That Bloody Kidney: Case of renal hemorrhage secondary to overwarfarinization

Abstract

Introduction

Renal hemorrhage is a rare cause of abdominal pain and can be easily missed. We report a case of elderly gentleman with left renal hemorrhage detected by bedside ultrasound in emergency department.

Case description

A 62 year old gentleman was known case of end stage renal failure (ESRF) and was on tablet warfarin for previous deep vein thrombosis. He presented to the emergency department with history of abdominal pain for three days. There was no history of trauma, fever or intestinal obstruction symptoms. On examination, patient was hypotensive and pale. Physical examination revealed palpable mass over the left upper quadrant, measuring 10cm x 6cm which was firm, non-mobile and tender on palpation. Laboratory findings revealed white blood cell count of 5.26 x 10⁹/L, hemoglobin 6.7g/dL, platelet count 220 x 10⁹/L, lactate 16.8mmol/L PT 45s, APTT 51.2s and INR 4. Bedside ultrasound over the left kidney showed gross hydronephrosis with heterogenous contents within the renal pyramids. Based on clinical, laboratory and bedside ultrasound findings, the working diagnosis was left kidney hemorrhage secondary to overwarfarinization. The contrast-enhanced CT Abdomen confirmed that there was spontaneous active left renal intraparenchymal hemorrhage with extensive perirenal hematoma.  Patient then underwent left renal artery embolization and was transfused with 3 pints of packed cells and 4 units of fresh frozen plasma prior to this procedure. The abdominal pain resolved after the procedure and patient was discharged well subsequently and could carry on with hemodialysis for his ESRF. 

Discussion

ESRF patients run the risk of being overwarfarinized leading to renal hemorrhage. The diagnosis should be considered in patients presenting with abdominal pain and high lactate. Bedside ultrasound able to detect the source of bleeding for this patient.  Renal artery embolization stops bleeding in this case. 

Conclusion

Renal hemorrhage could be detected quickly with the use of bedside ultrasound. High index of suspicion should be exercised for patients who are on anticoagulant.