1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. (( والعصر إن الانسان لفي خسر ))

3. RENAL INFARCTION Presented by: Dr. Barakat M. AL-Otaibi Medical Student August 2008

4. objectives Causes Diagnosis Treatment

5. WHAT ARE THE CAUSES?

6. EMBOLIZATION Thromboembolism: - atrial fibrillation,most common etiology (left atrium or left atrial appendage ) - left ventricular thrombus (myocardial infarction, dilated cardiomyopathy) - thromboemboli originating from complex plaque in the aorta. Valvular vegetations in infective endocarditis. Tumor and fat emboli and paradoxical embolism through a patent foramen ovale.

7. EMBOLIZATION The reported incidence of renal thromboembolism in patients with atrial fibrillation was 2 % in a series of almost 30,000 patients followed for up to 13 years. Incident thromboembolism in the aorta and the renal, mesenteric, pelvic, and extremity arteries after discharge from the hospital with a diagnosis of atrial fibrillation. Arch Intern Med 2001; 161:272.

8. WHAT ARE THE CAUSES?

9. Transesophageal echo showing a thrombus in the left atrial appendage of a patient with atrial fibrillation

10. WHAT ARE THE CAUSES? Transesophageal echo showing spontaneous contrast "smoke" in the left atrial appendage of a patient with atrial fibrillation.

11. WHAT ARE THE CAUSES? Left ventricular apical thombus

12. THROMBOSIS Renal artery thrombosis: ( atherosclerotic renovascular disease, traumatic intimal tear, vasculitis). Spontaneous or iatrogenic renal artery or aortic dissection. Complication following endovascular (aortic or renal) intervention. Antiphospholipid syndrome, although mostly microvascular disease.

13. WHAT ARE THE CAUSES? Cocaine Cocaine-induced renal infarction: report of a case and review of the literature. BMC Nephrol. 2005 Sep 22;6:10 Idiopathic renal infarction. Idiopathic renal infarction.Am J Med. 2006 Apr;119(4):356.e9-12.

14. CLINICAL MANIFESTATION acute onset of : nausea vomiting flank pain generalized abdominal pain and tenderness fever oliguria acute elevation in blood pressure

15. Laboratory manifestations Elevated peripheral white blood cell count. Elevated serum creatinine concentration, particularly in patients with a large embolus or bilateral disease. Gross or microscopic hematuria (30%-50%). Proteinuria. Markedly elevated serum lactate dehydrogenase (LDH), with little or no rise in serum aminotransferases, is strongly suggestive of renal infarction. Urinary LDH excretion is increased.

18. DIAGNOSIS Spiral CT without contrast Contrast – enhanced CT

20. Sensitivity of imaging studies 90% Perfusion scan 80% CT with contrast 11% Ultrasound

29. Differential diagnosis flank pain Renal colic Hematuria Normal LDH Acute pylonephritis Fever Chills & rigors Pyuria & WBC casts Other causes of acute abdomen

30. treatment The optimal treatment for renal infarction is uncertain, given the absence of comparative studies. Reported approaches include: anticoagulation endovascular therapy open surgery

31. Anticoagulation The primary aim of anticoagulation is to prevent future events. Renal prognosis has generally been favorable, but there are no reports comparing outcomes with untreated patients.

32. Thrombolysis and thrombectomy experience is so limited that recommendations for therapy cannot be made with confidence.

33. Local infusion of fibrinolytic agents for acute renal artery thromboembolism: report of ten cases. Ann Vasc Surg 1993; 7:21.

34. 30% 3 Thrombosis of a stenosed vessel 20% 2 Renal artery embolism 40% 4 Complication of percutaneous transluminal angioplasty 10% 1 Aortic occlusion

35. Clinical presentation Flank pain present in all cases (100%). Hematuria in four cases (40%). ARF in four cases (40%).

36. All cases treated with selective thrombolysis 5 cases combined with ballon catheter angioplasty

37. outcomes 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. No major bleeding complications were encountered and there were no deaths in this group of patients. Radioisotope renogram performed in all patients at two months, only three had improvement in renal perfusion and function, including one of the four patients with acute renal failure.

38. Effect of local low-dose thrombolysis on clinical outcome in acute embolic renal artery occlusion. Radiology 1993 Nov;189(2):549-54. 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.

39. 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.

40. SURGERY There are no data comparing surgery to anticoagulation, local thrombolytic therapy, or catheter thrombectomy. Most of the reported are old and data summarizing experience from 1970 to 1982 noted an operative mortality rate of 11 percent. Based upon such observations, there seems to be little indication for primary surgical therapy in the current era, particularly in patients with two functioning kidneys and unilateral disease. A possible exception is the trauma patient in whom surgery is indicated for other reasons.