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      Post-Renal Biopsy Acute Kidney Injury and Page Kidney from Intra-Renal Hematoma Aggravated by Reversible Contrast-Induced Nephropathy Following Renal Arterial Embolization

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          Abstract

          Patient: Male, 73-year-old

          Final Diagnosis: Page kidney from intra-renal hematoma aggravated by reversible contrast-induced nephropathy following renal arterial embolization

          Symptoms: Flank pain • nausea • vomiting

          Medication: Apixaban

          Clinical Procedure: Kidney biopsy and subsequent renal arterial embolization

          Specialty: Nephrology

          Objective:

          Rare co-existance of disease or pathology

          Background:

          Page kidney was described by Dr. Irving Page in animal kidneys in 1939 with renal failure and persistent arterial hypertension from “cellophane perinephritis”. By 2009, about 100 cases of Page kidney had been reported. Bleeding complications after percutaneous kidney biopsy has, however, been well described. Moreover, the perioperative management of the recently introduced non-vitamin K antagonist anticoagulants (NOACs) remains uncertain due to inadequate evidence.

          Current guidelines to determine the appropriate duration of withholding NOACs before a surgical procedure, and when to restart NOACs safely after a procedure, however, cognizant of the implications of renal dysfunction, and levels of risk of the procedure are still unclear and sometimes conflicted.

          Case Report:

          We describe a case of Page kidney from an intrarenal hematoma complicating ultrasound-guided percutaneous right native kidney biopsy with acute kidney injury after withholding apixaban, a NOAC, for 3 days. Computed tomography evidence of continuing intrarenal bleeding from a renal pseudoaneurysm was treated with super-selective renal artery embolization; the case was further complicated by superimposed acute kidney injury from contrast-induced nephropathy.

          Conclusions:

          We reviewed the vagaries of Page kidney with respect to the presence, or otherwise, of hypertension and how to explain worsening renal failure despite only unilateral involvement of a single kidney in a patient with 2 kidneys. Furthermore, we revisit the risks of contrast-induced nephropathy following iodinated contrast exposure. We explored the alternative management options for a post-biopsy renal pseudoaneurysm, that would avoid the use of iodinated contrast that could have potentially mitigated, if not fully prevented, the ensuing contrast-induced acute kidney injury.

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          Most cited references 28

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          Risk factors for bleeding complications in percutaneous renal biopsy.

          Among the complications in percutaneous renal biopsy, bleeding is the most frequent and sometimes becomes fatal. We prospectively studied 394 consecutive percutaneous renal biopsies in 359 patients (male/female = 188/171). The mean age of the patients was 44.0 +/- 17.2 years. Percutaneous renal biopsies were performed on native kidneys under direct visualization by ultrasound, using an automated spring-loaded biopsy device and a 16-cm 18 G needle. The most common complication was hematoma (n = 149, 37.8%). "De novo macrohematuria" was observed in 29 patients (7.4%). Other complications included pain (n = 27, 6.9%), loss of blood (n = 17, 4.3%), and renal dysfunction (increase of serum creatinine more than 0.2 mg/dl, n = 9, 2.2%). Although there were no severe complications such as loss of blood requiring a blood transfusion, loss of kidney function, or death, 10 patients had an extended rest period in bed because of moderate complications. Hypertension and amyloidosis had significant influence on the complications. For those who are clinically suspected of having amyloidosis or hypertension, more careful biopsy procedures and observations are necessary.
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            Renal Functional Reserve and Renal Recovery after Acute Kidney Injury

             Aashish Sharma,  Marìa Jimena Mucino,  Claudio Ronco (corresponding) (2014)
            Renal functional reserve (RFR) represents the capacity of the kidney to increase glomerular filtration rate (GFR) in response to certain physiological or pathological stimuli or conditions. Once baseline GFR is determined, RFR can be assessed clinically after an oral protein load or intravenous amino acid infusion. In clinical practice, baseline GFR displays variable levels due to diet or other factors. RFR is the difference between peak ‘stress' GFR induced by the test (p.o. or i.v.) and the baseline GFR. In clinical scenarios where hyperfiltration is present (high baseline GFR due to pregnancy, hypertension or diabetic nephropathy, in solitary kidney or kidney donors), RFR may be fully or partially used to achieve normal or supranormal renal function. Since commonly used renal function markers, such as GFR, may remain within normal ranges until 50% of nephrons are lost or in patients with a single remnant kidney, the RFR test may represent a sensitive and early way to assess the functional decline in the kidney. RFR assessment may become an important tool to evaluate the ability of the kidney to recover completely or partially after a kidney attack. In case of healing with a defect and progressive fibrosis, recovery may appear complete clinically, but a reduced RFR may be a sign of a maladaptive repair or subclinical loss of renal mass. Thus, a reduction in RFR may represent the equivalent of renal frailty or susceptibility to insults. The main aim of this article is to review the concept of RFR, its utility in different clinical scenarios, and future perspective for its use.
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              Renal functional reserve in humans. Effect of protein intake on glomerular filtration rate.

              This study was designed to investigate the effect of protein intake on glomerular filtration rate, and to demonstrate and evaluate the functional reserve of the kidney. Normal subjects ingesting a protein diet had a significantly higher creatinine clearance than a comparable group of normal subjects ingesting a vegetarian diet. A progressive increment in protein intake in normal volunteers resulted in a significant increase in creatinine clearance. Diurnal variations in creatinine clearance were found. These daily variations correlated well with the periods of food intake. The capacity of the kidney to increase its level of function with protein intake suggests a renal function reserve. In short-term studies, the effect of a protein load on glomerular filtration rate was evaluated. Normal subjects showed an increase in glomerular filtration rate two and a half hours after protein load to a maximal glomerular filtration rate of 171.0 +/- 7.7 ml per minute. In patients with a reduced number of nephrons, renal functional reserve may be diminished or absent.
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                Author and article information

                Journal
                Am J Case Rep
                Am J Case Rep
                amjcaserep
                The American Journal of Case Reports
                International Scientific Literature, Inc.
                1941-5923
                2020
                22 January 2020
                : 21
                : e919701-1-e919701-5
                Affiliations
                Division of Nephrology, Department of Medicine, The Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, VT, U.S.A.
                Author notes

                Authors’ Contribution:

                [A]

                Study Design

                [B]

                Data Collection

                [C]

                Statistical Analysis

                [D]

                Data Interpretation

                [E]

                Manuscript Preparation

                [F]

                Literature Search

                [G]

                Funds Collection

                Conflict of interest: None declared

                Corresponding Author: Macaulay Amechi Chukwukadibia Onuigbo, e-mail: macaulay.onuigbo@ 123456uvmhealth.org
                Article
                919701
                10.12659/AJCR.919701
                6998796
                31964858
                © Am J Case Rep, 2020

                This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International ( CC BY-NC-ND 4.0)

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