今日の臨床サポート

腎梗塞

著者: 伊藤千春1) 真岡メディカルクリニック

著者: 長田太助2) 自治医科大学 腎臓内科学

監修: 岡田浩一 埼玉医科大学 腎臓内科

著者校正済:2022/11/09
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 腎動脈塞栓症・腎梗塞の症例では、最初に心房細動が基礎疾患であることを疑う(推奨度1)
  1. 腎梗塞の診断のとき血尿がなくとも否定はできない(推奨度1)
  1. 腎動脈塞栓症の画像診断の第1選択は造影CTである(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
伊藤千春 : 特に申告事項無し[2022年]
長田太助 : 特に申告事項無し[2022年]
監修:岡田浩一 : 講演料(アストラゼネカ,協和キリン,第一三共,田辺三菱製薬,鳥居薬品),研究費・助成金など(協和キリン),奨学(奨励)寄付など(中外製薬,協和キリン,小野薬品工業,バイエル薬品)[2022年]

改訂のポイント:
  1. 最近発表された臨床検討の報告と、本症のシステマティック・レビューの結果を表記した。
  1. 本症に特徴的なCT所見を記載した。
  1. Covid-19と腎移植例での本症合併について加筆を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腎梗塞は、腎動脈主幹部もしくはその分枝が何らかの原因により閉塞し、虚血・低酸素により腎組織が傷害を受ける疾患である。
  1. 腎梗塞の頻度は、新規入院あるいは入院中症例の0.0016~0.003%[1][2]、救急外来受診者の0.007~0.013%[2][3]、側腹部痛を訴える患者の1.8%と報告されている[4]。発症者の年齢は60歳程度で、やや男性に多い(60%程度)。塞栓による腎梗塞は、左側が右側より多い報告もあるが、確定的ではない。凝固能亢進が原因となる場合、両側性に起こることが多い。
  1. 腎梗塞の病因は大きく、心および血管原性(心房細動、心弁膜症、虚血性心疾患、動脈粥腫由来血栓)、腎動脈障害性(腎動脈狭窄症、腎動脈解離、線維筋性異形成)、凝固能亢進(遺伝性血栓症、高ホモシスチン血症、抗リン脂質抗体症候群)、特発性に分けられる[5]。既往歴・心血管合併症など臨床的背景を把握することが、原因同定には重要である。本邦での報告も散見されるが、世界的にcovid-19での報告が多くなっている[6]。その治療過程で血管侵襲性の高いムコール症を合併し、本症を発症している例も散見される。外傷やコカインによる血管攣縮も一因となる。
  1. 心および血管原性は全体の45%、腎動脈障害性は16%、凝固能亢進は9%で、心および血管原性のうち、心房細動は76%程度である[7]
  1. 急激な側腹部痛、背部痛、悪心嘔吐などを訴える場合から無症状までさまざまであるが、早期診断・早期治療が重要であるため、リスクファクターを有し、尿所見や血液検査で本疾患の可能性がある場合、必ず鑑別診断に入れる必要がある[8][9]
  1. これまでの報告では、診断まで数日かかる例も散見され、可及的早期に造影CT、待機的とはあるが、MRI、腎動態シンチグラフィ(レノグラム)などの画像検査を施行して、確定診断を目指す[10][11]。Hazonavらは89例の腎梗塞例で、入院時の正診率は33%であり、48%が診断までに48時間以上経過していたと報告している[9]
問診・診察のポイント  
高頻度に認められる症状:[8][9][12]
  1. 急激な側腹部・腹部・背部痛とそれに伴う悪心・嘔吐・発熱

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文献 

Tasuku Nagasawa, Ken Matsuda, Yoichi Takeuchi, Hirotaka Fukami, Hiroyuki Sato, Ayako Saito, Yoichiro Chikamatsu, Yasumichi Kinoshita
A case series of acute renal infarction at a single center in Japan.
Clin Exp Nephrol. 2016 Jun;20(3):411-5. doi: 10.1007/s10157-015-1168-1. Epub 2015 Sep 16.
Abstract/Text BACKGROUND: The prevalence of acute renal infarction (ARI) in Japan remains unclear. We describe the clinical features and renal prognosis of ARI in Japanese patients.
METHODS: This single-center, retrospective, observational study included 33 patients with newly diagnosed ARI (2009-2013). Their clinical features and long-term renal outcomes were evaluated.
RESULTS: The prevalence of ARI among emergency room patients was 0.013 %. The incidence of ARI among in-patients was 0.003 % (mean age 71.9 ± 13.4 years; men 63 %). Enhanced computed tomography or renal isotope scans were obtained to diagnose ARI. ARI involved the left kidney in 70 %, right kidney in 18 %, and both kidneys in 12 % of patients. Four cases had splenic infarction, and 70 % of patients had atrial fibrillation. We noted abdominal or flank pain in 66 %, fever (>37.6 °C) in 36 %, and nausea/vomiting in 6 % of patients. The white blood cell count, and levels of lactate dehydrogenase and C-reactive protein peaked at 2-4 days after onset. Acute kidney injury due to ARI occurred in 76 % of patients. The estimated glomerular filtration rate decreased to ~70 % and recovered to ~80 % of the original value after 1 year. The mortality rates were 9 and 15 % at 1 month and 1 year, respectively.
CONCLUSIONS: We determined the prevalence of ARI among emergency room patients, its incidence among in-patients, and short-term and long-term mortality. The majority of ARI cases were of cardiac origin, and the others were due to trauma or systemic thrombotic disease. Clinicians should recognize ARI as a fatal arterial thrombotic disease.

PMID 26377692
H Domanovits, M Paulis, M Nikfardjam, G Meron, I Kürkciyan, A A Bankier, A N Laggner
Acute renal infarction. Clinical characteristics of 17 patients.
Medicine (Baltimore). 1999 Nov;78(6):386-94.
Abstract/Text We analyzed the medical records of patients with an established diagnosis of acute renal infarction to identify predictive parameters of this rare disease. Seventeen patients (8 male) who were admitted to our emergency department between May 1994 and January 1998 were diagnosed by contrast-enhanced computed tomography (CT) as having acute renal infarction (0.007% of all patients). We screened the records of the 17 patients for a history with increased risk for thromboembolism, clinical symptoms, and urine and blood laboratory results known to be associated with acute renal infarction. A history with increased risk for thromboembolism with 1 or more risk factors was found in 14 of 17 patients (82%); risk factors were atrial fibrillation (n = 11), previous embolism (n = 6), mitral stenosis (n = 6), hypertension (n = 9), and ischemic cardiac disease (n = 7). All patients reported persisting pain predominantly from the flank (n = 11), abdomen (n = 4), and lower back (n = 2). On admission, elevated serum lactate dehydrogenase was found in 16 (94%) patients, and hematuria was found in 12 (71%) of 17 patients. After 24 hours all patients showed an elevated serum lactate dehydrogenase, and 14 (82%) had a positive test for hematuria. Our findings suggest that in all patients presenting with the triad--high risk of a thromboembolic event, persisting flank/abdominal/lower back pain, elevated serum levels of lactate dehydrogenase and/or hematuria within 24 hours after pain onset--contrast-enhanced CT should be performed as soon as possible to rule out or to prove acute renal infarction.

PMID 10575421
Sangun Nah, Sangsoo Han, Han Bit Kim, Sohyeon Chun, Sechan Kim, Seungho Woo, Ji Eun Moon, Young Soon Cho
Predictors of renal infarction in patients presenting to the emergency department with flank pain: A retrospective observational study.
PLoS One. 2021;16(12):e0261054. doi: 10.1371/journal.pone.0261054. Epub 2021 Dec 7.
Abstract/Text OBJECTIVES: Flank pain is a common symptom in the emergency department and can be caused by a variety of diseases. Renal infarction (RI) is a very rare disease, and many RI patients complain of flank pain. However, there is no definitive predictor of RI when patients complain of flank pain. This study aimed to identify the clinical factors for predicting RI in patients with flank pain.
METHODS: This retrospective single-center study was conducted on patients complaining of flank pain from January 2016 to March 2020 at a South Korean tertiary care hospital. Exclusion criteria included patients who did not undergo contrast-enhanced computed tomography, age < 18 years, and trauma. Demographic and laboratory data were obtained from medical records. Logistic regression analysis was conducted to identify predictors of RI occurrence.
RESULTS: In all, 2,131 patients were enrolled, and 39 (1.8%) had RI. From a multivariable logistic regression analysis, an age ≥ 65 years (odds ratio [OR], 3.249; 95% confidence interval [CI], 1.366-7.725; p = 0.008), male sex (OR, 2.846; 95% CI, 1.190-6.808; p = 0.019), atrial fibrillation (OR, 10.386; 95% CI, 3.724-28.961; p < 0.001), current smoker (OR, 10.022; 95% CI, 4.565-22.001; p < 0.001), and no hematuria (OR, 0.267; 95% CI, 0.114-0.628; p = 0.002) were significantly associated with the occurrence of RI.
CONCLUSIONS: Five clinical factors, i.e., age ≥ 65 years, male sex, atrial fibrillation, current smoker, and no hematuria, were significantly associated with the occurrence of RI in patients with flank pain.

PMID 34874969
Yun Kuy Oh, Chul Woo Yang, Yong-Lim Kim, Shin-Wook Kang, Cheol Whee Park, Yon Su Kim, Eun Young Lee, Byoung Geun Han, Sang Ho Lee, Su-Hyun Kim, Hajeong Lee, Chun Soo Lim
Clinical Characteristics and Outcomes of Renal Infarction.
Am J Kidney Dis. 2016 Feb;67(2):243-50. doi: 10.1053/j.ajkd.2015.09.019. Epub 2015 Nov 4.
Abstract/Text BACKGROUND: Renal infarction is a rare condition resulting from an acute disruption of renal blood flow, and the cause and outcome of renal infarction are not well established.
STUDY DESIGN: Case series.
SETTING & PARTICIPANTS: 438 patients with renal infarction in January 1993 to December 2013 at 9 hospitals in Korea were included. Renal infarction was defined by radiologic findings that included single or multiple wedge-shaped parenchymal perfusion defects in the kidney.
PREDICTOR: Causes of renal infarction included cardiogenic (n=244 [55.7%]), renal artery injury (n=33 [7.5%]), hypercoagulable (n=29 [6.6%]), and idiopathic (n=132 [30.1%]) factors.
OUTCOMES: We used recurrence, acute kidney injury (AKI; defined as creatinine level increase ≥ 0.3mg/dL within 48 hours or an increase to 150% of baseline level within 7 days during the sentinel hospitalization), new-onset estimated glomerular filtration rate (eGFR)<60mL/min/1.73m(2) (for >3 months after renal infarction in the absence of a history of decreased eGFR), end-stage renal disease (ESRD; receiving hemodialysis or peritoneal dialysis because of irreversible kidney damage), and mortality as outcome metrics.
RESULTS: Treatment included urokinase (n=19), heparin (n=342), warfarin (n=330), and antiplatelet agents (n=157). 5% of patients died during the initial hospitalization. During the median 20.0 (range, 1-223) months of follow-up, 2.8% of patients had recurrent infarction, 20.1% of patients developed AKI, 10.9% of patients developed new-onset eGFR<60mL/min/1.73m(2), and 2.1% of patients progressed to ESRD.
LIMITATIONS: This was a retrospective study; it cannot clearly determine the specific causal mechanism for certain patients or provide information about the causes of mortality. 16 patients were excluded from the prognostic analysis.
CONCLUSIONS: Cardiogenic origins were the most important causes of renal infarction. Despite aggressive treatment, renal infarction can lead to AKI, new-onset eGFR<60mL/min/1.73m(2), ESRD, and death.

Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
PMID 26545635
Maximilian S Jentzsch, Leon Hsueh, Kevin J Pallapati, Kate Mayans
Abdominal Pain Due to Renal Infarction: An Unexpected Presentation of COVID-19.
R I Med J (2013). 2021 Aug 2;104(6):16-19. Epub 2021 Aug 2.
Abstract/Text Although respiratory symptoms dominate the clinical presentation of COVID-19, atypical, misleading non-pulmonary complaints can occur. Here we present a case of an otherwise healthy 28-year-old cisgender woman whose initial presentation of COVID-19 was unexplained acute abdominal pain, which was later found to be due to renal infarction. She was treated with anti-coagulation and was discharged after a short hospital stay. This case demonstrates the heterogeneous presentations that are associated with COVID-19. Medical providers must be aware that this virus may mimic a diverse array of disorders, even in the absence of respiratory symptoms.

PMID 34323873
Ana Carina Pizzarossa, Valentina Mérola
[Etiology of renal infarction. A systematic review].
Rev Med Chil. 2019 Jul;147(7):891-900. doi: 10.4067/S0034-98872019000700891.
Abstract/Text BACKGROUND: Renal infarction is a rare and usually underdiagnosed entity.
AIM: To study the etiology of renal infarction in published series.
MATERIAL AND METHODS: A systematic review was carried out selecting 28 series that included 1582 patients.
RESULTS: The proposed cause was cardiac or aortic embolism in 718 cases (45%), an arterial injury in 253 (16%), prothrombotic factors in 146 (9%) and other causes in 79 (5%). 291 cases were classified as idiopathic (18.4%). Atrial fibrillation was present in 542 of the 718 patients with cardiac or aortic embolism.
CONCLUSIONS: The main cause of renal infarction is cardiac or aortic embolism and among this group, most cases are due to atrial fibrillation. One out of five cases is labeled as idiopathic.

PMID 31859988
Ze'ev Korzets, Eleanora Plotkin, Jacques Bernheim, Rivka Zissin
The clinical spectrum of acute renal infarction.
Isr Med Assoc J. 2002 Oct;4(10):781-4.
Abstract/Text BACKGROUND: Acute renal infarction is an oft-missed diagnosis. As a result, its true incidence, although presumed to be low, is actually unknown. Surprisingly, the medical literature on the subject, other than anecdotal case reports, is scarce.
OBJECTIVES: To increase physician awareness of the diagnosis and to identify predictive clinical and laboratory features of the entity.
METHOD: Between 1 November 1997 and 31 October 2000, 11 cases of acute renal infarction in 10 patients were diagnosed in our center by contrast-enhanced computerized tomography. The medical charts of these patients were reviewed regarding risk factors, clinical presentation, possible predictive laboratory examinations, and outcome.
RESULTS: During the 36 month observation period, the incidence of acute renal infarction was 0.007%. The mean age of the patients (5 men and 5 women) was 67.4 +/- 21.1 (range 30-87 years). In four cases the right and in five the left kidney was involved; in the other two cases bilateral involvement was seen. In 7/10 patients, an increased risk for thromboembolic events was found. Six had chronic atrial fibrillation and one had a combined activated protein C resistance and protein S deficiency. Three patients had suffered a previous thromboembolic event. Two cases were receiving anticoagulant therapy with an INR of 1.6 and 1.8, respectively. On admission, flank pain was recorded in 10/11, fever in 5 and nausea/vomiting in 4 cases. Hematuria was detected in urine reagent strips in all cases. Serum lactate dehydrogenase and white blood cell count were elevated in all cases (1,570 +/- 703 IU/L and 12,988 +/- 3,841/microliter, respectively). In no case was the diagnosis of acute renal infarction initially entertained. The working diagnoses were renal colic in 2, pyelonephritis in 3, renal carcinoma, digitalis intoxication, and suspected endocarditis in one patient each, and an acute abdomen in 3. Time from admission to definitive CT diagnosis ranged from 24 hours to 6 days. Three patients were treated with intravenous heparin and another with a combination of i.v. heparin and renal intra-arterial urokinase infusion with, in the latter case, no recovery of function of the affected kidney. With the exception of this one patient (with a contralateral contracted kidney) who required maintenance dialysis, in all other cases serum creatinine levels remained unchanged or reverted to the baseline mean of 1.1 mg/dl (0.9-1.2).
CONCLUSIONS: Acute renal infarction is not as rare as previously assumed. The entity is often misdiagnosed. Unilateral flank pain in a patient with an increased risk for thromboembolism should raise the suspicion of renal infarction. In such a setting, hematuria, leucocytosis and an elevated LDH level are strongly supportive of the diagnosis.

PMID 12389340
Natasha Hazanov, Marina Somin, Malka Attali, Nick Beilinson, Michael Thaler, Meir Mouallem, Yasmin Maor, Nurit Zaks, Stephen Malnick
Acute renal embolism. Forty-four cases of renal infarction in patients with atrial fibrillation.
Medicine (Baltimore). 2004 Sep;83(5):292-9.
Abstract/Text Acute renal embolus is rarely reported in the medical literature; thus, accurate data regarding presentation, laboratory tests, diagnostic techniques, and treatment are lacking. To better define this condition, we examined the medical records of all patients admitted to Kaplan Medical Center and Sheba Medical Center in central Israel from 1984 to 2002 who had a diagnosis of renal infarction and atrial fibrillation. We noted demographic, clinical, and laboratory parameters; method of diagnosis; treatment received; and patient outcome. We identified 44 cases of renal embolus: 23 females and 21 males, with an average age of 69.5 +/- 12.6 years. Thirty (68%) patients had abdominal pain, and 6 (14%) had a previous embolic event. Nine patients were being treated with warfarin on admission, 6 (66%) of whom had an international normalized ratio (INR) < 1.8. Hematuria was present in 21/39 (54%), and 41 (93%) patients had a serum lactate dehydrogenase (LDH) level > 400 U/dL. The mean LDH was 1100 +/- 985 U/dL. Diagnostic techniques included renal isotope scan, which was abnormal in 36/37 cases (97%); contrast-enhanced computed tomography (CT) scan, which was diagnostic in 12/15 cases (80%); and ultrasound, which was positive in only 3/27 cases (11%). Angiography was positive in 10/10 cases (100%). Twenty-three (61%) of 38 patients had normal renal function on follow-up. The 30-day mortality was 11.4%. Renal embolus was diagnosed mainly in patients aged more than 60 years, some of whom had a previous embolic event. Most of those receiving anticoagulant therapy had a subtherapeutic INR. Abdominal pain was common, as well as hematuria and an elevated LDH. These patients are at risk of subsequent embolic events to other organs. The most sensitive diagnostic technique in this population is a renal isotope scan, but contrast-enhanced CT scan requires further assessment.

Copyright 2004 Lippincott Williams & Wilkins
PMID 15342973
R K Lessman, S F Johnson, J W Coburn, J J Kaufman
Renal artery embolism: clinical features and long-term follow-up of 17 cases.
Ann Intern Med. 1978 Oct;89(4):477-82.
Abstract/Text Spontaneous renal artery embolism is not rare, but a correct diagnosis and appropriate treatment are often delayed. Clinical features and follow-up of 17 cases are reported. Cardiac disease or arrhythmias pre-existed in 16 patients. Initial symptoms included flank pain (seven cases), abdominal or chest pain alone (seven), and nausea and vomiting (eight). Fever (greater than or equal to 37.5 degree C) occurred in 10 cases and flank tenderness in only eight. Laboratory findings included leukocytosis, proteinuria, hematuria, and elevated levels of lactic dehydrogenase, serum glutamic-oxalacetic transaminase, serum glutamic-pyruvic transaminase, and alkaline phosphatase. Serum creatinine level exceeded 1.3 mg/dl in 88% and 4.0 mg/dl in 65%; four patients required dialysis. The diagnosis, made by scintiscan, arteriography, or both was often delayed. Renal embolization was bilateral in seven patients and unilateral in 10, with serum creatinine level above 4.0 mg/dl in five of the latter. Emboli to other organs caused early death; cardiovascular disease led to later death. With anticoagulants, renal function returned in patients surviving more than 1 month, even those with bilateral emboli. Thus, renal embolism is recognizable if the disease is considered, and a favorable outcome is common with long-term anticoagulants.

PMID 697226
M Gasparini, R Hofmann, M Stoller
Renal artery embolism: clinical features and therapeutic options.
J Urol. 1992 Mar;147(3):567-72.
Abstract/Text Renal artery embolism is an infrequent but important cause of renal loss. However, due to its rarity and nonspecific presentation diagnosis is often delayed and occasionally missed. Furthermore, proper therapeutic intervention is not well established and aggressive surgical management is often ill-advised. We review the literature and present 3 cases seen recently at our institution. Selective intra-arterial infusion of thrombolytic agents appears to be the most favorable treatment. The duration of occlusion does not necessarily correlate with the return of renal function, and the degree of collateral renal blood flow can be important.

PMID 1538430
Pei-Lun Chu, Yu-Feng Wei, Jenq-Wen Huang, Shih-I Chen, Tzong-Shinn Chu, Kwan-Dun Wu
Clinical characteristics of patients with segmental renal infarction.
Nephrology (Carlton). 2006 Aug;11(4):336-40. doi: 10.1111/j.1440-1797.2006.00586.x.
Abstract/Text BACKGROUND: Renal infarction is usually an underestimated disease due to its rare and non-specific presentations; the renal survival of these patients is not well studied. The aim of the present analysis is to study the clinical features and outcome in patients who had documented renal infarction.
METHODS: Twenty-two patients (12 men and 10 women, mean age of 57.7 +/- 3.44 years (28.4-83.3 years)) with image-confirmed segmental renal infarction in the past 15 years were enrolled. All patients were followed up at outpatient department with a median of 4 years (1-14 years). Initial and follow-up clinical characteristics and laboratory results were recorded.
RESULTS: The most common underlying disease was cardiovascular disease. Renal infarction often presented with non-specific symptoms, including flank pain (55%), vague abdominal pain (50%), nausea/vomiting (46%) and fever (27%). The levels of leucocytes, lactate dehydrogenase, blood urea nitrogen and serum creatinine were all elevated at admission. The early diagnosis group (12/22) had more obvious flank pain, nausea/vomiting (P < 0.001) and higher alanine transaminase (P = 0.02). It also predisposed to undergo antiplatelet or anticoagulant therapy (all P < 0.04). During follow up, there was no recurrence in the whole study group, and a trend of better recovery of renal function was noted in the early diagnosis group.
CONCLUSION: The serum creatinine level correlates with longer hospitalization length (P < 0.05). As regards long-term prognosis, no definite factor or treatment was found to have significant effect in segmental renal infarction patients. However, early diagnosis and early initiation of treatment seems to have a positive effect on future renal outcome.

PMID 16889574
Sheru Kansal, Myra Feldman, Stephen Cooksey, Susanj Patel
Renal artery embolism: a case report and review.
J Gen Intern Med. 2008 May;23(5):644-7. doi: 10.1007/s11606-007-0489-5. Epub 2008 Jan 26.
Abstract/Text Renal artery embolism was first described in 1940, but it is only recently becoming recognized as a clinically significant entity. Although relatively uncommon, it is clearly responsible for considerable morbidity in patients who experience it. The pathogenesis is typically related to cardiac thrombus formation with subsequent embolization, although other etiologies have been described. The authors present a case report followed by a review of the literature to highlight the clinical characteristics of this phenomena. Presentation, diagnostics, and treatment options will be reviewed with the aim of increasing awareness of renal artery embolism. As clinicians become more familiar with this condition, they will be more likely to consider it as a possible diagnosis in patients with a typical presentation. This will hopefully lead to improved care through prompt diagnosis and treatment, particularly as one treatment option may be time sensitive.

PMID 18224377
Marie Bourgault, Philippe Grimbert, Catherine Verret, Jacques Pourrat, Michel Herody, Jean Michel Halimi, Alexandre Karras, Zahir Amoura, Noémie Jourde-Chiche, Hassan Izzedine, Hélène François, Jean-Jacques Boffa, Aurélie Hummel, Pauline Bernadet-Monrozies, Denis Fouque, Florence Canouï-Poitrine, Philippe Lang, Eric Daugas, Vincent Audard
Acute renal infarction: a case series.
Clin J Am Soc Nephrol. 2013 Mar;8(3):392-8. doi: 10.2215/CJN.05570612. Epub 2012 Nov 30.
Abstract/Text BACKGROUND AND OBJECTIVES: Renal infarction is an arterial vascular event that may cause irreversible damage to kidney tissues. This study describes the clinical characteristics of patients with renal infarction according to underlying mechanism of vascular injury.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study retrospectively identified 94 patients with renal infarction diagnosed between 1989 and 2011 with the aim of highlighting potential correlations between demographic, clinical, and biologic characteristics and the etiology of renal infarction. Four groups were identified: renal infarction of cardiac origin (cardiac group, n=23), renal infarction associated with renal artery injury (renal injury group, n=29), renal infarction associated with hypercoagulability disorders (hypercoagulable group, n=15), and apparently idiopathic renal infarction (idiopathic group, n=27).
RESULTS: Clinical symptoms included abdominal and/or flank pain in 96.8% of cases; 46 patients had uncontrolled hypertension at diagnosis. Laboratory findings included increase of lactate dehydrogenase level (90.5%), increase in C-reactive protein level (77.6%), and renal impairment (40.4%). Compared with renal injury group patients, this study found that cardiac group patients were older (relative risk for 1 year increase=1.21, P=0.001) and displayed a lower diastolic BP (relative risk per 1 mmHg=0.94, P=0.05). Patients in the hypercoagulable group had a significantly lower diastolic BP (relative risk=0.86, P=0.005). Patients in the idiopathic group were older (relative risk=1.13, P=0.01) and less frequently men (relative risk=0.11, P=0.02). Seven patients required hemodialysis at the first evaluation, and zero patients died during the first 30 days.
CONCLUSIONS: This study suggests that the clinical and biologic characteristics of patients can provide valuable information about the causal mechanism involved in renal infarction occurrence.

PMID 23204242
Fernando Caravaca-Fontán, Saúl Pampa Saico, Sandra Elías Triviño, Cristina Galeano Álvarez, Antonio Gomis Couto, Inés Pecharromán de las Heras, Fernando Liaño
Acute renal infarction: Clinical characteristics and prognostic factors.
Nefrologia. 2016;36(2):141-8. doi: 10.1016/j.nefro.2015.09.015. Epub 2015 Dec 15.
Abstract/Text INTRODUCTION: Acute renal infarction (ARI) is an uncommon disease, whose real incidence is probably higher than expected. It is associated with poor prognosis in a high percentage of cases.
OBJECTIVES: To describe the main clinical, biochemical and radiologic features and to determine which factors are associated with poor prognosis (death or permanent renal injury).
MATERIALS AND METHODS: The following is a retrospective, observational, single-hospital-based study. All patients diagnosed with ARI by contrast-enhanced computed tomography (CT) over an 18-year period were included. Patients were classified according to the cardiac or non-cardiac origin of their disease. Clinical, biochemical and radiologic features were analysed, and multiple logistic regression model was used to determine factors associated with poor prognosis.
RESULTS: A total of 62 patients were included, 30 of which had a cardiac origin. Other 32 patients with non-cardiac ARI were younger, had less comorbidity, and were less frequently treated with oral anticoagulants. CT scans estimated mean injury extension at 35%, with no differences observed between groups. A total of 38% of patients had an unfavourable outcome, and the main determinants were: Initial renal function (OR=0.949; IC 95% 0.918-0.980; p=0.002), and previous treatment with oral anticoagulants (OR=0.135; IC 95% 0.032-0.565; p=0.006).
CONCLUSIONS: ARI is a rare pathology with non-specific symptoms, and it is not associated with cardiological disease or arrhythmias in more than half of cases. A substantial proportion of patients have unfavourable outcomes, and the initial renal function is one of the main prognostic factors.

Copyright © 2015 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.
PMID 26698927
Shahrooz Bemanian, Mazda Motallebi, Saeid M Nosrati
Cocaine-induced renal infarction: report of a case and review of the literature.
BMC Nephrol. 2005 Sep 22;6:10. doi: 10.1186/1471-2369-6-10. Epub 2005 Sep 22.
Abstract/Text BACKGROUND: Cocaine abuse has been known to have detrimental effects on the cardiovascular system. Its toxicity has been associated with myocardial ischemia, cerebrovascular accidents and mesenteric ischemia. The pathophysiology of cocaine-related renal injury is multifactorial and involves renal hemodynamic changes, alterations in glomerular matrix synthesis, degradation and oxidative stress, and possibly induction of renal atherogenesis. Renal infarction as a result of cocaine exposure, however, is rarely reported in the literature.
CASE PRESENTATION: A 48 year-old male presented with a four-day history of severe right flank pain following cocaine use. On presentation, he was tachycardic, febrile and had severe right costovertebral angle tenderness. He had significant proteinuria, leukocytosis and elevated serum creatinine and lactate dehydrogenase. Radiographic imaging studies as well as other screening tests for thromboembolic events, hypercoagulability states, collagen vascular diseases and lipid disorders were suggestive of Cocaine-Induced Renal Infarction (CIRI) by exclusion.
CONCLUSION: In a patient with a history of cocaine abuse presenting with fevers and flank pain suggestive of urinary tract infection or nephrolithiasis, cocaine-induced renal infarction must be considered in the differential diagnosis. In this article, we discuss the prior reported cases of CIRI and thoroughly review the literature available on this disorder. This is important for several reasons. First, it will allow us to discuss and elaborate on the mechanism of renal injury caused by cocaine. In addition, this review will demonstrate the importance of considering the diagnosis of CIRI in a patient with documented cocaine use and an atypical presentation of acute renal injury. Finally, we will emphasize the need for a consensus on optimal treatment of this disease, for which therapy is not yet standardized.

PMID 16176587
S J Stinchcombe, A R Manhire, M C Bishop, R H Gregson
Renal arterial fibromuscular dysplasia: acute renal infarction in three patients with angiographic evidence of medial fibroplasia.
Br J Radiol. 1992 Jan;65(769):81-4. doi: 10.1259/0007-1285-65-769-81.
Abstract/Text
PMID 1486375
Mizuho Nara, Atsushi Komatsuda, Masumi Fujishima, Naohito Fujishima, Miho Nara, Takako Iino, Hiroshi Ito, Ken-ichi Sawada, Hideki Wakui
Renal paradoxical embolism in a hypertensive young adult without acute ischemic symptoms.
Clin Exp Nephrol. 2011 Aug;15(4):582-5. doi: 10.1007/s10157-011-0436-y. Epub 2011 Mar 24.
Abstract/Text A 22-year-old woman, who often carried heavy books, was admitted for evaluation of hyperreninemic hypertension. Two months prior to admission, she noted leg edema. Radiological examinations revealed bilateral renal infarction with no other abnormal findings. An echocardiography showed a patent foramen ovale (PFO). Hypertension was considered secondary to renal infarction caused by paradoxical embolism through PFO. Antihypertensive and anticoagulant therapy led to improvement of hypertension. In previously reported cases of renal paradoxical embolism, multiorgan involvement was usually observed. Our case is unique in that embolism was confirmed only in the kidneys, and that clinical characteristics of renal embolism were not observed.

PMID 21431897
H B Carey, R Boltax, K W Dickey, F O Finkelstein
Bilateral renal infarction secondary to paradoxical embolism.
Am J Kidney Dis. 1999 Oct;34(4):752-5. doi: 10.1016/S0272-6386(99)70403-8.
Abstract/Text Paradoxical embolism is an uncommon but increasingly reported cause of arterial embolic events. Involvement of the kidney is rarely reported. Autopsy studies suggest, however, that embolic renal infarction is underdiagnosed antemortem. We report a case of bilateral, main renal artery occlusion and acute renal failure secondary to paradoxical embolism. Clinical and laboratory data at presentation were not suggestive of renal infarction. Support for the diagnosis of paradoxical embolism, which most commonly occurs across a patent foramen ovale, was made by contrast echocardiography, which provides a sensitive method for detecting right-to-left intracardiac shunts. The often subtle presentation of renal infarction suggests patients with peripheral or central arterial embolic events should be carefully observed for occult renal involvement. Contrast echocardiography should be performed when renal infarction occurs without a clear embolic source to evaluate for paradoxical embolism.

PMID 10516359
M Gavalas, R Meisner, N Labropoulos, A Gasparis, A Tassiopoulos
Renal infarction complicating fibromuscular dysplasia.
Vasc Endovascular Surg. 2014 Oct-Nov;48(7-8):445-51. doi: 10.1177/1538574414551206. Epub 2014 Sep 15.
Abstract/Text Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease that most commonly affects the renal and extracranial carotid arteries. We present 3 cases of renal infarction complicating renal artery FMD in 42-, 43-, and 46-year-old females and provide a comprehensive review of the literature on this topic. In our patients, oral anticoagulation therapy was used to treat all cases of infarction, and percutaneous angioplasty was used nonemergently in one case to treat refractory hypertension. All patients remained stable at 1-year follow-up. This is consistent with outcomes in previously published reports where conservative medical management was comparable to surgical and interventional therapies. Demographic differences may also exist in patients with renal infarction and FMD. A higher prevalence of males and a younger age at presentation have been found in these patients when compared to the general population with FMD.

© The Author(s) 2014.
PMID 25227972
S P Stawicki, J C Rosenfeld, N Weger, E L Fields, J D Balshi
Spontaneous renal artery dissection: three cases and clinical algorithms.
J Hum Hypertens. 2006 Sep;20(9):710-8. doi: 10.1038/sj.jhh.1002045. Epub 2006 May 18.
Abstract/Text Spontaneous renal artery dissection (SRAD) is rare. Clinical manifestations vary from minimal symptoms to life-threatening hypertension. We analysed three cases from our institution and conducted a literature review in order to design diagnostic and treatment algorithms for SRAD.

PMID 16710291
P Orlic, D Vukas, I Drescik, A Ivancic, G Blecic, B Budiselic, G Velcic, A Maricic, R Oguic, V Mozetic, M Valencic, S Sotosek, D Vukas
Vascular complications after 725 kidney transplantations during 3 decades.
Transplant Proc. 2003 Jun;35(4):1381-4. doi: 10.1016/s0041-1345(03)00506-2.
Abstract/Text Among 725 renal transplantations, the most common vascular complication was arterial stenosis, which was observed in 23 patients (3.17%). The majority of 20 (6.49%) arterial stenoses appeared in our initial experiences when we routinely used end-to-end renal graft to internal iliac artery anastomoses. A significant reduction in this incidence (0.72%) was achieved by introducing end-to-side anastomoses of the renal graft artery to the external or common iliac arteries. Intractable hypertension or impaired renal function in 14 patients (60.87%) with arterial stenosis demanded treatment. Patch angioplasty was more successful than other methods. The limited possibilities of conservative treatment of arterial hypertension at that time were the main reason for this frequent surgical repair. Among other vascular complications, the most serious were 12 episodes of arterial bleeding in 10 patients. Five kidneys were lost because of ruptured arterial anastomoses. In 6 patients, the common or external iliac artery was ligated as to achieve hemostasis with acute arterial insufficiency of the lower extremity in 4 patients. One patient required leg amputation, whereas 2 underwent extra-anatomic bypass procedures and 1 died because of hepatic failure. The majority of vascular complications occurred in the initial period of our transplantation practice. However, in spite of progress in diagnostic and treatment options, vascular complications may cause considerable clinical problems.

PMID 12826165
Burapa Kanchanabat, Mark Siddins, Toby Coates, Mark Tie, Christine H Russell, Timothy Mathew, Mohan M Rao
Segmental infarction with graft dysfunction: an emerging syndrome in renal transplantation?
Nephrol Dial Transplant. 2002 Jan;17(1):123-8. doi: 10.1093/ndt/17.1.123.
Abstract/Text BACKGROUND: Segmental allograft infarction is a poorly characterized complication following renal transplantation. The present study was undertaken with the goal of defining the incidence, clinical characteristics, pathogenesis, and prognosis of this entity.
METHODS: A retrospective study was performed, reviewing the renal scans performed on all renal transplant recipients at our institution, from January 1997 to January 2000. Segmental infarction was diagnosed on the basis of a significant elevation in lactate dehydrogenase (>500 U/l) together with a photopenic perfusion defect. In these patients, graft characteristics, operative details, clinical course, and long-term outcomes were evaluated.
RESULTS: Segmental infarction was identified in 13 of 277 consecutive renal transplant recipients (4.7%). In nine recipients the onset of infarction occurred within 24 h after transplantation. All received marginal grafts, and in five recipients the transplant operation was complicated by major blood loss. Eight of these recipients exhibited primary non-function, or developed dialysis-dependent renal failure after the onset of infarction. In four patients, the onset of infarction occurred after 24 h (35 h to 10 days). One recipient demonstrated primary non-function, and renal function deteriorated after the onset of infarction in the remaining three. Overall, long-term graft function was impaired. Two allografts never functioned, and six recipients had nadir creatinine clearances below 60 ml/min.
CONCLUSIONS: The pathogenesis of segmental infarction appears to be multi-factorial, reflecting the combination of an initiating anatomic lesion and potentiating thrombogenic milieu. Segmental infarction typically occurs in the early postoperative period, and prompt diagnosis is difficult to obtain. In view of this, prophylactic heparin may be warranted for those at highest risk. There was no correlation between the infarct area and the graft function, and the long-term graft function is compromised out of proportion to the extent of parenchymal loss. This finding highlights the role of predisposing factors, particularly marginal graft quality, in determining the functional outcome. Segmental infarction may be more frequently encountered as cadaveric organ shortages encourage greater use of marginal donor kidneys.

PMID 11773475
Marco Fiore, Lorenzo Andreana
Contrast-enhanced ultrasound as imaging technique for patients with acute flank pain into the ED.
Am J Emerg Med. 2016 Feb;34(2):324-5. doi: 10.1016/j.ajem.2015.11.020. Epub 2015 Nov 10.
Abstract/Text
PMID 26639455
Fabrice Ivanes, Jean Dewaele, Caroline Touboul, Philippe Gatault, Bénédicte Sautenet, Christelle Barbet, Matthias Büchler, Laurent Quilliet, Denis Angoulvant, Jean-Michel Halimi
Renal arteriography with endovascular ultrasound for the management of renal infarction patients.
BMC Nephrol. 2020 Jul 14;21(1):273. doi: 10.1186/s12882-020-01929-z. Epub 2020 Jul 14.
Abstract/Text BACKGROUND: Renal infarction (RI) is a rare disease with poor prognosis. Appropriate secondary prevention treatment is essential and requires an exhaustive etiological assessment. We aimed to determine whether invasive endovascular explorations may improve the diagnostic process and change the secondary prevention treatment strategy in RI patients.
METHODS: We report a retrospective observational study of 25 RI patients referred to Tours University Hospital between 2011 and 2018 for etiological investigation including renal arteriography and intravascular ultrasonography (IVUS). We sought for antithrombotic treatment regimen, vital status, bleeding and ischemic outcomes during the median follow-up of 59 months.
RESULTS: Invasive explorations showed local arterial disease in 14 patients (56%). This led to a diagnosis or change in diagnosis in 9 patients (36%) and to a change in antithrombotic strategy in 56% of cases, with an increased prescription of antiplatelet therapy. No patient died, only two patients (8%) had persistent mild renal insufficiency. One IVUS complication was reported and treated without any significant long-term consequences.
CONCLUSION: Invasive endovascular investigations of RI may modify the secondary prevention treatment through a better assessment of the aetiology of RI. Multicentric randomized studies are necessary to advocate the hypothesis that invasive exploration of renal artery can improve long-term prognosis.

PMID 32664890
Bruno Paris, Guillaume Bobrie, Patrick Rossignol, Sylvie Le Coz, Antoine Chedid, Pierre-François Plouin
Blood pressure and renal outcomes in patients with kidney infarction and hypertension.
J Hypertens. 2006 Aug;24(8):1649-54. doi: 10.1097/01.hjh.0000239302.55754.1f.
Abstract/Text OBJECTIVE: To assess the causes and frequency of kidney infarction associated with hypertension, and the blood pressure and renal function outcomes.
METHODS: We analyzed the records of patients with kidney infarction documented by angiography and referred to a hypertension unit.
RESULTS: Spontaneous kidney infarction was documented in 55 of 18,287 patients and was associated with renal artery disease in 41 cases. Twenty-five patients had a longstanding history of hypertension at referral, and 30 patients presented with acute hypertension. Patients with acute hypertension were more likely to report a history of lumbar pain and to develop malignant hypertension than patients with longstanding hypertension; they also had higher plasma renin concentrations. Data for long-term follow-up after referral were available for 36 patients, including 15 patients who underwent surgery or renal artery angioplasty. From referral to most recent follow-up, the blood pressure decreased from 176/111 to 143/89 mmHg in patients with longstanding hypertension, and from 183/111 to 127/80 mmHg in those with acute hypertension (P = 0.007/0.041 for between-group differences). Three patients with acute hypertension had normal blood pressure without treatment at follow-up. Patients with long-term follow-up displayed no change in the glomerular filtration rate.
CONCLUSION: Kidney infarction is a rare cause of hypertension, usually associated with renal artery lesions. In cases of kidney infarction with acute hypertension, the blood pressure outcome is favorable following intervention and/or medication, and hypertension may resolve spontaneously.

PMID 16877969
Po-Jen Hsiao, Tsung-Jui Wu, Shih-Hua Lin
Cortical rim sign and acute renal infarction.
CMAJ. 2010 May 18;182(8):E313. doi: 10.1503/cmaj.091110. Epub 2010 Mar 22.
Abstract/Text
PMID 20308268
Okan Suzer, Ali Shirkhoda, S Zafar Jafri, Beatrice L Madrazo, Kostaki G Bis, James F Mastromatteo
CT features of renal infarction.
Eur J Radiol. 2002 Oct;44(1):59-64. doi: 10.1016/s0720-048x(01)00476-4.
Abstract/Text PURPOSE: To demonstrate the different patterns of renal infarction to avoid pitfalls. To present 'flip-flop enhancement' pattern in renal infarction.
MATERIALS AND METHODS: Retrospective review of a total of 41 renal infarction in 37 patients were done. These patients underwent initial CT and the diagnosis of renal infarction was confirmed with either follow up CT or at surgery.
RESULTS: Twenty-three patients had wedge-shaped focal infarcts, nine patients had global and five patients had multifocal infarcts of the kidneys. Cortical rim sign was seen predominantly with global infarcts. In five patients, a 'flip-flop enhancement' pattern was observed. In two patients, planned renal biopsies due to tumefactive renal lesions were cancelled because of 'flip-flop enhancement' pattern on follow up CTs.
CONCLUSION: Although most of our cases were straightforward for the diagnosis of renal infarction, cases with tumefactive lesions and global infarctions without the well-known cortical rim sign were particularly challenging. We describe a new sign, flip-flop enhancement pattern, which we believe solidified the diagnosis of renal infarction in five of our cases. The authors recommend further investigations for association of flip-flop enhancement and renal infarction.

PMID 12350414
M Lacombe
Acute non-traumatic obstructions of the renal artery.
J Cardiovasc Surg (Torino). 1992 Mar-Apr;33(2):163-8.
Abstract/Text Twenty patients were operated upon for acute obstruction of their main renal arteries (25 kidneys at risk), 18 hours to 68 days after the onset of obstruction. Three nephrectomies were necessary because of total renal infarction but revascularization was possible in all the other cases. The postoperative mortality rate was 15%; definitive kidney salvage rate was 64%. The function of the preserved kidneys was usually satisfactory. This surgical experience has led us to the following conclusions: acute obstruction of a main renal artery does not necessarily cause renal infarction as viability of the kidney can be maintained over long periods of time by the collateral circulation; neither non-function of the kidney, nor the duration of renal artery obstruction must be regarded as signs of renal infarction; no investigation can provide information as to the exact condition of the kidney before surgery. Apart from critically ill patients or segmental renal obstructions, the treatment should be surgical, irrespective of the time that has elapsed from the onset of the obstruction.

PMID 1572872
U Blum, P Billmann, T Krause, A Gabelmann, E Keller, E Moser, M Langer
Effect of local low-dose thrombolysis on clinical outcome in acute embolic renal artery occlusion.
Radiology. 1993 Nov;189(2):549-54. doi: 10.1148/radiology.189.2.8210388.
Abstract/Text PURPOSE: To determine the utility of local thrombolysis in treatment of acute embolic renal artery occlusion.
MATERIALS AND METHODS: Fourteen patients with acute embolic renal artery occlusion treated with local low-dose thrombolysis were studied. Diagnosis was made with renal scintigraphy and selective renal arteriography.
RESULTS: Thrombolysis was successful in 13 of 14 patients. During 1-72 months of follow-up (mean, 27.1 months), renal function did not improve on the side of complete renal artery occlusion, whereas stabilization of renal function at the pretherapy level was seen in patients with incomplete obstruction of the renal artery or complete obstruction at the level of segmental branches. In none of the patients did renal function return to normal.
CONCLUSION: In acute embolic renal artery occlusion, thrombolytic therapy does not restore renal function and is therefore not indicated once the ischemic tolerance of the kidney (approximately 90 minutes) has been exceeded.

PMID 8210388
Jae Hyun Kwon, Bum Jin Oh, Sang Ook Ha, Dae Yong Kim, Han Ho Do
Renal Complications in Patients with Renal Infarction: Prevalence and Risk Factors.
Kidney Blood Press Res. 2016;41(6):865-872. doi: 10.1159/000452589. Epub 2016 Nov 21.
Abstract/Text BACKGROUND/AIMS: This study aimed to investigate the incidence and risk factors for acute kidney injury (AKI) and chronic kidney disease (CKD) in patients with renal infarction.
METHODS: A single-center retrospective study was conducted from January 2005 to December 2013. Baseline and clinical characteristics of the enrolled patients with renal infarction were evaluated and analyzed according to the presence of AKI and CKD. In particular, predictors for AKI and CKD were determined using logistic regression analysis.
RESULTS: Of the 105 patients included in present study, 41 (39.0%) patients had AKI. A total of 80 patients were followed up for 2 years after hospital discharge. Among these patients, 27 (33.8%) patients had CKD. In the multivariate analysis, the predictors were mean blood pressure (odds ratio [OR] 1.062, 95% confidence interval [CI] 1.015-1.112, p = 0.009) and bilateral involvement (OR 4.396, 95% CI 1.096-17.632, p = 0.037) for AKI, and AKI (OR 14.799, 95% CI 4.173-52.490, p < 0.001) and old age (OR 1.065, 95% CI 1.016-1.116, p = 0.009) for CKD.
CONCLUSIONS: Physicians should pay attention to the development of AKI and CKD after renal infarction and follow patients over a long term.

© 2016 The Author(s) Published by S. Karger AG, Basel.
PMID 27871081
Jihyun Yang, Jun Yong Lee, Young Ju Na, Sung Yoon Lim, Myung-Gyu Kim, Sang-Kyung Jo, Wonyong Cho
Risk factors and outcomes of acute renal infarction.
Kidney Res Clin Pract. 2016 Jun;35(2):90-5. doi: 10.1016/j.krcp.2016.04.001. Epub 2016 May 11.
Abstract/Text BACKGROUND: Renal infarction (RI) is an uncommon disease that is difficult to diagnose. As little is known about clinical characteristics of this disease, we investigated its underlying risk factors and outcomes.
METHODS: We performed a retrospective single-center study of 89 patients newly diagnosed with acute RI between January 2002 and March 2015 using imaging modalities. Clinical features, possible etiologies, and long-term renal outcome data were reviewed.
RESULTS: The patients' mean age was 63.5 ± 15.42 years; 23.6% had diabetes and 56.2% had hypertension. Unilateral and bilateral involvements were shown in 80.9% and 19.1% of patients, respectively; proteinuria and hematuria were reported in 40.4% and 41.6%, respectively. Cardiovascular disease was the most common underlying disease, followed by renal vascular injury and hypercoagulability disorder. Fourteen patients had no specific underlying disease. At the time of diagnosis, acute kidney injury (AKI) was found in 34.8% of patients. Univariate analysis revealed diabetes mellitus (DM), leukocytosis, and high C-reactive protein (CRP) as significant risk factors for the development of AKI. On multivariate analysis, DM and high CRP levels were independent predictors for AKI. During follow-up, chronic kidney disease developed in 27.4% of patients. Univariate and multivariate Cox regression analyses showed old age to be an independent risk factor for this disease, whereas AKI history was a negative risk factor.
CONCLUSION: DM patients or those with high CRP levels should be observed for renal function deterioration. Clinicians should also monitor for RI in elderly patients.

PMID 27366663
Saeko Kagaya, Ojima Yoshie, Hirotaka Fukami, Hiroyuki Sato, Ayako Saito, Yoichi Takeuchi, Ken Matsuda, Tasuku Nagasawa
Renal infarct volume and renal function decline in acute and chronic phases.
Clin Exp Nephrol. 2017 Dec;21(6):1030-1034. doi: 10.1007/s10157-017-1399-4. Epub 2017 Mar 10.
Abstract/Text BACKGROUND: Acute renal infarction (ARI) is a rare disease. ARI causes decline in renal function in both the acute and chronic phases. However, the correlation between the volume of the infarction and degree of renal function decline has not been fully investigated. Therefore, we aimed to examine the relationship between the volume of the infarction and degree of renal function decline.
METHODS: We performed a single-center, retrospective, observational study investigating clinical parameters and the volume of the infarction. The volume of the infarction was measured using reconstructed computed tomography data.
RESULTS: A total of 39 patients (mean age, 72.6 ± 13.2 years; men, 59%) were enrolled. The median infarction volume was 45 mL (interquartile range, 14-91 mL). The volume of the infarction was significantly associated with the peak lactate dehydrogenase (LDH) level (median, 728 IU/L; interquartile range, 491-1227 U/L) (r = 0.58, p < 0.01) and the degree of renal function decline in both acute and chronic phases (r = -0.44, -0.38, respectively, p < 0.05). The peak LDH level was significantly correlated with the degree of renal function decline in the acute phase but not in the chronic phase (r = -0.35, -0.21; p < 0.05, N.S., respectively).
CONCLUSIONS: The volume of the infarction may be a factor in the degree of renal function decline in ARI. Therefore, assessment of infarct volume in ARI is important.

PMID 28283850
G Glück, M Croitoru, D Deleanu, P Platon
Local thrombolytic treatment for renal arterial embolism.
Eur Urol. 2000 Sep;38(3):339-43. doi: 20303.
Abstract/Text OBJECTIVE: To determine the utility of local thrombolysis in the treatment of acute renal arterial occlusion.
METHODS: We used local thrombolytic treatment in a female patient, aged 76, with 72 h of anuria, right lumbar and flank pain. She had a 3-year history of ischemic heart disease and atrial fibrillation controlled with digital treatment. Also, she was nephrectomized on the left side 33 years ago for lithiasic pyonephrosis. A normal right urinary tract was demonstrated with ultrasound examination, KUB radiography and retrograde pyelography. The next step was diagnostic abdominal angiography and local thrombolytic treatment with streptokinase.
RESULT: Thrombolysis with streptokinase was successful following 72 h of renal artery occlusion. After 24 months the patient is doing well.
CONCLUSION: Local intra-arterial thrombolysis is the treatment of choice in renal artery occlusion.

PMID 10940710
Arnaud Delezire, Marianne Terrasse, Julien Bouet, Maxence Laot, Vanessa Brun, Emmanuel Oger, Cécile Vigneau
Acute renal infarction: long-term renal outcome and prognostic factors.
J Nephrol. 2021 Oct;34(5):1501-1509. doi: 10.1007/s40620-020-00953-4. Epub 2021 Mar 25.
Abstract/Text INTRODUCTION: Acute renal infarction is a rare occurence, whose  prognosis and long-term outcomes remain poorly studied. This study evaluated whether clinical and radiological features at diagnosis can be associated with the long-term outcomes (blood pressure, kidney function and mortality).
METHODS: We retrospectively analyzed the demographic, clinical, biological and radiological data of patients with acute renal infarction hospitalized at Rennes University Hospital between 1997 and 2017 (n = 94).
RESULTS: Patients were followed-up for a median of 60 months. At time of diagnosis of acute renal infarction median age was 53 years, 45% of the patients had acute hypertension, and 31% had Acute Kidney Injury (AKI) requiring dialysis in seven patients. The median Lactate DeHydrogenase (LDH) level was 977 IU/mL. The median extent of kidney damage was 14%, with left renal involvement in 51% of patients. At 60 months of follow-up, 66% of patients had developed Chronic Kidney Disease (CKD) stage 3 or higher, and 55% had hypertension since diagnosis. Age, acute development of hypertension and AKI at diagnosis were associated with long-term CKD (stage 3 or higher) in multivariate analyses, but the extent of kidney damage was not. During the follow-up, 21% of patients died, and only age resulted as a predisposing factor. No tested factor was correlated with long-term hypertension.
DISCUSSION: Age, acute development of hypertension, and AKI were correlated with long term CKD, whereas no factor was correlated with long-term hypertension after acute renal infarction.

© 2021. Italian Society of Nephrology.
PMID 33765299
Harin Rhee, Sang Heon Song, Dong Won Lee, Soo Bong Lee, Ihm Soo Kwak, Eun Young Seong
The significance of clinical features in the prognosis of acute renal infarction: single center experience.
Clin Exp Nephrol. 2012 Aug;16(4):611-6. doi: 10.1007/s10157-012-0605-7. Epub 2012 Feb 18.
Abstract/Text OBJECTIVE: Acute renal infarct (ARI) is a common renovascular disease caused by the abrupt interruption of renal blood flow. Since the presenting symptoms are often non-specific, a major concern in ARI has been prompt diagnosis, and its long-term outcome has never been studied.
MATERIALS AND METHODS: From January 2000 through to December 2009, adult patients with ARI were enrolled in this study. We retrospectively reviewed their clinical data, and followed them up until July 2011. Renal outcome and all-cause mortality were measured.
RESULTS: A total of 67 patients were finally enrolled in this study. Their mean age was 56.1 ± 16.4 years, and 52.2% of them were male. Over 76% of patients were identified to have more than one comorbidity and concurrent thromboembolic events occurred in 16.4% of the patients. Although, acute kidney injury (AKI) was present in 40.7% of the patients, long-term renal outcome was relatively good. In all cases, AKI was resolved within a month, and renal loss was found in only one patient. In-hospital mortality was 8.9% and during the median follow-up period of 40.6 months, long-term mortality was 19.7%. Independent risk factors for mortality were age, atrial fibrillation, myocardial infarction and hematuria [hazard ratio (HR) 1.051, 95% confidence interval (CI) 1.008-1.096; HR 3.322, 95% CI 1.119-9.860; HR 9.315, 95% CI 1.555-55.796 and HR 7.745, 95% CI 1.606-37.353, respectively].
CONCLUSIONS: Our study suggested that in-hospital and long-term outcomes of ARI were closely related to the comorbidities or underlying disease of ARI, rather than the disease itself.

PMID 22350465
T A Salam, A B Lumsden, L G Martin
Local infusion of fibrinolytic agents for acute renal artery thromboembolism: report of ten cases.
Ann Vasc Surg. 1993 Jan;7(1):21-6. doi: 10.1007/BF02042655.
Abstract/Text Management of acute renal artery occlusion remains a therapeutic challenge. We report our experience with 10 cases of acute renal artery occlusion treated primarily by local infusion of fibrinolytic agents. Renal artery occlusion occurred as a result of thrombosis of a stenosed vessel in three cases, from renal artery embolism in two cases, as a complication of percutaneous transluminal angioplasty in four cases, and in association with aortic occlusion in one case. Flank pain was present in all cases and hematuria in four cases. Acute renal failure was seen at the time of presentation in four cases (one case from bilateral occlusion and three cases from an associated nonfunctioning contralateral kidney). Diagnosis was confirmed by renal isotope scanning and arteriography in all cases. All patients were treated by selective infusion of streptokinase or urokinase into the occluded renal arteries. In five cases this was combined with balloon catheter angioplasty. Therapy was initiated within 24 hours from the onset of symptoms in three cases, within 3 days in four cases, within 6 days in two cases, and after 5 weeks in one case. Successful revascularization was initially achieved in 7 of the 10 cases by arteriographic criteria. Rethrombosis occurred in one patient after 3 days and fibrinolytic therapy was repeated successfully. Renal function was restored in one of the four patients presenting with acute renal failure. One complication necessitating resection occurred as a result of fibrinolytic therapy in the form of acute mesenteric embolism with descending colon infarction. No major bleeding complications were encountered and there were no deaths in this group of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 8518115

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