今日の臨床サポート

腎梗塞

著者: 伊藤千春1) 自治医科大学 腎臓内科

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/監修レビュー済:2019/10/03
患者向け説明資料

概要・推奨   

  1. 腎動脈塞栓症・腎梗塞の患者では、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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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
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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。
※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、実際の保険適用の査定において保険適用及び保険適用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用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 : 未申告[2021年]
長田太助 : 未申告[2021年]
監修:岡田浩一 : 講演料(協和キリン,中外製薬,田辺三菱,第一三共),研究費・助成金など(協和キリン),奨学(奨励)寄付など(協和キリン,中外製薬,田辺三菱,第一三共,アステラス,MSD,武田薬品,鳥居薬品,ファイザー,ノバルティス,日本ベーリンガーインゲルハイム,大塚製薬,塩野義,大日本住友)[2021年]

改訂のポイント:
  1. 画像診断について一部改訂を行った。
  1. 急性腎障害、慢性腎障害の危険因子について加筆修正を行った。

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. 心房細動、心弁膜症、虚血性心疾患に併発する塞栓性閉塞による頻度が最も高いが、動脈硬化を基盤とする腎動脈狭窄などに起因することもあり、既往歴・心血管リスクなど臨床的な背景を把握することが重要である[1][2][3]
 
腎動脈塞栓症のリスクファクター

基礎疾患としては圧倒的に心房細動が多いことがわかる。また少なからず心筋症が背景にある場合もある。

出典

img1:  Renal artery embolism: a case report and review.
 
 J Gen Intern Med. 2008 May;23(5):644-7. ・・・
 
  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[1][2]
  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CT、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[4][5]
問診・診察のポイント  
高頻度に認められる症状:[1][2][3]
  1. 急激な側腹部・腹部・背部痛とそれに伴う悪心・嘔吐・発熱

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Ze'ev Korzets, Eleanora Plotkin, Jacques Bernheim, Rivka Zissin
雑誌名: 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  Isr Med Assoc J. 2002 Oct;4(10):781-4.
著者: Natasha Hazanov, Marina Somin, Malka Attali, Nick Beilinson, Michael Thaler, Meir Mouallem, Yasmin Maor, Nurit Zaks, Stephen Malnick
雑誌名: 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  Medicine (Baltimore). 2004 Sep;83(5):292-9.
著者: Pei-Lun Chu, Yu-Feng Wei, Jenq-Wen Huang, Shih-I Chen, Tzong-Shinn Chu, Kwan-Dun Wu
雑誌名: 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  Nephrology (Carlton). 2006 Aug;11(4):336-40. doi: 10.11・・・
著者: R K Lessman, S F Johnson, J W Coburn, J J Kaufman
雑誌名: 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  Ann Intern Med. 1978 Oct;89(4):477-82.
著者: M Gasparini, R Hofmann, M Stoller
雑誌名: 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  J Urol. 1992 Mar;147(3):567-72.
著者: H Domanovits, M Paulis, M Nikfardjam, G Meron, I Kürkciyan, A A Bankier, A N Laggner
雑誌名: 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  Medicine (Baltimore). 1999 Nov;78(6):386-94.
著者: Sheru Kansal, Myra Feldman, Stephen Cooksey, Susanj Patel
雑誌名: 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  J Gen Intern Med. 2008 May;23(5):644-7. doi: 10.1007/s1・・・
著者: 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
雑誌名: 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  Clin J Am Soc Nephrol. 2013 Mar;8(3):392-8. doi: 10.221・・・
著者: 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
雑誌名: 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  Am J Kidney Dis. 2016 Feb;67(2):243-50. doi: 10.1053/j.・・・
著者: Fernando Caravaca-Fontán, Saúl Pampa Saico, Sandra Elías Triviño, Cristina Galeano Álvarez, Antonio Gomis Couto, Inés Pecharromán de las Heras, Fernando Liaño
雑誌名: 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  Nefrologia. 2016;36(2):141-8. doi: 10.1016/j.nefro.2015・・・
著者: Shahrooz Bemanian, Mazda Motallebi, Saeid M Nosrati
雑誌名: 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  BMC Nephrol. 2005 Sep 22;6:10. doi: 10.1186/1471-2369-6・・・
著者: S J Stinchcombe, A R Manhire, M C Bishop, R H Gregson
雑誌名: Br J Radiol. 1992 Jan;65(769):81-4. doi: 10.1259/0007-1285-65-769-81.
Abstract/Text
PMID 1486375  Br J Radiol. 1992 Jan;65(769):81-4. doi: 10.1259/0007-1・・・
著者: Mizuho Nara, Atsushi Komatsuda, Masumi Fujishima, Naohito Fujishima, Miho Nara, Takako Iino, Hiroshi Ito, Ken-ichi Sawada, Hideki Wakui
雑誌名: 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  Clin Exp Nephrol. 2011 Aug;15(4):582-5. doi: 10.1007/s1・・・
著者: H B Carey, R Boltax, K W Dickey, F O Finkelstein
雑誌名: 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  Am J Kidney Dis. 1999 Oct;34(4):752-5. doi: 10.1016/S02・・・
著者: S P Stawicki, J C Rosenfeld, N Weger, E L Fields, J D Balshi
雑誌名: 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  J Hum Hypertens. 2006 Sep;20(9):710-8. doi: 10.1038/sj.・・・
著者: Bruno Paris, Guillaume Bobrie, Patrick Rossignol, Sylvie Le Coz, Antoine Chedid, Pierre-François Plouin
雑誌名: 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  J Hypertens. 2006 Aug;24(8):1649-54. doi: 10.1097/01.hj・・・
著者: Marco Fiore, Lorenzo Andreana
雑誌名: 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  Am J Emerg Med. 2016 Feb;34(2):324-5. doi: 10.1016/j.aj・・・
著者: M Lacombe
雑誌名: 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  J Cardiovasc Surg (Torino). 1992 Mar-Apr;33(2):163-8.
著者: U Blum, P Billmann, T Krause, A Gabelmann, E Keller, E Moser, M Langer
雑誌名: 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  Radiology. 1993 Nov;189(2):549-54. doi: 10.1148/radiolo・・・
著者: Jihyun Yang, Jun Yong Lee, Young Ju Na, Sung Yoon Lim, Myung-Gyu Kim, Sang-Kyung Jo, Wonyong Cho
雑誌名: 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  Kidney Res Clin Pract. 2016 Jun;35(2):90-5. doi: 10.101・・・
著者: Saeko Kagaya, Ojima Yoshie, Hirotaka Fukami, Hiroyuki Sato, Ayako Saito, Yoichi Takeuchi, Ken Matsuda, Tasuku Nagasawa
雑誌名: 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  Clin Exp Nephrol. 2017 Dec;21(6):1030-1034. doi: 10.100・・・
著者: G Glück, M Croitoru, D Deleanu, P Platon
雑誌名: 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  Eur Urol. 2000 Sep;38(3):339-43. doi: 20303.
著者: Paul A Tunick, Ambika C Nayar, Gregory M Goodkin, Sunil Mirchandani, Steven Francescone, Barry P Rosenzweig, Robin S Freedberg, Edward S Katz, Robert M Applebaum, Itzhak Kronzon, NYU Atheroma Group
雑誌名: Am J Cardiol. 2002 Dec 15;90(12):1320-5.
Abstract/Text Severe aortic plaques seen on transesophageal echocardiography (TEE) are a high-risk cause of stroke and peripheral embolization. Evidence to guide therapy is lacking. Retrospective information was obtained regarding the occurrence of embolic events (stroke, transient ischemic attacks, or peripheral emboli) in 519 patients with severe thoracic aortic plaque seen on TEE since 1988. Treatment with statins, warfarin, or antiplatelet medications was noted. Treatment was not randomized. In a matched-paired analysis, each patient taking each class of therapy was matched for age, gender, previous embolic event, hypertension, diabetes, congestive failure, and atrial fibrillation to someone not taking that medication. Multivariate analysis was also performed. An embolic event occurred in 111 patients (21%). Multivariate analysis showed that statin use was independently protective against recurrent events (p = 0.0001). Matched analysis also showed a protective effect of statins (p = 0.0004; absolute risk reduction 17%, relative risk reduction 59%, number needed to treat [n = 6]). No protective effect was found for warfarin or antiplatelet drugs. The odds ratio for embolic events was 0.3 (95% confidence interval [CI] 0.2 to 0.6) for statin therapy, 0.7 (95% CI 0.4 to 1.2) for warfarin, and 1.4 (95% CI 0.8 to 2.4) for antiplatelet agents. Thus, there is a protective effect of statin therapy, and no significant benefit of warfarin or antiplatelet drugs on the incidence of stroke and other embolic events in patients with severe thoracic aortic plaque on TEE.

PMID 12480041  Am J Cardiol. 2002 Dec 15;90(12):1320-5.
著者: T A Salam, A B Lumsden, L G Martin
雑誌名: 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  Ann Vasc Surg. 1993 Jan;7(1):21-6. doi: 10.1007/BF02042・・・

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