenal and perirenal hematoma as a complication of PCNL. Angioembolization and percutaneous aspiration were failed, and the antihypertensives also failed to control the blood pressure. Therefore, she underwent a left-side simple nephrectomy and had an uneventful recovery with reversal of normal blood pressure.

CONCLUSION

Post-surgical page kidney needs to identify early to facilitate the percutaneous radiological interventions that may preserve the renal parenchyma and avoid further surgeries. Nevertheless, late cases or the failed radiologically intervened cases need open renal exploration and simple nephrectomy, which may be the bailed-out procedure to reverse the consequence of page kidney.