Chapter 28-14: Thromboembolism of the Renal Arteries

TEXTBOOK PRESENTATION

Most patients have flank pain, often with hematuria or anuria.

DISEASE HIGHLIGHTS

1. Clinical features depend on severity and location of emboli.

2. Bilateral emboli or emboli to a solitary kidney more likely to produce AKI and anuria.

3. 75% of patients have abdominal or flank pain.

4. Variably see nausea, vomiting, hematuria

5. Fever and hypertension are common, but fever is often delayed until second or third day.

6. Sources of emboli

   1. Cardiac: atrial fibrillation, myocardial infarction, rheumatic valvular disease, prosthetic valves, subacute bacterial endocarditis

   2. Aortic or renal aneurysms

   3. Intra-arterial catheterization

EVIDENCE-BASED DIAGNOSIS

1. Diagnosed at onset of symptoms in only 30% of patients

2. Usually have leukocytosis, increased lactate dehydrogenase (LD) and transaminases; the LD is increased more than the transaminases.

3. Alkaline phosphatase elevated in 30–50% of patients.

4. Angiography is gold standard for diagnosis; infused CT can be diagnostic.

TREATMENT

1. Unilateral embolism and normal contralateral kidney: streptokinase and/or angioplasty, followed by anticoagulation; no indication for surgery

2. Bilateral emboli, or embolus to solitary kidney: same as above, but try surgical reconstruction if cannot restore blood flow