Spontaneous renal subcapsular haematoma and acute renal failure complicated by severe pre-eclampsia

Sik Lee1, Sung Kwang Park1, Gong Yong Jin2, Jong Heon Kim3, Sung Nam Cho3, Sung Kyew Kang1 and Won Kim1

1 Department of Internal Medicine 2 Department of Radiology 3 Department of Obstetrics and Gynecology and Institute for Clinical Sciences, Chonbuk National University, Medical School, Chonju, South Korea. Email: kwon{at}moak.chonbuk.ac.kr

Sir,

Spontaneous renal subcapsular haematoma is rare and seldom suspected clinically. The characteristic clinical features are abdominal pain, a mass in the flank and signs of internal bleeding. The known causes of spontaneous renal subcapsular haematoma are tumours, vascular diseases, infectious diseases, severe pre-eclampsia and blood dyscrasias [1,2]. Because renal function is decreased in spontaneous renal subcapsular haematoma, early clinical awareness, appropriate investigation and management may be life saving.

Case. A 27-year-old pregnant woman was admitted with complaints of generalized oedema, high blood pressure and headaches. The menstrual age was 34 weeks 5 days. She denied any trauma or drug use. She had no history of bleeding tendency, hypertension, renal disease or easy bruising. On admission, her blood pressure was 170/130 mmHg. Her haemoglobin level was 10.3 g/dl. Urinalysis showed protein 3+. Her renal and hepatic functions were all within the normal range. On the second day, an obstetric examination revealed decreased fetal heartbeats and movements. She complained of blurred vision. An ophthalmological examination showed mild detachment of the retinas. An emergent Caesarean section was performed. On the third post-operative day, her urine amount decreased. Serum creatinine was 4.2 mg/dl. Her blood pressure continued to be >150/100 mmHg despite the Caesarean section. On the next day, she presented with sudden onset of severe left flank pain. Physical examination disclosed marked tenderness and guarding in the left flank. Her haemoglobin level decreased to 7.9 g/dl. An abdominal sonography showed increased size of ~13 cm and heterogeneous echogenicity in the entire left kidney. A non-contrast abdominal computerized tomography (CT) revealed a crescentric hyperdense lesion in the subcapsular area of the left kidney. The parenchyma of the left kidney was compressed. Four days later, a follow-up abdominal magnetic resonance imaging (MRI) demonstrated subcapsular lesions of the right kidney in addition to left kidney. T1-weighted image showed heterogeneous low signal intensity and T2-weighted image revealed heterogeneous high signal intensity (Figure 1Go). The renal parenchyma was extremely compressed. Because the patient's haemodynamic status was stable and flank pain subsided gradually, we treated her conservatively. Her renal function (serum creatinine 1.4 mg/dl) and haematoma have improved.



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Fig. 1.  Abdominal MRI demonstrated subcapsular lesions of the right kidney in addition to the left kidney. T2-weighted image revealed heterogeneous high signal intensity.

 
Comment. Hepatic haematoma is often accompanied by severe pre-eclampsia. But, an isolated spontaneous renal subcapsular haematoma without hepatic haematoma is extremely rare. The suggested treatment of spontaneous renal haematoma is nephrectomy if the underlying cause is a tumour or if there is persistent bleeding and the patient is in an unstable condition. However, follow-up radiologic evaluation and conservative treatment may prevent unnecessary nephrectomy in stable patients. Our case is the first report to reveal an isolated renal haematoma and acute renal failure, which were treated conservatively, after a Caesarean section associated with severe pre-eclampsia. We believe that the major causes of haematoma in this case were uraemia and intractable hypertension after delivery. It is very important to control blood pressure after an emergent laparotomy and Caesarean section associated with severe pre-eclampsia. Plus, the possibility of a renal haematoma should be considered when a patient with severe pre-eclampsia presents the characteristic clinical features of abdominal pain, a mass in the flank and signs of internal bleeding.

References

  1. Elimelech Z, Ines M, Daniel E et al. Spontaneous perinephric hemorrhage in a middle-aged diabetic woman. J Urol1994; 151:977–979[ISI][Medline]
  2. Jun EJ, Kim YO, Lim SJ et al. Spontaneous renal subcapsular hematoma in a patient with severe preeclampsia. Nephron2000; 86:515–516[CrossRef][ISI][Medline]




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