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Spontaneous renal hemorrhage (SRH) is a diagnostic challenge and a significant cause of morbidity, and sometimes mortality. Early identification is essential to institute lifesaving and reno-protective interventions. In this review, we classify spontaneous renal hemorrhage by location, presentation and etiology. We also discuss the diagnostic approach to renal hemorrhage and optimum imaging modalities to arrive at the diagnosis. Finally, we review strategies to avoid missing a diagnosis of SRH and discuss the pitfalls of imaging in the presence of renal hemorrhage. [ABSTRACT FROM AUTHOR]

We describe a rare case of Wunderlich syndrome with bilateral renal hemorrhage in a patient under anticoagulant therapy for atrial fibrillation. An 84-year-old woman came to our department complaining of acute bilateral flank pain. Clinical and laboratory examinations revealed a condition of hypovolemic shock. An abdominal contrast-enhanced CT scan detected the presence of a bilateral hemorrhage affecting the peri- and para-renal spaces. Planning an appropriate management strategy considering the anticoagulated treatment required a multidisciplinary approach in the case of the Wunderlich syndrome diagnosis.

Background: To evaluate the safety and efficacy of percutaneous transcatheter super-selective renal arterial embolization (SRAE) with N-butyl cyanoacrylate (NBCA) for iatrogenic renal hemorrhage. Methods: Between January 2014 and December 2019, 45 patients (including 18 patients with coagulopathy), who underwent percutaneous transcatheter SRAE with NBCA for iatrogenic renal hemorrhage at our institution, were retrospectively reviewed. The technical success rate, clinical success rate, and embolization-related complications were analyzed. The values of estimated glomerular filtration rate (eGFR), serum creatinine (sCr), and serum urea (sUr) were analyzed at the time of pre-SRAE, post-SRAE, and last follow-up to evaluate the effects of NBCA-based SRAE on renal function. Results: Diagnostic renal arteriography revealed contrast extravasation in 18 patients and pseudoaneurysms in 27 patients. NBCA mixed with iodized oil in a 1:2–1:4 ratio was the sole embolic agent. No procedure-related mortality or major complications occurred. The technical and clinical success rates were both 100%. The values of eGFR, sCr and sUr were not found to be significantly different between pre-SRAE, post-SRAE and last follow-up (eGFR: 91.52 ​± ​21.17 vs. 90.98 ​± ​22.11 vs. 92.14 ​± ​23.51 ​mL/min/1.73 ​m2, p ​= ​0.729; sCr: 74.73 ​± ​11.08 vs. 75.27 ​± ​12.43 vs. 73.95 ​± ​10.14 ​μmol/L, p ​= ​0.543; sUr: 5.69 ​± ​0.84 vs. 5.71 ​± ​0.96 vs. 5.70 ​± ​0.79, p ​= ​0.515, respectively). Conclusions: Percutaneous transcatheter SRAE with NBCA is a safe and effective treatment modality for iatrogenic renal hemorrhage with no deterioration of renal function.

OBJECTIVE: Life-threatening renal hemorrhage after flexible ureterorenoscopy and laser lithotripsy (FURSL) is a rare complication. We aim to review our unit's experience with super-selective renal artery embolization as therapeutic options for such patients. METHODS: From January 2015 to November 2021, total 1125 patients underwent the FURSL procedures in our unit. Patients with life-threatening renal hemorrhage were reviewed and the information of peri-operative, operative and post-operative were recorded. RESULTS: Of the 1125 patients who underwent FURSL procedure, two patients with life-threatening renal hemorrhage were diagnosis; the age is 67 and 42 years old, respectively. Preoperative imaging examination showed that two patients had upper ureteral stone and renal stone ranging in size from 1.2 to 3.0 cm. Female patient placed the D-J stent for two weeks before FURSL. After the operation, both patients had the massive gross hematuria, significant drop of hemoglobin (Hgb), blood pressure lowering and needed to transfusion. CT scan showed that the male patient had an intrarenal hematoma. All these two were treated by super-selective renal artery embolization and had a successful outcome. CONCLUSION: Life-threatening renal hemorrhage after FURSL is a rare and severe complication. Super-selective renal artery embolization is a safe and effective method for the treatment of patients with severe renal hemorrhage, preserving healthy renal parenchyma and renal function. [ABSTRACT FROM AUTHOR]

Acquired hemophilia A (AHA) is characterized by the development of neutralizing autoantibodies, called "inhibitors," against intrinsic factor VIII. Its presentation differs profoundly from congenital hemophilia. Here, we present the case of a 69-year-old patient presenting with right-sided flank pain and hematuria, initially diagnosed with acute pyelonephritis, who was found to have bilateral renal hemorrhage during the course of his hospitalization. Later, after a thorough diagnostic evaluation, he was deemed to have AHA., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Ayoobkhan et al.)

Tanapoom Limtrakul,1 Ukrit Rompsaithong,1 Anucha Ahooja,2 Pakorn Kiatsopit,1 Supanut Lumbiganon,1 Kachit Pachirat,1 Wichien Sirithanaphol1 1Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 2Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, ThailandCorrespondence: Wichien SirithanapholDepartment of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, ThailandTel +66-43-363664Fax +66-43-202491Email wichsir@kku.ac.thBackground: Emergency renal artery embolization (RAE) is a useful method in treating renal trauma and bleeding renal tumors. The aim of this study was to evaluate the clinical efficacy and safety of emergency RAE, and factors associated with RAE failure.Methods: This retrospective study included patients treated with emergency RAE for acute renal hemorrhage between 1 January 2009 and 31 October 2019 in Srinagarind Hospital. The embolization was performed using coils, glues, and/or gel foams. Factors associated with unsuccessful outcomes were analyzed using univariate and multivariate regression analyses.Results: A total of 94 patients were treated at the center during the study period with the clinical success rate of 91.5%. The most common cause of acute renal hemorrhage was iatrogenic injury (76.5%). Factors associated with unsuccessful RAE according to multivariate analyses were hypertension (adjusted odds ratio [AOR] 24.2) and ruptured tumor/aneurysm (AOR 26.8).Conclusion: RAE is an effective procedure for acute renal hemorrhage. Hypertension and ruptured tumor/aneurysm were negative predictors for success.Keywords: renal artery embolization, renal trauma, renal hemorrhage, PCNL, kidney biopsy, renal tumor

The clinical outcomes of major bleeding events following ultrasound-guided native and allograft parenchymal renal biopsy were evaluated. Forty-eight bleeding complications after biopsy (Society of Interventional Radiology adverse event grade ≥ 2) from 2002 to 2018 were identified. The primary outcome assessed was renal function. The clinical outcomes and interventions performed, including blood transfusion, angiography with or without embolization, nephrostomy tube placement, surgery, nephrectomy, hospitalization, intensive care unit admission, dialysis, and survival, were noted. Renal function may be moderately diminished in the short-term periprocedural setting. None of the patients studied died or required nephrectomy or the initiation of dialysis as a result of a major bleeding complication after the renal biopsy. [ABSTRACT FROM AUTHOR]

Abstract Wunderlich syndrome, or spontaneous renal hemorrhage (SRH), is a rare condition encountered in patients undergoing chronic hemodialysis (HD) usually attributed to acquired cystic kidney disease (ACKD) among other causes. In the literature, colonoscopy is associated with splenic injuries, and renal hemorrhage has not been previously described. Management can range from conservative treatment to angiographic embolization or exploration and nephrectomy. Here we report an unusual case of a 54-year-old woman HD patient who presented with SRH within a few days of colonoscopy. The reason of SRH was rupture of an ACKD cyst. We assumed that colonoscopy was a provoking factor and elaborated hypotheses for its etiopathogenesis. The patient underwent successful left nephrectomy. The importance of this case lies in the fact that colonoscopy is not always an innocent procedure in HD patients, and could be complicated by renal cyst hemorrhage.

Hantaan virus (HTNV) infects humans and causes hemorrhagic fever with renal syndrome (HFRS). The development of well-characterized animal models of HFRS could accelerate the testing of vaccine candidates and therapeutic agents and provide a useful tool for studying the pathogenesis of HFRS. Because NLRC3 has multiple immunoregulatory roles, we investigated the susceptibility of Nlrc3−/− mice to HTNV infection in order to establish a new model of HFRS. Nlrc3−/− mice developed weight loss, renal hemorrhage, and tubule dilation after HTNV infection, recapitulating many clinical symptoms of human HFRS. Moreover, infected Nlrc3−/− mice showed higher viral loads in serum, spleen, and kidney than wild type C57BL/6 (WT) mice, and some of them manifested more hematological disorders and significant pathological changes within multiple organs than WT mice. Our results identify that HTNV infected Nlrc3−/− mice can develop clinical symptoms and pathological changes resembling patients with HFRS, suggesting a new model for studying the pathogenesis and testing of candidate vaccines and therapeutics.

Hantaan virus (HTNV) infects humans and causes hemorrhagic fever with renal syndrome (HFRS). The development of well-characterized animal models of HFRS could accelerate the testing of vaccine candidates and therapeutic agents and provide a useful tool for studying the pathogenesis of HFRS. Because NLRC3 has multiple immunoregulatory roles, we investigated the susceptibility of Nlrc3−/− mice to HTNV infection in order to establish a new model of HFRS. Nlrc3−/− mice developed weight loss, renal hemorrhage, and tubule dilation after HTNV infection, recapitulating many clinical symptoms of human HFRS. Moreover, infected Nlrc3−/− mice showed higher viral loads in serum, spleen, and kidney than wild type C57BL/6 (WT) mice, and some of them manifested more hematological disorders and significant pathological changes within multiple organs than WT mice. Our results identify that HTNV infected Nlrc3−/− mice can develop clinical symptoms and pathological changes resembling patients with HFRS, suggesting a new model for studying the pathogenesis and testing of candidate vaccines and therapeutics. [ABSTRACT FROM AUTHOR]

Abstract Background Thoracic endovascular aortic repair (TEVAR) is the therapeutic choice for type B aortic dissection. One of the most unfavored complications of this procedure is hemorrhage, which has a low incidence but high mortality. Renal hemorrhage (RH) after endovascular aortic repair has been rarely reported. We presented two cases of unexpected RH after TEVAR for complicated type B aortic dissection, and the potential causes, diagnosis and therapeutic management were discussed. Case presentation A 67-year-old female developed hypotension and progressively decrease of hemoglobin within 5 h after TEVAR for acute complicated type B dissection. Bedside ultrasonography and abdominal computed tomography angiography revealed a massive right perinephric hematoma. The right renal angiography detected multiple tortuous vascular branches with diffuse perinephric bleeding. The main trunk of right renal artery was embolized. The patient recovered uneventfully and presented with normal renal function 6 months later. Another patient was a 69-year-old male who was admitted for endovascular repair of a chronic complicated type B aortic dissection. The patient presented with hemodynamic instability early after TEVAR. Bedside ultrasonography showed a giant left retroperitoneal hematoma. The abdominal angiography revealed two active bleeding sits located in the distal branches of left renal artery. A super-selective embolization of the two arteries was performed, however the patient developed abdominal compartment syndrome and died of multiple organ failure. Conclusions Unexpected RH after endovascular repair of aortic dissection might be associated with iatrogenic and idiopathic factors. Close surveillance and clinician’s awareness of this rare complication is crucial for accurate and prompt diagnosis. Renal angiography and subsequent selective embolization of bleeding vessels are effective interventions for treating this fatal condition.

Superior soft-tissue contrast and high sensitivity of magnetic resonance imaging (MRI) for detecting and characterizing disease may provide an expanded role in acute abdominal and pelvic imaging. Although MRI has traditionally not been exploited in acute care settings, commonly used in biliary obstruction and during pregnancy, there are several conditions in which MRI can go above and beyond other modalities in diagnosis, characterization, and providing functional and prognostic information. In this manuscript, we highlight how MRI can help in further assessment and characterization of acute renal emergencies. Currently, renal emergencies are predominantly evaluated with ultrasound (US) or computed tomography (CT) scanning. US may be limited by various patient factors and technologist experience while CT imaging with intravenous contrast administration can further compromise renal function. With the advent of rapid, robust non-contrast MRI, and magnetic resonance angiography (MRA) imaging studies with short scan times, free-breathing techniques, and lack of ionization radiation, the utility of MRI for renal evaluation might be superior to CT not only in diagnosing an emergent renal process but also by providing functional and prognostic information. This review outlines the clinical manifestations and the key imaging findings for acute renal processes including acute renal infarction, hemorrhage, and renal obstruction, among other entities, to highlight the added value of MRI in evaluating the finer nuances in acute renal emergencies. [ABSTRACT FROM AUTHOR]

Traumatic injuries to the kidney and collecting system can range widely from small lacerations to significant bleeding and its sequelae. Urinary obstruction can occur in the renal pelvis, ureters, or urethra. Interventional radiology plays a significant role in treatment and management, in many cases requiring emergent action. Endovascular embolization is frequently the first-line approach to treating hemorrhage. Percutaneous interventions for urinary obstruction include nephrostomy and suprapubic catheter placement. In this article, we outline the clinical approach and interventional methods used in the evaluation and treatment of renal trauma. Several case presentations demonstrate the role of interventional radiology in renal trauma. [ABSTRACT FROM AUTHOR]

Abstract Embolization is a well-known and accepted form of treatment for bleeding caused by a multitude of renal procedures. We present a case of a 66-year-old woman who had a history of left nephrectomy for clear cell carcinoma seven years previously and now presented with a 6 cm tumor involving the solitary kidney. She underwent partial laparoscopic nephrectomy with removal of the tumor on the right kidney. In the immediate postoperative period she had important and persistent hematuria associated with tachycardia, hypotension, and lumbar pain. After showing signs of hemodynamic instability, she was taken to the catheter laboratory where selective angiography of the right kidney was performed. Superselective embolization with controlled release of fibrous microcoils was performed. The superselective renal embolization technique performed on an emergency basis to control hemorrhage after a urological procedure is effective and achieves lasting resolution of symptoms.

Objectives: Percutaneous renal biopsy (PRB) plays a critical role in the work-up of renal parenchymal disease. Although it is considered a low-risk procedure, additional interventions may be required in about 7% of the cases following biopsy. We purpose of this study was to identify risk factors for major hemorrhage by microscopic analysis of the cores obtained following PRB, with an intent to enhance the sensitivity and specificity of the risk stratification process, especially in patients undergoing this procedure in an outpatient setting. Material and Methods: A retrospective review identified 17 of 179 patients (9.50%) with major hemorrhage following PRB between July 2014 and June 2019. Using propensity score matching, 26 controls (without major hemorrhage) were matched to 17 cases (with major hemorrhage). We biopsy cores obtained from the cases and controls were analyzed by a single pathologist for medullary, cortical, total (medullary + cortical) lengths, and the number of arcuate arteries (AAs). Medullary:cortical (M:C), cortical:total (C:T), and medullary:total (M:T) length ratios were then calculated. Results: A stratified version of logistic regression was used to test for an association between each of the variables identified on the cores and the probability of a major hemorrhage. We analysis revealed that there was a statistically significant association between the number of AAs per specimen with the risk of major hemorrhage (P = 0.0006). When 0, 1, or >2 AAs were identified, the frequency of major hemorrhage was 13.04%, 66.67%, and 75.00%, respectively. We odds of major hemorrhage were 6 times higher with one AA and (95% CI, 1.28-32.30) and 15 times higher with >2 AAs (95% CI, 1.41-169.57). No significant association was found between medullary length (P = 0.228), medulla:cortex (M:C) (P = 0.089), medulla:total (M:T) (P = 0.108), or cortex:total (C:T) (P = 0.112) length ratios and major hemorrhage. Conclusion: Were was a strong and incremental correlation between major renal hemorrhage following PRB and the number of AAs per core specimen. Identification of AAs by the pathologist, while assessing for sample adequacy, in the US suite can help predict major hemorrhage in patients undergoing PRBs. [ABSTRACT FROM AUTHOR]

Embolization is a well-known and accepted form of treatment for bleeding caused by a multitude of renal procedures. We present a case of a 66-year-old woman who had a history of left nephrectomy for clear cell carcinoma seven years previously and now presented with a 6 cm tumor involving the solitary kidney. She underwent partial laparoscopic nephrectomy with removal of the tumor on the right kidney. In the immediate postoperative period she had important and persistent hematuria associated with tachycardia, hypotension, and lumbar pain. After showing signs of hemodynamic instability, she was taken to the catheter laboratory where selective angiography of the right kidney was performed. Superselective embolization with controlled release of fibrous microcoils was performed. The superselective renal embolization technique performed on an emergency basis to control hemorrhage after a urological procedure is effective and achieves lasting resolution of symptoms. [ABSTRACT FROM AUTHOR]

Wunderlich syndrome (WS) is an uncommon cause of flank pain wherein spontaneous bleeding occurs into the subcapsular and perirenal spaces of the kidney. İt is most commonly attributed to renal tumors, especially angiomyolipomas. We report a case of a patient who presented to an emergency department (ED) with flank pain and symptoms of hemodynamic instability; radiologic imaging led to the diagnosis of WS. The patient’s condition was managed conservatively first; then, selective embolization was performed. For patients who present to ED with flank pain and negative hematuria, an important diagnosis that can be fatal, if not recognized early, is WS. İt is classically presented with acute flank pain, flank mass, and hypovolemic shock, together known as Lenk’s triad. İt can be fatal if not recognized and managed early, and radiological confirmation is required for accurate diagnosis.Therefore, physicians in ED should keep this syndrome in mind to prevent misdiagnosis (for e.g., as renal colic pain); and thereby the mortality.

Background: This study aims to investigate the correlation between computed tomography (CT) and digital subtraction angiography (DSA) findings in patients affected by acute post-traumatic intraparenchymal renal hemorrhages and evaluate their conservative management with superselective embolization. Methods: This retrospective multicenter analysis focuses on patients affected by renal bleedings detected by contrast-enhanced CT and treated with superselective endovascular embolization. CT findings were compared to DSA. Embolization procedural data were analyzed and renal function was evaluated before and after the intervention. Results: Twenty-seven patients were retrospectively evaluated in one year. Compared to DSA, CT showed 96.3% diagnostic accuracy in terms of hemorrhage recognition; concerning the type of vascular lesion, there was discrepancy between CT and DSA in five cases. The technical success rate of embolization was 100%, while primary clinical success was 88.9%. The inferior parenchymal third was the most frequent site of renal injury. Microcoils were the most adopted embolics. Renal function did not change significantly before and after embolization. Conclusions: CT has elevated diagnostic accuracy in detecting post-traumatic intraparenchymal renal hemorrhages; in a small percentage, the type of vascular lesion may differ from the findings observed at DSA. In this scenario, superselective embolization presents high clinical success with a low complication rate.

Wunderlich syndrome is a rarely entity. We report our case of a 60-year-old female, who presented in the emergency medicine department with acute right flank pain, tender mass right upper quadrant abdomen, hypotension, and visible hematuria. Urgent computerized tomogram confirmed bleeding in the right renal angiomyolipoma. Selective angioembolization was done. The patient recovered and was sent home after 1 week. On follow-up after 1 month, she is doing fine, and on ultrasound, AML had interval decrease in size.

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The overall rate of major bleeding in patients with atrial fibrillation receiving warfarin therapy is approximately 4%. Among these 4% patients, spontaneous retroperitoneal hemorrhage (SRH) is a rare but potentially lethal complication with a nonspecific presentation that can lead to missed or delayed diagnosis. The current literature provides little direction for diagnosis and management of such cases. Anticoagulation-related SRH is associated with a high mortality rate (approximately 20%). Despite the vague presentation, prompt diagnosis is crucial to reverse the anticoagulation and prevent further bleeding. Contrast-enhanced computed tomography (CT) of the abdomen is the imaging modality of choice in suspected cases. Patients with SRH require aggressive treatment with blood transfusions, interventional radiological procedures, percutaneous drainage or surgical evacuation of the hematoma. We report a case of warfarin-induced SRH from the renal vein in a patient who presented to our emergency department with acute, nonspecific abdominal pain and shock. We diagnosed the patient with warfarin-induced SRH on the basis of clinical suspicion and characteristic CT findings. We initially treated the patient conservatively, followed by embolization of the right renal artery during the late course of hospital stay, and he was discharged with good recovery. SRH should be considered in the differential diagnosis of abdominal pain, hypotension, and/or decreased hemoglobin levels in patients receiving anticoagulation therapy, especially in those with preexisting end-stage renal disease. [ABSTRACT FROM AUTHOR]

Background: Thoracic endovascular aortic repair (TEVAR) is the therapeutic choice for type B aortic dissection. One of the most unfavored complications of this procedure is hemorrhage, which has a low incidence but high mortality. Renal hemorrhage (RH) after endovascular aortic repair has been rarely reported. We presented two cases of unexpected RH after TEVAR for complicated type B aortic dissection, and the potential causes, diagnosis and therapeutic management were discussed.Case Presentation: A 67-year-old female developed hypotension and progressively decrease of hemoglobin within 5 h after TEVAR for acute complicated type B dissection. Bedside ultrasonography and abdominal computed tomography angiography revealed a massive right perinephric hematoma. The right renal angiography detected multiple tortuous vascular branches with diffuse perinephric bleeding. The main trunk of right renal artery was embolized. The patient recovered uneventfully and presented with normal renal function 6 months later. Another patient was a 69-year-old male who was admitted for endovascular repair of a chronic complicated type B aortic dissection. The patient presented with hemodynamic instability early after TEVAR. Bedside ultrasonography showed a giant left retroperitoneal hematoma. The abdominal angiography revealed two active bleeding sits located in the distal branches of left renal artery. A super-selective embolization of the two arteries was performed, however the patient developed abdominal compartment syndrome and died of multiple organ failure.Conclusions: Unexpected RH after endovascular repair of aortic dissection might be associated with iatrogenic and idiopathic factors. Close surveillance and clinician's awareness of this rare complication is crucial for accurate and prompt diagnosis. Renal angiography and subsequent selective embolization of bleeding vessels are effective interventions for treating this fatal condition. [ABSTRACT FROM AUTHOR]

Background: Hemorrhagic fever with renal syndrome (HFRS) caused by hantavirus infection is characterized by fever, renal dysfunction and hemorrhage. An animal model mimicking symptoms of HFRS remains to be established. In this study, we evaluated the pathogenicity of an HFRS patient-derived Hantaan virus (HTNV) in adult mice. Methods: Five clones of HTNV strain KHF 83-61 BL (KHFV) that was derived from blood of an HFRS patient were obtained by plaque cloning. The pathogenicity of the virus clones was evaluated by using 6-week-old female BALB/c mice. Sequence analysis of the viral genome was performed by conventional methods. Results: All of the mice intravenously inoculated with KHFV clone (cl)-1, -2, -3 and -5 showed signs of disease such as transient body weight loss, ruffled fur, reduced activity and remarkably prominent hemorrhage in the renal medulla at 6 to 9 days post-inoculation (dpi) and then recovered. In contrast, mice intravenously inoculated with KHFV cl-4 did not show any signs of disease. We selected KHFV cl-5 and cl-4 as representative of high-pathogenic and lowpathogenic clones, respectively. Quantities of viral RNA in kidneys of KHFV cl-5-infected mice were larger than those in KHFV cl-4-infected mice at any time point examined (3, 6, 9 and 12 dpi). The quantities of viral RNA of KHFV cl-5 and cl-4 peaked at 3 dpi, which was before the onset of disease. Sequence analysis revealed that the amino acid at position 417 in the glycoprotein Gn was the sole difference in viral proteins between KHFV cl-5 and cl-4. The result suggests that amino acid at position 417 in Gn is related to the difference in pathogenicity between KHFV cl-5 and cl-4. When the inoculum of KHFV cl-5 was pretreated with a neutralizing antibody against HTNV strain 76-118, which belongs to the same serotype as KHFV clones, mice did not show any signs of disease, confirming that the disease was caused by KHFV infection. Conclusion: We found that an HFRS patient-derived HTNV caused renal hemorrhage in adult mice. We anticipate that this infection model will be a valuable tool for understanding the pathogenesis of HFRS. [ABSTRACT FROM AUTHOR]