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| Year : 2007 | Volume
: 18
| Issue : 3 | Page : 426-429 |
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| Renal Tamponade Secondary to Subcapsular Hematoma |
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Nasrulla Abutaleb1, Abdulmunaem Obaideen2
1 Department of Nephrology, North West Armed Hospital, Tabuk, Saudi Arabia
2 Department of Radiology, North West Armed Hospital, Tabuk, Saudi Arabia
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 Abstract | | |
We report the occurrence of renal biopsy induced subcapsular (SC) hematoma in two patients. The first was a recently transplanted elderly man, while the second was a woman with class IV lupus nephritis. Though hematoma size was initially small, early significant renal dysfunction was noted in both patients followed by eventual recovery of renal function in both patients; the first recovered within one day, while the second case within 10 days. Keywords: Acute Renal Failure, Anuria, Hematoma, Tamponade, Biopsy, Transplantation
How to cite this article:
Abutaleb N, Obaideen A. Renal Tamponade Secondary to Subcapsular Hematoma. Saudi J Kidney Dis Transpl 2007;18:426-9 |
| Introduction | |  |
Anuria secondary to SC hematoma in patients with solitary kidneys including renal transplant patients was reported in a few reports. [2],[3],[4] We report the occurrence of renal biopsy induced subcapsular (SC) hematoma in two patients. The first was a recently transplanted elderly patient. Though hematoma size was initially small, early significant renal dysfunction was noted in both patients.
| Case report 1 | | |
A 65-year-old ESRD patient received a living unrelated renal transplant (LUR) with later rise of serum Cr (creatinine). The patient had a history of congestive heart failure (CHF), mitral valve disease and atrial fibrillation (AF). Renal Biopsy (one core) was obtained through a single ultrasound (U/S) guided pass, utilizing an 18 gauge needle and an automated Biopty gun. The patient did not receive any antiplatelet drugs or heparin prior to the biopsy. He developed anuria after the procedure for no obvious reasons. U/S performed six hours later revealed a one cm SC hematoma with no evidence of urinary tract obstruction. A renal scan confirmed the presence of renal perfusion. Anuria resolved spontaneously about 12 hours later, and urine output increased to a rate of > 100ml/ hour. However, the renal function tests did not improve. Within 36 hours, the patient became oliguric again. Follow up U/S two days later revealed a resistive index (RI) value of > 1.0 with a stable hematoma size. The renal biopsy revealed good renal tissue with no specific pathological findings. The patient developed severe bilateral broncho-pneumonia early after his admission. The oligoanuria persisted and the pneumonia became exacerbated. The patient was maintained on regular hemodialysis. One week later, the repeat of U/S demonstrated expansion of the SC hematoma to 2 cm [Figure - 1]A, which was confirmed by a nonenhanced computerized tomography (NECT) scan [Figure - 1]B. However, the R.I measured with U/S improved to 0.81. Meanwhile, the patient condition deteriorated and mechanical ventilation was initiated. Later, septicemia with multi-drug resistant acinobacter complicated the patient's condition and immunosuppressive therapy was withdrawn. Despite the use of colistin, antibiotic used for multidrug resistant acinobacter, the condition progressed over a week later into a resistant shock that ended with the patient's death.
| Case Report 2 | | |
A 21-year-old female patient with lupus nephritis class IV on mycophenolate mefotil (MMF) maintenance therapy was admitted for evaluation of recent deterioration of renal function with increased serum creatinine (S.Cr) to 140-150 µmol/L. S. Cr increased to 170 µmol/l, prior to renal biopsy, despite the initiation of IV pulse methylprednisolone (1 gm IV QD) on admission. Renal biopsy was performed (two cores obtained) utilizing an 18 G Biopty needle and a biopty gun with U/S guidance. The patient did not receive any antiplatelet drugs or heparin prior to the biopsy. Follow-up U/S three days later to investigate a significant decrease of hemoglobin revealed a SC hematoma. Post biopsy, the patient received subcutaneous prophylactic heparin that was discontinued immediately after the U/S findings. Over the following two weeks, the patient was transfused four units of packed red blood cells in addition to platelet transfusion. Meanwhile, the patient was treated additionally with IV pulse cyclophosphamide and a course of plasma exchange sessions. The renal biopsy revealed Class IV lupus nephritis with superimposed severe crescentic glomerulonephritis; Chronic changes were significant. We contemplated surgical drainage of the hematoma with the continued rise of S.Cr that peaked to 280 µmol/L within five days post biopsy. However, the thrombocytopenia that developed discouraged us from draining the hematoma. Later, renal function recovered on conservative management over two months, and a S.Cr value of 110 µmol/L was attained again. However, the SC hematoma remained with significant dimensions on U/S at the same time [Figure - 2]. Surgical drainage was then sought again but disproved by surgical colleagues. A renal scan performed 10 weeks post biopsy revealed the contribution of the Lt. Kidney to 35% of the total renal function.
| Discussion | | |
Murty et al [1] reported an incidence of SCH in 10.7% of their renal biopsies, probably because of an active search for the problem. The reported cases are the only clinically evident cases out of 400 procedures performed in our institute. Many symptomless cases could have been missed.
In the first case, anuria could be explained by the pressure effect on the kidney exerted by the hematoma contained within the renal capsule that seems severe initially and out of proportion to its size. The picture may be analogous to pericardial effusion and cardiac tamponade. Uremic patients may arrest because of a cardiac tamponade of 1.5 cm in diameter, while they tolerate huge chronic pericardial effusions. The rate of accumulation is a deciding factor for the tamponade effect. It is for this similarity that the term 'renal tamponade' is being quoted in this article. Recovery in urine output and improvement of R.I were observed despite the increase in size of the SC hematoma.
The 'renal tamponade' effect was difficult to assess in the second case in the presence of a functioning contralateral kidney. Conceivably, the rise of S.Cr value in the post biopsy period was related to the temporary loss in the function of the biopsied kidney. Obviously, this effect might have been more difficult to notice in patients with lower baseline S.Cr values. A renal scan proven recovery of the renal function of the biopsied kidney is consistent with the 'renal tamponade' effect that resolved prior to notable absorption of the hematoma.
Rea et al considered SC hematomas of < 2 cm as insignificant, [5] while Rea et al [4] indicated that the size of hematoma on the renal capsule could be out of proportion to its effect on renal function. Prior thickening of the perinephric capsule could predispose the significant effect of small hematomas.
The management of SC hematomas presented in this report was conservative. However, it seems very appropriate in many occasions, especially in patients with solitary kidneys, to consider surgical drainage. Bakri et al [6] reported prompt recovery of urine output, hypertension and renal function upon surgical intervention for SC hematomas (400 to 600 ml drained) in three cases of solitary kidneys, two of which were in renal grafts post biopsy.
Possible long term effects of undrained SC hematomas have been also reported. [7] Guilherme H et al [8] reported the development of systemic hypertension as a result of direct renal compression by a subcapsular calcified hematoma. Decapsulation with resection of the hematoma resulted in complete normalization of BP within a week after surgery. One year follow-up confirmed the persistence of a normotensive state without the use of antihypertensive medication.
In summary, early tamponade like effect of SC hematomas can be observed with small size hematomas of one cm width. Later spontaneous recovery develops usually but may not be complete. A more aggressive attitude toward draining SC hematomas may be warranted if the renal dysfunction persists. Long term complications such as hypertension may occur.
| References | | |
| 1. | Murty MS. Should we be doing renal graft biopsy without ultrasound guidance?, Indian J Nephrol 2002;12: 25-6.  |
| 2. | Pastural M, Mycoplasma hominis infection in renal transplantation, Nephrol Dial Transplant 2002;17:495-6. |
| 3. | Figueroa TE, Frentz GD. Anuria secondary to percutaneous needle biopsy of a transplant kidney: a case report. J Urol 1988;140(2):355-6. |
| 4. | Lee S, Partk SK, Jin GY, et al. Spontaneous renal subcapsular haematoma and acute renal failure complicated by severe pre-eclampsia. Nephrol Dial Transplant 2003;18:625-6. |
| 5. | Rea R, Anderson K, Mitchell D, Harper S, Williams T. Subcapsular haematoma: a cause of post biopsy oliguria in renal allograft. Nephrol Dial Transplant 2000; 15:1104-5. [PUBMED] [FULLTEXT] |
| 6. | Bakri RS, Prime M, Haydar A, Glass J, Goldsmith DJ. Three 'Pages' in a chapter of accidents. Nephrol Dial Transplant 2003;18:1917-9. [PUBMED] [FULLTEXT] |
| 7. | Tuvell et al, Traumatic Renal Transplant Subcapsular Hematoma: Diagnosis by Douplex Ultrasound, Journal for Vascular Ultrasound, Volume 29, Number 1, March 2005, pp. 39-41. |
| 8. | Guilherme H et al, Residents' Clinic: 23Year-Old Man With Hypertension and Flank Trauma, Mayo Clin Proc. 2002;77:1229-1232. |
Correspondence Address:
Nasrulla Abutaleb
King Fahad Specialist Hospital, P.O. Box 15215, Dammam-31444
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 17679758 
[Figure - 1], [Figure - 2] |
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