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Retroperitoneal hematoma (RPH) is a well-recognised, albeit rare complication of percutaneous transfemoral cardiac catheterization. We describe an unusual case of renal perforation and RPH following transfemoral cardiac catheterization for endomyocardial biopsy. Diagnosis was made based on multidetector computed tomography (MDCT) which clearly depicted active renal hemorrhage in short acquisition time. The case expands the spectrum of possible complications of percutaneous transfemoral cardiac catheterization and illustrates the usefulness MDCT in quickly and adequately detecting RPH.

Background The aims of this study were to assess the value of multislice CT-angiography (MS-CT-A) in percutaneous postinterventional kidney bleeding and to determine the influence of diagnostic outcome on therapeutic patient management. A recommendation for the interdisciplinary patient work-up for the emergency room was offered. Methods Between April 2003 and January 2006, 12 patients with hematuria and clinically suspected renal bleeding underwent MS-CT-A for emergency diagnostic assessment. The spectrum of kidney injuries on CT was analyzed according to an organ-scaling scheme. The efficacy of MS-CT-A with regard to confirmation of active arterial bleeding was evaluated as well as the therapeutic consequences for patient management. Results In seven patients (59%) staged grade V renal injury, active renal arterial bleeding was detected on CT-A. Patients immediately underwent therapeutic angiography with confirmation of arterial bleeding and successful embolization. Four patients (33%) were staged grade I renal injury with subcapsular kidney hematoma but no active hemorrhage. Therefore, these patients were not exposed to further therapeutic intervention. One patient (8%) was diagnosed grade II renal injury with superficial cortical renal parenchyma tear and no active bleeding on CT-A. Conclusions MS-CT-A is a valuable, fast and objective emergency tool for assessment of postinterventional renal hemorrhage. Detection of contrast material extravasation to affirm ongoing arterial bleeding and to localize bleeding site at the level of segmental or interlobar renal artery is a predictor for the need for further treatment and justifies therapeutic radiological or surgical management.

Wilms tumor typically presents as an abdominal mass, though occasionally patients present with other manifestations. We report a case of a child presenting with a perirenal hemorrhage and an initially occult Wilms tumor, found only on subsequent renal arteriography. Symptoms in this patient were caused by the presence of perirenal and subcapsular hemorrhage rather than the tumor itself. Despite an unusual presentation, we need to consider underlying neoplasia in children with renal hemorrhage and the absence of a history of trauma. Follow-up studies might help clarify initial negative imaging results.

PURPOSE To evaluate the diagnostic impact of multislice computed tomography (MSCT) in treatment planning prior to transarterial coil embolization of iatrogenic renal injuries. METHODS Nine patients (median age 54 years, range 36-66) with iatrogenic renal vascular injury were treated with superselective coil embolization. Prior to therapy, a dual-phase (40 and 120 seconds) contrast-enhanced MSCT was applied in 6 patients. Seven patients underwent renal ultrasonography. Multiplanar reconstructions of the MSCT scans were used to affirm ongoing bleeding and to localize the bleeding site at the level of the segmental or interlobar artery. MSCT and angiographic findings were compared to evaluate the accuracy of MSCT in the detection of the bleeding source prior to therapy. RESULTS Multiplanar reconstructions of early-phase MSCT scans allowed precise identification of the bleeding interlobar or segmental artery in all 6 cases prior to angiography. In one case, MSCT was even able to detect a source of bleeding that was not revealed by selective renal angiography. CONCLUSIONS Multiplanar reconstructions of MSCT data demonstrate not only the presence of hematoma but also confirm ongoing bleeding and the location of the feeder artery prior to minimally invasive therapy.

We assessed the role of laparoscopic management in patients following spontaneous retroperitoneal hemorrhage from a renal tumor.A retrospective chart review revealed 4 patients with spontaneous retroperitoneal hemorrhage treated at our institution in the last 2 years. After conservative management elsewhere patients were referred for definitive therapy. Patient characteristics and tumor size were examined and correlated with ease of surgical dissection and surgical outcome. No patient had any history of trauma. Computerized tomography was used to identify the initial extent of hemorrhage in all patients.All patients underwent successful laparoscopic exploration without the need for open conversion. Three patients underwent radical nephrectomy and 1 underwent laparoscopic partial nephrectomy. Renal hemorrhage extending outside of the renal capsule was associated with significantly more adhesions than renal hemorrhage confined to the renal capsule. Mean patient age was 56 years (range 36 to 70). Mean retroperitoneal tumor size was 5.3 cm (range 2.5 to 10). Three renal hematomas were extracapsular and 1 was subcapsular. Mean operative time was 182.3 minutes (range 59 to 235). Average estimated blood loss was 800 cc (range 150 to 2,100).Nontraumatic retroperitoneal hemorrhage of renal origin may be managed using traditional laparoscopic techniques with results similar to those achieved with open renal exploration. These cases may prove technically challenging due to fibrosis and associated tissue plane loss.

A case of polycystic kidney disease (PKD) associated with Klippel-Trenaunay-Weber syndrome is described. A 58-year-old man with chronic renal failure experienced urinary retention following gross hematuria. Intermittent drainage was necessary for significant urination for five days. Thereafter his urinary retention was relieved, but renal failure progressively developed and hemodialysis was started. Right hydronephrisis and hydroureter disappeared one month later. In spite of relief of obstruction, of which the cause was likely blood clots, renal function was not restored. Obstructive nephropathy was most likely explicable for notable deterioration in renal function. Our case might have susceptibilities to PKD development in terms of angiogenesis.

Keywords Chronic kidney disease Perirenalhemorrhage Warfarin Wunderlich syndromeA 68-year-old man with advanced diabetic nephropathywas transferred to our hospital for arteriovenous fistulacreation. One month before admission, he had startedanticoagulation therapy with warfarin potassium andreceived permanent IVH filter placement for deep venousthrombosis. On the fifth day of admission, macrohematuriaand acute bilateral flank pain developed. Laboratory testsdisclosed a sudden increase in the serum creatinine con-centration (from 7.0 to 9.1 mg/dl), progression of anemia(from 9.4 to 7.7 g/dl), and markedly elongated PT-INR(6.79). Unenhanced CT revealed low- to middle-attenua-tion fluid collection in subcapsular and perirenal retro-peritoneal spaces (Fig. 1). There was no history oftraumatic injury. Spontaneous perirenal hemorrhage wasdiagnosed. He was kept at absolute rest and vitamin K2was administered intravenously. Follow-up CT showedsubstantial improvement of the hemorrhagic lesion(Fig. 2), and no suspicious underlying etiology wasdetected.Spontaneous renal hemorrhage into the perirenal retro-peritoneal spaces is called Wunderlich syndrome [1].Underlying etiologies include benign and malignantneoplasms, rupture of fragile cysts, vascular disease, andcoagulation disorders. In cases with uncontrollable bleed-ing, partial or complete nephrectomy is necessary. Mark-edly elongated PT-INR due to warfarin potassium is aplausible cause of the bilateral perirenal hemorrhage in thepresent case. Recently, a relationship between acutelyincreased PT-INR and exacerbation of renal dysfunctionwas reported [2, 3]. In addition to hematuria and acuterenal dysfunction, perirenal hemorrhage should also beconsidered in patients receiving anticoagulation therapy.

The generation of ultrasound (US) bioeffects using a clinical imaging system is controversial. We tested the hypothesis that the presence of microbubbles in the US field of a medical imager induces biologic effects. Both kidneys of anesthetized rats were insonified for 5 min using a medical imaging system after the administration of microbubbles. One kidney was insonified using a continuous mode (30 Hz) and the opposite kidney was insonified using an intermittent (1 Hz) technique. The microbubbles were exposed to three different transducer frequencies and four transducer output powers. After insonification, the animals were euthanized, the kidneys were removed and their gross appearance scored under “blinded” conditions using a defined scale. After the administration of microbubbles, US imaging of the kidney caused hemorrhage in the renal tissue. The severity and area of hemorrhage increased with an increase in the transducer power and a decrease in the transducer frequency. Intermittent insonification in the presence of microbubbles produced a greater degree of renal hemorrhage than continuous imaging techniques. (E-mail: james.wible@tycohealthcare.com)

True emergencies of the urinary tract center on three major issues, including uncontrolled renal hemorrhage, accumulation of urine within the peritoneal cavity or retroperitoneal space, and obstruction to urine outflow. Successful management of urinary tract emergencies in small animal patients is based not only on the severity of the injury or obstruction but on the condition of the patient at the time of diagnosis and the patient's response to medical stabilization. When most urinary tract emergencies are initially recognized, patients are metabolically and hemodynamically unstable. Therefore, urinary tract emergencies are first regarded as medical emergencies, and emergency surgical procedures are aimed at patient stabilization and lifesaving measures.

A massive post-nephrolithotomy renal hemorrhage was successfully controlled by selective arterial embolization using Gelfoam particles. Prior to embolization, the kidney showed no excretory function due to complete obstruction of its collecting system by blood clots. Long-term observation revealed restoration of excretory function of the treated kidney and only minimal loss of its parenchyma.

The purpose of this study was to determine the usefulness of contrast-enhanced sonography in the detection of acute parenchymal injury.In a model of acute renal injury in pigs, four separate renal parenchymal bleeds were created by puncturing an interlobar artery of the upper and lower poles of the kidneys. B-mode gray-scale scans of the kidneys before and after injury, and after the administration of i.v. and intraarterial (i.a.) contrast agents were recorded on videotape for 5 min for each condition (baseline, after injury, after i.v. contrast administration, and after i.a. contrast administration). For each condition and injury, selected frames were analyzed with regions of interest of the normal renal parenchyma, the area of injury, and the perinephric space. Randomized videotape clips from each of the experimental conditions were rated by three sonologists as to the presence or absence of increased intrarenal parenchymal echogenicity, perinephric echogenicity, and confidence as to whether renal injury was present.Areas of renal injury were isoechoic with normal parenchyma on unenhanced scans. After both i.v. and i.a. contrast material injection, areas of injury were visible as areas of increased echogenicity. Contrast increased from 0.2 on unenhanced images to 4.0 and 4.5, respectively, after i.v. and i.a. administration of the new contrast agent. The three observers' ability to diagnose renal injury increased from 0.61, 0.64, and 0.54 to 0.71, 0.70, and 0.74 after i.v. injection and to 0.93, 0.92, and 0.97 after i.a. injection as indicated by the area under the curve in the receiver operating characteristic analysis.Transabdominal contrast-enhanced gray-scale sonography can reveal the area of acute renal hemorrhage. This procedure may be applicable in patients when sonographic contrast agents, imaging procedures, and modes of contrast administration are optimized for clinical use in trauma.

Spontaneous ruptures of the kidney sometimes require emergency surgery, at which time the etiology for the rupture becomes evident. Because the patient with previously existing renal pathology is asymptomatic, when these ruptures do occur one should be suspect of underlying disease. We present a case and discuss the relevant aspects of such entities.

Background Recently studies have demonstrated improved outcomes in patients undergoing nephron-sparing surgery (NSS) for low stage renal tumors, thus NSS is widely accepted as the treatment option for these patients. With NSS, there is a risk of renal hemorrhage and thus haemostatic agents may be routinely applied to the cut surface of the kidney. Herein we compare two commercially available haemostatic agents applied intra-operatively to the cut surface of the kidney. Post-operative outcomes (oncologic and non-oncologic) are reported. Methods The medical records of 23 patients with suspicious renal mass documented on axial imaging and who underwent open NSS via a mini-subcostal incision were extensively reviewed. One of two haemostatic agents (Floseal®, n = 11; Arista®, n = 12) was intra-operatively applied to the cut surface of the kidney. Chi-square and T- student test was used to compare outcomes between the cohort of 11 patients who had Floseal® and the 12 patients who had Arista®. Results Median pre-operative size of renal mass was 4.3 cm (range 1.5-7.0 cm). Final pathology revealed 3 oncocytomas and 20 renal cell carcinoma (17 clear cell, 1 chromophobe and 2 papillary), pT1a = 14 and pT1b = 6. Mean intra-operative blood loss and hospital stay between the Floseal® vs. Arista® cohorts did not significantly differ (227 mL vs. 250 mL, p = 0.68 and 4.4 days vs. 4.5 days, p = 0.76, respectively). Intra-operative and post-operative complications were not different between the two cohorts. No recurrences have been documented with a mean follow-up of 18 months. Conclusion Along with meticulous surgical technique, the use of either haemostatic agent (Floseal® or Arista®) was not associated with high rate of intra-operative or post-operative haemorrhage. Thus either haemostatic agent may be successfully used during NSS.

A 47-year-old man with polycystic kidney disease, who was on hemodialysis for several years, presented with gross hematuria. Although radionuclide imaging is successfully used to detect minimal gastrointestinal bleeding with Tc-99m labeled RBCs, this technique is not usually applied to the evaluation of genitourinary bleeding because there is some excretion of free pertechnetate by the kidneys. The authors report the successful identification of a renal hemorrhage in a patient with polycystic kidneys using labeled RBC scintigraphy. This finding is important because it guided the surgeon to remove the appropriate kidney.

PURPOSE Renal osteosarcoma may arise as a metastasis from a primary bone osteosarcoma or as a primary renal tumor. Metastatic renal osteosarcoma has been found at autopsy in approximately 10% of patients who die of this disease. PATIENT AND METHODS A case report of a young Chinese patient presenting with acute onset of renal infarction and hemorrhage from a renal metastasis of osteosarcoma is presented, as well as a review of the literature. RESULTS Some patients with solitary renal metastatic osteosarcoma may have long-term disease-free survival after nephrectomy. Early diagnosis and thus increased awareness of this condition is important.

Two patients with renal hemorrhage treated by arterial embolization are reported. In one patient, one kidney was injured and the another had poor function. The other patient had one kidney. Although both patients had hematuria and underwent percutaneous nephrostomy, the bleeding location was not detected angiographically. Repeated embolization and irrigations through a nephrostomy catheter following each embolization arrested the bleeding.

Percutaneous renal procedures have become the standard technique for diagnosis and treatment of a number of renal pathologies. Hemorrhage and vascular lesions are the most serious complications. We report our experience with 15 patients treated by hyperselective vascular embolization. Fifteen patients (10 men and 5 women; mean age 55 years) had severe perioperative hemorrhage after percutaneous renal procedures, due to arterial renal major injury. All patients underwent duplex US, CT, and renal arteriography demonstrating the presence of arteriovenous fistulas (n=2), renal hematoma (n=3), pseudoaneurysms (n=3), and hematoma with pseudoaneurysm (n=7). Four patients showed transient renal dysfunction, with an increase in serum creatinine levels. One patient had a solitary transplanted kidney. Hyperselective arterial embolization was performed successfully by means of coils (n=14), associated with gelfoam in 4 cases; homologous blood clot was used in 1 patient. No major complications occurred, and renal function rapidly normalized in the 4 patients with transient renal failure. Imaging follow-up confirmed the successful devascularization of the lesion. Renal arterial hemorrhage following percutaneous procedures is a rare but severe complication. Hyperselective renal artery embolization, with particles and/or coils, represents the first-choice treatment option, being safe and effective in stopping the bleeding.

Wunderlich syndrome is a rare entity characterized by acute onset of spontaneous, non-traumatic renal hemorrhage into the subcapsular and perirenal spaces. It can be fatal if not promptly recognized clinically and treated aggressively. We report a case of a 63-year-old Caucasian female who was presented to the emergency department with acute onset of sharp abdominal and right flank pain, and hypotension. An urgent abdominal and pelvic computed tomography scan with contrast demonstrated a large (13 × 12 × 8.5 cm) right perinephric hematoma of unknown etiology. The patient subsequently underwent renal angiogram that demonstrated active extravasation of the right superior renal artery. She underwent successful embolization procedure and responded well to fluid resuscitation. She remained hemodynamically stable and was discharged home without further events.

To the Editor, We are grateful to the investigators for their interest in our article [1]. They report a similar case (post-stenting renal hemorrhage) with a different management strategy: renal preservation rather than ablation. We agree with these investigators that renal preservation should be preferred to ablation in the treatment of a patient with renal hemorrhage, even in an emergency situation. However, there were differences between the two cases that affected the different treatment strategies. First, in contrast to the other investigators’ case, our patient’s bleeding kidney was atrophic, and the contralateral kidney was functional. Second, there were innumerous bleeding cortical vessels (not just two or three) throughout the kidney. The duration of selective embolization of all vessels would have lasted longer than ablation and would have been risky in our hemodynamically unstable patient. Moreover, selective embolization of bleeding vessels would act as near-total ablation. Therefore, we chose renal ablation as a fast and effective treatment option suitable for our case. We suggest that in multifocal renal bleeding cases, a treatment strategy should be planned for each patient taking into account the clinical status of the patient, the functional status of both the affected and the contralateral kidneys, and the number of bleeding vessels.

We report a case of bilateral intrarenal, subcapsular and perirenal hematomas after extracorporeal shock wave lithotripsy. Following treatment chest pain developed necessitating monitoring in the intensive care unit and cardiac evaluation. Serial hematocrit levels during the next 2 days revealed a decrease from 48 to 23%, requiring multiple transfusions. After therapy it was recognized that the patient had taken aspirin on a daily basis within 1 week before lithotripsy. We postulate that the aspirin ingestions acted as a potential predisposing factor in the formation of the bilateral renal hematoma.

We report on 2 patients who presented with massive intraperitoneal hemorrhage. In spontaneous renal hemorrhage there is often an underlying pathological condition, usually renal carcinoma. The investigation of choice is computerized tomography, while arteriography is reserved for cases in which no renal mass is found. Nephrectomy may be life-saving but conservative treatment is an acceptable alternative when the underlying pathological condition is benign and the patient is in stable condition.

We report a patient with biopsy-proven polyarteritis nodosa with massive hemorrhage from presumed interlobar artery rupture. The use of interventional radiology techniques such as embolization are discussed in the acute management of such patients. Embolization by interventional radiology should be considered a useful alternative to surgery in these patients. The utility of angiography as a diagnostic and therapeutic tool is demonstrated in this case.

Purpose: Renal hemorrhage is one of the most common and worrisome complications of percutaneous renal surgery. We studied the incidence of renal hemorrhage and transfusion rates in patients undergoing balloon or Amplatz fascial dilation of the nephrostomy tract.Materials and Methods: Medical records of 143 patients who underwent 150 percutaneous renal procedures, including percutaneous nephrolithotomy, antegrade endopyelotomy and percutaneous treatment of stones in caliceal diverticula, were reviewed. The nephrostomy tract was dilated with balloon (50 patients) or Amplatz sequential (100) dilators. Perioperative decreases in hemoglobin level and blood transfusion rates were compared between the 2 groups.Results: Of the 100 patients undergoing percutaneous renal Amplatz dilation 25 (25%) required a blood transfusion, compared to only 5 of 50 (10%) undergoing balloon dilation. The difference in the transfusion rates between the 2 groups was statistically significant (p = 0.048).Conclusions: Improvem...

A systemic streptococcal infection in cultured bullfrogs in Brazil was characterized by necrotizing splenitis and hepatitis with hepatic and renal hemorrhage. A non-hemolytic Group B Streptococcus appeared to be the cause of the lesions, and the stimulus for the splenic reticuloendothelial hyperplasia observed in the animals. Stress may have been a factor in the development of the pathological condition.

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3). The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and 0 per cent in group 3. Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3. Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively. Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.

This is a report of two brothers, born within a year of each other, with a similar skeletal disorder of severe congenital metaphyseal involvement, mild rhizomelic shortness of upper limbs, and mild platyspondyly. Both died at three days of cardio-respiratory insufficiency, but only one had ante-mortem lab tests which showed low calcium, high phosphorus, and high alkaline phosphatase levels attributed to a renal defect. On autopsy this same infant was found to have pulmonary, renal and adrenal hemorrhage, and subendocardial myocarditis and myocardial necrosis. The pathogenetic relationship between these manifestations is presently unclear; however, since parents are normal and recently had an affected baby girl, it is presumed that this disorder is an autosomal recessive trait.

From October 1983, (installation of the extracorporeal shock wave lithotripsy unit) to August 1985, 207 patients presented at the Katharinenhospital Stuttgart with complicated renal stone disease (70 borderline stones, 77 partial and 60 complete staghorn calculi). 197 patients were treated with the new technology for urinary stone therapy, i.e. extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCN), and ureterorenoscopy. The combination of PCN and ESWL proved to be the optimal therapeutic approach in the majority of cases (44%), particularly for partial and complete staghorns, whereas PCN or ESWL monotherapy are indicated for borderline stones (51% ESWL, 26% PCN, 20% combination, 3% surgery) and selected cases of staghorn calculi only. Based on this treatment policy (minimal invasiveness and morbidity), 75 patients with partial staghorn (21% ESWL, 28 PCN, 44% combination, 7% surgery) and 52 cases of complete staghorn stone (2% ESWL, 13% PCN, 74% combination, 11% surgery) have been treated successfully. The rate of major complications was low (2.5% septicemia, 2% major renal hemorrhage, 0.5% mortality). With this new concept of multimodal therapy (ESWL and endourology), even cases of malignant stone formation ('stone cancer') may be treatable, since these methods can be applied repeatedly without damaging the renal parenchyma.

The clinical records of 67 patients who underwent surgical exploration for stab wounds associated with hematuria were reviewed in an attempt to evaluate the need for mandatory operation and to define criteria for possible nonoperative of such cases. Minor renal injuries without associated intra-abdominal lacerations were found in 61 per cent of the patients. Delayed renal hemorrhage occurred in 15 per cent of the patients despite early exploration, suture and drainage of the kidney, and antibiotic prophylaxis. Of 7 nephrectomies 5 were performed for secondary hemorrhage. Postoperative pulmonary complications arose in 28 per cent of the patients. A policy of mandatory operation on all patients with stab wounds and hematuria led to apparently needless surgery in 61 per cent of the patients in this series. Retrospective analysis revealed that the rate of probably unnecessary operations could have been reduced to 24 per cent by selecting for operation only those patients with signs of severe hemorrhage, associated intra-abdominal injury or major extravasation of contrast material on excretory urography.

Extracorporeal shock wave lithotripsy (ESWL), either alone or in combination with percutaneous or retrograde techniques, has rapidly become the procedure of choice for the treatment of intrarenal and upper ureteral calculi. Complications have been few so far and usually have been urinary obstructions or hemorrhages. Most fluid collections observed after ESWL are asymptomatic and their detection usually does not prolong hospitalization or alter therapy. In five patients out of 2,149 patient treatments symptomatic renal hematomas developed within a few hours after ESWL for renal calculi. In two of these patients the partial thromboplastin time was mildly prolonged. In four patients blood volume replacement was required to treat a falling hematocrit reading or hypotension. Diagnosis of the hematomas was initially made with sonography, although computed tomography and magnetic resonance imaging were used to further define the distribution and extent of retroperitoneal hematomas. Severe ipsilateral flank pain and rapid decrease in the hematocrit reading after ESWL strongly suggest significant bleeding from the treated kidney and require prompt radiologic confirmation and careful clinical treatment until there is evidence that the hemorrhage has stopped.

The causes of nontraumatic renal hemorrhage are reviewed and the roentgenographic criteria for distinguishing intrarenal, subcapsular and perirenal types outlined. A statistical analysis of 22 cases is presented: 10 were caused by tumors, some undetectable roentgenographically. Surgical exploration of the kidney is recommended in all cases of spontaneous renal and perirenal hematoma, if all medical causes for bleeding can be excluded.

This report of 9 cases of spontaneous renal hemorrhage illustrates the wide variety of responsible conditions that may be found in a small series and the tendency for some of these conditions to coexist. In particular, all 3 patients with a bleeding diathesis had an associated anatomic lesion, and it was concluded that this group of patients required aggressive radiologic investigation. Three main clinical presentations were identified: sudden severe flank pain, symptomless hypertension, and a palpable mass with few or no symptoms. The radiologic signs are reviewed with emphasis on a recently described sign of streaky retroperitoneal fat. Treatment is discussed briefly.

Refractory renal haemorrhage following low velocity penetrating trauma has conventionally been treated by nephrectomy or partial nephrectomy. Anatomical studies have demonstrated that the renal artery branches are end-arteries, each branch supplying a renal segment, with no collateral artery supply between segments. Lifethreatening haemorrhage is arterial, and usually issues from a single segmental artery easily demonstrable by renal angiography. Fourteen patients had various segmental arteries ligated to control haemorrhage. Associated visceral injuries were present in 4 patients. Preoperative selective renal arteriography was possible in 13 patients and demonstrated the bleeding site in all cases. Segmental dearterialization produced haemostasis in 12 of the 14 patients. One patient required nephrectomy and one patient ligation of a second segmental artery to control bleeding. All the patients survived the operative procedure. Supine renin levels were normal on the fourteenth postoperative day and no patient developed hypertension during the follow-up period of 9–24 months. Segmental renal dearterialization by open operation is a simple and effective technique of controlling refractory renal haemorrhage with maximum preservation of renal parenchyma.

Dysmorphic erythrocytes have been described in the urine sediment of patients with renal parenchymal bleeding. This study compares the prevalence of dysmorphic erythrocytes in 5,128 urine specimens with blood, erythrocytic, or fibrin casts, proteinuria, and significant numbers of exfoliated renal tubular cells (RTCs). Of the 510 samples containing pathologic casts, 15% had dysmorphic erythrocytes, 60% had proteinuria, 71% had RTCs, and 12% had no other urinalysis abnormality. Of the 186 samples containing dysmorphic erythrocytes, 55% had pathologic casts, 42% had proteinuria, 71% had RTCs, and 13% had no other abnormality. Renal hematuria can best be evaluated by examination of all four of these urinalysis abnormalities rather than using a single entity for diagnosis. Patients with urinalysis evidence of renal hematuria should be evaluated further for renal disease rather than lower urinary tract disorders.

Extracorporeal shock wave lithotripsy (ESWL) is an accepted method of treatment for renal calculi. Complications are rare, although most patients experience temporary hematuria. Shock waves generated by a spark plug in a tubless lithotripter administered to stones placed into the renal pelves of dogs, resulted in interstitial renal hemorrhage developing acutely, and interstitial fibroblastic reactions chronically. The latter were linear, and were in the cortex and/or medulla. They resulted from organisation of the interstitial hemorrhages. In addition interstitial nephritis was present and this could be the result of the surgery, the stones, preexisting infection or the ESWL. Other organs were intact, with the exception of a hematoma in the large bowel of one dog. Lithotripsy, in this dog model, produced a spectrum of kidney injury.

Eighteen consecutive patients with acute spontaneous perinephric hemorrhage were examined with computed tomography (CT) (n = 18), ultrasonography (US) (n = 15), and angiography (n = 9). Renal cell carcinoma was found in 10 patients; angiomyolipoma, three; and segmental renal infarction, arteriovenous malformation (AVM), hemorrhagic cyst, abscess, and idiopathic hemorrhage, one each. Initial CT examinations demonstrated the extent of hemorrhage in all cases and a distinct mass in 12 (67%), with CT characteristics suggestive of the correct diagnosis in 11. In the other six patients (33%), a discrete mass was not seen at initial CT, and in five cause of hemorrhage was not clear. Two of the five underwent follow-up CT, which correctly demonstrated carcinoma in both. Overall, CT findings suggested the correct diagnosis in 14 patients (78%). US was sensitive for detection of an abnormality but nonspecific as to its nature. Angiography demonstrated unsuspected AVM in one patient, segmental renal infarction seen at CT in one, but only one of five carcinomas suspected at CT. Data from this study suggest that CT is the most valuable examination for patients with spontaneous renal hemorrhage.

Transcatheter therapeutic arterial embolization was employed in 11 patients with gastrointestinal hemorrhage and 8 patients with bleeding from other sites. Hemorrhage was stopped successfully in all of the patients with gastrointestinal bleeding and 6 of the 7 patients with active bleeding from other sites. There were no significant complications or sequelae, although ischemia msy cause problems in such patients. Embolization is of considerable value when pharmacological therapy fails or is not appropriate due to the site of bleeding. In some cases it may represent the definitive treatment, as in pelvic trauma or renal hemorrhage; in others, embolization may serve to halt bleeding long enough to permit surgery. Therapeutic embolization should be considered whenever active extravasation of contrast material is demonstrated.

Two patients with acute bleeding from the kidney are reported.The hemorrhage followed percutaneous renal biopsy in one and partial nephrectomy in the other. In both cases the site of bleeding was identified by selective renal arteriography and confirmed by total nephrectomy.

ObjectiveTo estimate the incidence rates of kidney-related clinical outcomes among patients with tuberous sclerosis complex (TSC)-related angiomyolipoma (AML) compared to an age-matched control cohort in the United States.Materials and MethodsThis was a retrospective, observational study. Administrative data from the MarketScan Research Databases were used to select patients with TSC and renal AML. An age-matched group with no TSC or renal AML was identified for comparison. Outcomes were incidence rates per 100 patient-years and number of months to development of hematuria, chronic kidney disease, renal hemorrhage, kidney failure, and inpatient death.ResultsAmong the commercially insured TSC-renal AML patients (N = 605) and matched controls (N = 1815), 37.2% were

A case of stable blunt renal trauma is presented. The patient a 20-year-old pregnant woman, was heparinized and 2 days later developed severe renal bleeding. Her kidney returned to near normal with nonoperative measures. Care should be taken in the decision to heparinize such patients following renal trauma because of the possibility of delayed hemorrhage.