1. Case of the week
신장내과 R2 이재연

2. Case 1 C.C.) Rt abdomen pain o/s 내원 1 달전 Hematuria o/s 내원 1 일전 P.I. )
신 O 천 (M/52) adm
C.C.)
Rt abdomen pain o/s 내원 1 달전
Hematuria o/s 내원 1 일전
P.I. )
’94년 r/o GN ESRD로 HD start
AVF occlusion 으로 수 차례 angioplasty ,
02 년 AVF op 재시행
’01년 11월 Rt abdominal pain 있어 개인병원 방문, Rt renal mass 의심되어 전원 , abdomen CT에서 both kidney의 multiple small cyst 와 cyst rupture의한 Rt renal hematoma
소견 보여 항생제 및 conservative Mx 후 퇴원함
이후 AVF occlusion 으로 수 차례 angioplasty 시행 받음

3. ’06년 7월 , 갑자기 Lt flank pain 이 발생하여 응급실 내원
CT 촬영 결과 Known acquired cystic kidney disease에
Lt renal hematoma 발생하여 bleeding control 및 conservative Mx 후 비뇨기과 상의결과 elective nephrectomy 고려하기로 하고 퇴원함.
‘06년 9월 recurrent AV graft site infection 과 occlusion 으로 warfarin 복용 시작함
’06년 10월 중순부터 Rt abdominal pain 있고 내원 전일
혈뇨 발생하여 응급실로 내원함

4. PMHx) DM/ HTN/ pul. Tb/ hepatitis(-/+/-/-)
HTN: ’89년 CKD 진단 시 같이 진단
Op Hx)
AVF op.: ‘94. 12, ‘02. 3 , ’06.11
d/t recurrent AVF obstruction
PHx) alcohol (-)
smoking (-)

5. Review of system Physical examination
General fever(-) chill(-) malaise(-)
GI A/N/V/D/C(+/-/-/-/-)
diffuse abdominal pain(+): both (Rt.>Lt.)
GU Urine output<10cc/day
hematuria(+) voiding difficulty(-)
Physical examination
V/S /70mmHg- 74회/min- 18회/min- 36.7°C
Chest CBS without crackle
RHB without murmur
Abd soft and flat abdomen
abdominal Td/ RTd (+ / -) : Rt. flank area
Rt abdominal palpable mass(+)
B/Ext CVA tenderness ( + / - ) pitting edema(-/-)
Rt. arm AVF site thrill & bruit: good

6. Initial lab finding CBC/DC 7530/mm3- 6.4g/dL-20.0%-268K(seg 68.7%)
PT/PTT
3.55(INR) / sec.
Chemistry
TB/DB / 0.2 mg/dL AST/ALT 29/ 16 U/L
ALP/GGT 64/ 6 mg/dL Prot/alb 7.0/ 3.7 g/dL
LD/CK / 2.5 U/L Glucose 104 mg/dL
BUN/Cr / 11.8 mg/dL Na/K/Cl 138/5.3/99 mmol/L
CRP: mg/dL
EKG N.S.R

7. Chest PA

8. Abd CT ( )
Hemorrhage at Lt perirenal space

9. Initial problem lists
1. Rt. Flank pain & hematuria
Acquired cystic kidney disease, s/p Lt cyst rupture
2. ESRD on HD

10. Initial assessement & plan
1.R/o Recurred vessel rupture of
acquired cystic kidney disease
p) f/u Abdomen CT (이전 CT와 비교)
CBC/DC f/u  transfusion if need
pain 양상 관찰, HR 관찰
Wafarin medication 중단
Vit K supply
2. ESRD on HD
p) HD without heparin

11. HD 2
Hb level 1g/dL
이상 감소
HR 증가 소견
응급 CT시행

12. Right renal hemorrhage with large perirenal hematoma
Abdomen CT ( )
06.7월 abdomen CT
Right renal hemorrhage with large perirenal hematoma
Acquired renal cystic disease
Emergent embolization 결정!

13. Embolization
Renal cystic artery중
2곳 embolization시행

14. f/u Abdomen CT ( )

15. Final diagnosis
1. Acquired cystic kidney disease
with recurred cystic vessel rupture s/p embolization
2. ESRD on HD

16. Case 2
오O근 ( M/54) adm
C.C.) diffuse abdominal pain o/s 1일 전
P.I.)
‘18년 전 Type 2 DM 진단
‘10년 전부터 DM nephropathy ESRD로 CAPD 시행
CAPD Peritonitis로 2차례 입원 치료함
내원 1달 전 CAPD peritonitis 로 항생제 치료에 반응 없어
CAPD catheter 제거 후 HD로 전환함
17일 전에 퇴원 하여 동네 의원에서 HD 시행하며
경도의 diffuse abdominal pain 있어 항생제 치료 받음
내원 1일 전부터, diffuse abdominal pain 및
watery diarrhea 3-4회 있어 응급실 경유 입원.

17. PMHx)
당뇨병 : 18년전 진단, nateglinide 90mg tid
고혈압 : 10년전 진단 ,madipine 5mg qd cilazapril 2.5 mg qd
폐결핵 : 15년전 Pulmonay Tb.진단.약물 치료 후 완치 판정
B 형 간염 : 없음
수술력 : Lt. AV Fistula ( radiocephalic)
FHx) 특이사항 없음
PHx) 술(-), 담배 (-)

18. REVIEW OF SYSTEM
General : general weakness (+) fever (-) chill (-)
Skin : Itching (-) rash (-)
H & N : sore throat(-)
Resp. : cough(-) sputum(-) dyspnea(-)
Cardiac : chest pain(-) orthopnea(-)
G-I : abdominal pain(+) A/N/V/D/C(-/-/-/+/-)
G-U : dysuria(-) frequency(-) nocturia(-)
Endo. : polydipsia(-) polyuria(-)
M-S : arthralgia(-) : both wrist, elbow, ankle

19. PHYSICAL EXAMINATION
V/S : 130/70 mmHg - 78/min - 20/min ℃
Chest
Clear breathing sound without crackle or wheezing
Regular heart beat without murmur
Abdomen
Mild distended abdomen
Hyperactive bowel sound
Diffuse tenderness (+) or rebound tenderness (-)
Back/Extremity
CVA tenderness(-/-)
Peripheral pitting edema(-/-)
Lt. wrist ; thrill ( good)

20. PHYSICAL EXAMINATION
Abdomen
Mild distended abdomen
Hyperactive bowel sound
Diffuse tenderness (+) or rebound tenderness (-)
Back/Extremity
CVA tenderness(-/-)
Peripheral pitting edema(-/-)
Lt. wrist ; thrill ( good) ,
Nerology
Knee DTR(++/++) , Motor & sensory intact

21. Laboratory Finding
CBC/DC
10950 /mm g/dL % /㎣ (Seg %)
Chemistry
TB/DB 0.87/0.15 mg/dL T-cholesterol mg/dL
AST/ALT 48/ U/L ALP U/L
Pro/ALB 5.9/2.3 g/dL BUN/Cr /7.6 mg/dL
Glucose mg/dL Na/K/Cl /3.2/94 mmol/L
Ca/P/Mg /1.2/2.4 mg/dL
Urinalysis
Urine 없음

22. Chest PA

23. ABDOMEN SUPINE

24. ABDOMEN CT ( )

25. Initial problem lists
1. Abdominal pain & diarrhea
Known CAPD peritonitis
2. ESRD on HD
3. Type 2 DM
4. Known acquired renal cystic disease

26. Initial assessement & plan
1.AGE, CAPD peritonitis
p) stool culture, Widal test ,
ascites analysis ; cytology, gram stain, culture, chemistry
abdominal CT
if needed continue antibiotics
2. ESRD on HD
p) HD
3. Type 2 DM
p) continue current medication
4. Aquired renal cystic disease
p) abdominal CT

27. Initial lab finding CBC/DC
10,950/mm g/dL – 27.6% - 473K (seg %)
PT/PTT
1.05 (INR) 56c 33 sec.
Chemistry
TB/DB / 0.15 mg/dL AST/ALT 48/ 12 U/L
ALP/GGT 152/74 mg/dL Prot/alb 5.9/2.3 g/dL
Glucose mg/dL
BUN/Cr / 7.6 mg/dL Na/K/Cl 136/3.2/96 mmol/L
CRP: mg/dL ESR 42 mm/hr
Widal O,H,A,B titer < 20
Stool culture : negative
EKG N.S.R

28. Ascites
L.D unit
Amylase
RBC /m㎥
WBC /m㎥
Neutrophils 21 %
Lymphocytes 44
Eosinophils 1
Mono 28
Histio 6
Protein mg/dL
Glucose mg/dL
CL mmol
Cytology within noma limit
Gram stain not found
Culture not found

29. Abdominal CT (06-2-8)
RK, upper pole, large cyst with enhancing solid portion

30. Abdominal CT (06-2-8)

31. Further diagnostic plan
Kidney MRI
Bone scan

32. KIDNEY MRI – T1

33. RK, upper pole, large cyst with enhancing solid portion
KIDNEY MRI – T1 enhanced
RK, upper pole, large cyst with enhancing solid portion
T1WI에서 renal parenchyma와 isosignal intensity를 보이고 T2WI에서 약간 높은 signal intensity를 보이며 enhancement가 비교적 잘 되는 lobulating solid portion을 가지고 있음

34. BONE SCAN - no metastatic bone lesion

35. Renal angioinfarction (06-3-28)
lipiodol embolization

36. abd CT

37. Final diagnosis
1. Acquired cystic kidney disease with RCC
s/p Right renal infarction and atrophy
2. AGE, CAPD peritonitis
3. ESRD on HD
3. Type 2 DM

38. Thank you !!