1. Unusual complication of Nephrotic syndrome
Muzamil Latief
2nd year Resident Nephrology
GMC Secb’d

2. CASE DETAILS
25 years aged, resident of mahaboobnagar, daily labourer presented with
pedal edema, abdominal distention x 20 days
No H/o of hematuria, oliguria, abdominal pain, vomiting, dyspnea, fever

3. CASE DETAILS General physical examination :
Moderately built, moderately nourished
Pedal edema +,No pallor, icterus, lymphadenopathy
PR: 80 bpm regular.
BP : 140/ 80 mm Hg
Systemic examination : WNL

4. INVESTIGATIONS Hb: 12.8 gm/dl. TLC: 6500. PLT: 1.5 lakhs.
Serum creatinine : 1.0 mg/dl
Serum albumin: 2.3 mg/dl.
Total cholesterol :285, HDL : 57, LDL : 206, TG:170.
CUE : Albumin+++,RBC : Nil.
24 hrs urine protein : 3.6gm
HIV : NR, HbsAg : NR, HCV : NR
Ultrasound abdomen :
Both the kidneys :normal in size

5. Renal Biopsy
Biopsy includes 13 glomeruli, the glomeruli are enlarged in size with thickened basement membrane which show spikes. Tubules are closely packed. Interstitium and vessels are unremarkable.
IF IgG and C3 positive
Impression : Membranous nephropathy
Placed on ARB+MMF+steroids

6. Contd…..
remission till April 2018 (24 hr TUP 330mg) subsequently lost to follow up

7. Contd…..
September 2018:
Right loin pain x 5 days, no radiation of pain .
No H/o of burning micturition.
No H/o of fever, vomiting.
No H/o of oliguria, hematuria.
No H/o trauma.
No h/o stone disease
O/E : WNL

8. Investigations Hb 11gm/dl TLC 7500 plat: 2.5lac
S.creat 0.8mg/dl Prot 5.8gm/dl
S. alb 2.7gm/dl
CUE: alb :2+,PC 1-2, RBC NIL
24 HR TUP: 4.6 gm

9. Contd……
Ultrasound abdomen : Large perinephric collection surrounding the right kidney.
CT KUB : Large subcapsular collection tracking along the right psoas and in posterior pararenal space. Pelvicalyceal system is normal, there was no leak from the pelvicalyceal sytem on contrast administration

10. CT films

11. Differential diagnosis
Perinephric abscess :Bacterial vs TB
Urinoma
Perinephric hematoma
Transudative Perinephric Collection

12. Urologist opinion was taken and planned for RGP followed by PCN

13. RGP

14. Contd…..
There was no leak from the PCS into the perinephric collection and so a PCN was placed.
clear fluid drained from the PCN tube
About 500ml / day of fluid was draining from the PCN for 3 days
Fluid analysis :

15. Contd…… Transudative fluid collection of Nephrotic state
Perinephric fluid analysis DD
Clear, colourless,
No cells detected,
creatinine 0.9,
Amylase 76
Cultures : Sterile
CBNAAT :negative
Serum Creatinine 0.8
Urinoma
Pseudocyst of Pancreas
Transudative fluid collection of Nephrotic state

16. In our patient ….. Urinoma High fluid creatinine ✖
Transudative perirenal collection
High fluid creatinine ✖
Communication between renal pyelocalceal system and perirenal space ✖
Usually bilateral ✖
Transudative fluid✔
nephrotic state✔

17. Diagnosis
Nephrotic syndrome : Primary Glomerular disease : Membranous nephropathy in Relapse With Perirenal transudative fluid collection–Grade 3 - FLOATING KIDNEY

18. COURSE Patient has PCN in situ and started on Immunosuppression
Steriods/MMF +ARB

19. DISSCUSSION

21. D/D of Perirenal collection
Hematoma
Urinoma
Abscesses
Lymphangiomatosis
Xanthogranulomatous pyelonephritis
Pancreatitis
Pseudocyst of pancreas
Transudative Perirenal Collection
American Journal of Roentgenology. 2004;183: /ajr

22. Contd….
URINOMA
TRANSUDATIVE PERIRENAL COLLECTION
Usually bilateral unless a complication of renal vein thrombosis coexists
Transudative fluid
nephrotic state
Resolution with resolution of NS
Sparse literature
Accumulation of urine in subcapsular or perinephric space
Obstructive /nonobstructive
High fluid creatinine
Communication between renal pyelocalceal system and perirenal space

23. Contd….
Perirenal Fluid collections in Medical renal disease were ist called as “Renal sweat” it was described in 1999 by Nyassa et al (Los Angeles)
It was thought as a sign of Renal Failure
in 14% of patients - when present it was always bilateral and diagnosed on USG
Nyassa et al American j of Roetntgenology 99

24. Contd….
The source of the fluid is debated and its etiology has been ascribed to sodium retention and veno-occlusive state
On renal sonographic images, kidney sweat is seen as an anechoic lucent rim around the kidney
CT/MRI may be needed
Hira lal et al Abdom Radiol (2017)

25. Grading of Perirenal Collections
consisted of a small rim or thin layer of Fluid ranging from 3 to 10 mm in thickness surrounding part of the renal parenchyma, mainly the anterior aspect of the kidney and its lower pole or completely surrounding the kidney in a circumferential pattern
consisted of a moderate amount of Fluid ranging from 1 to 5 cm in thickness with evidence of strands and indentations of the renal parenchyma
consisted of a large Fluid collection greater than 5 cm in thickness surrounding the kidney “Floating Kidney”
Haddad et al Clinical Radiology (2001) 56: 979±983

26. Contd….
When a large volume of fluid surrounds the kidney it is called ‘‘floating kidney’’
The condition is usually bilateral
The presence of renal failure is not mandatory for the development of ‘‘renal sweat”
Hira lal et al Abdom Radiol (2017)

27. Contd… Unilateral Transudative Collection is a rare entity
Only few case reports available
A patient had nephrotic syndrome (Lupus), developed right renal vein thrombosis without evidence of perirenal fluid around the right kidney, but had unilateral left perirenal fluid
Royal college of Radiology Clinical Radiology (2001) 56: 979±983

28. Contd….
Another case of membranous Nephropathy and right renal vein thrombosis associated with ipsilateral perirenal subcapsular fluid collection managed with PCN and subsequently on antiplatelets and spontaneous remission of MN
Orofino et al 'ThE JOURNAL OF UrOLOGY July 1986.

33. Take Home message Floating Kidney is a rare entity
It can present as bilateral, bilateral with varying severity and rarely unilateral
It can be minimal “perirenal rim” to large volume “Floating Kidney”
Diagnosis is established based on Imaging and Fluid analysis
PCN drainage may be required in some cases and of course “Treat the cause”

34. Thanks