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CARBON DIOXIDE (C02) ANGIOGRAPHY IN THE DIAGNOSIS OF FIBROMUSCULAR DYSPLASIA (FMD): A CASE REPORT
NKF 2014 Spring Clinical Meetings Abstracts
125 ACUTE KIDNEY INJURY WITH PAPILLARY NECROSIS IN A CASE OF POST STEM CELL TRANSPLANT: A CASE REPORT Roveena Goveas, Zeenat Bhat, Wayne State University School of Medicine & Detroit Medical Center, Detroit, MI, USA Renal papillary necrosis is usually associated with conditions that lead to ischemia of the medullary pyramids. Its presentation in the absence of well-known risk factors is rare. 54year old Caucasian female with essential thrombocytopenia and myelofibrosis, was initially managed with chlorambucil, hydroxyurea and ruxolitinib and underwent a splenectomy. She was admitted for allogenic stem cell transplant, received anti thymocyte globulin, cellcept and tacrolimus for immunosupression, induction with Busulfan, Fludarabine and total body irradiation, and failed to engraft. On day 44 of allogenic stem cell transplant she developed acute kidney injury. Her creatinine trended up from 0.4 to 1.8. She denied dysuria, flank tenderness and hematuria. Denied use of non-steroidal antiinflammatory drugs in the recent past. She was treated with cefepime for febrile neutropenia and was on acyclovir for herpes infection. On examination she was normotensive, tachycardic. Renal US showed mild left hydronephrosis with dilated calyces containing echogenic debris which were suggestive of papillary necrosis. She had no known history of sickle cell hemoglobinopathies, diabetes mellitus or any history suggestive of vasculitis. Urine cultures were negative. Urinalysis showed hematuria. Given her immune compromised status and appearance of debris in renal ultrasound, fungal infection was considered and ruled out. She slowly recovered her renal functions with supportive care. Papillary necrosis characterized by coagulative necrosis of the renal medullary pyramids and papillae, is caused by conditions that induce ischemia of these structures. It is usually seen in patients with sickle cell disease, pyelonephritis, diabetes mellitus, and analgesic nephropathy. In our case we were not able to identify a definitive cause; she lacked common risk factors such as diabetes mellitus but could have been multifactorial. Most likely cause for papillary necrosis in this case was ischemic injury sustained from sepsis, altered renal hemodynamic leading to decreased renal perfusion and total body irradiation, as a contributory factor.
126 CARBON DIOXIDE (CO2) ANGIOGRAPHY IN THE DIAGNOSIS OF FIBROMUSCULAR DYSPLASIA (FMD): A CASE REPORT. Roveena Goveas, Humayun Ashraf, Noreen Rossi, John Flack, James Sondheimer. Wayne State University School of Medicine & Detroit Medical Center, Detroit, Michigan,USA. Middle aged females presenting with accelerated hypertension (HTN) pose a diagnostic challenge due to overlap between atherosclerotic lesions and FMD of the renal artery. A 45 year old Caucasian woman presented with complaints of headache, blurred vision, nausea, vomiting along with difficulty maintaining balance. She had no personal history but a strong family history of HTN. She was in hypertensive emergency with BP 300/175 mmHg. Physical exam revealed an S4 gallop, bilateral optic disc edema, flame hemorrhages and cotton wool spots. She had increased muscular tone, hyper reflexia, extensor plantar reflex on the right and dysmetria of the left upper extremity. Intravenous nicardipine was initiated. MRI showed two acute ischemic infarcts in the corona radiata and subacute hemorrhages in the left cerebellar hemisphere. Laboratory data showed creatinine 6.8 mg/dL (baseline of around 1.8 mg/dL), platelet count 145K/mm3 with anisocytosis. She was hemodialyzed acutely. Workup for secondary HTN was pursued. Renal artery duplex was negative. Nonetheless, CO2 angiography was performed and revealed bilateral lesions compatible with FMD. She underwent successful bilateral angioplasty after which her BP improved. She is currently on amlodipine, lisinopril and labetalol with good BP control, and partial recovery of renal function, creatinine 3.6 mg/dL. FMD should be suspected in middle aged females presenting with accelerated HTN. Unlike atherosclerotic disease in which angioplasty does not improve outcome compared with medical therapy, angioplasty may provide benefit in FMD. Our case highlights benefit of accurately diagnosing FMD in middle aged females and its subsequent treatment.
A50
127 NEPHRON SPARING THERAPY FOR INCIDENTAL DE NOVO RENAL CELL CARCINOMA (RCC) IN A KIDNEY ALLOGRAFT 15 YEARS AFTER TRANSPLANATATION: CASE REPORT Roveena Goveas, Mona Doshi, Wayne State University School of Medicine & Detroit Medical Center, Detroit, Michigan, USA. We report a case of a kidney transplant recipient who developed two foci of renal carcinomas of varying histology that were successfully treated with cryoablation and minimal loss of graft function. 49 year old African American lady status post deceased donor renal transplant 15 years ago who was noted to have abnormal urine analysis at a routine clinic visit. Subsequent work up including an MRI revealed two lesions over the transplanted kidney, a 2.3 cm lesion in the mid to upper pole and a 1.7 cm lesion in the mid to lower pole, both of which had features suspicious for renal malignancy. A CT guided biopsy of the upper pole lesion showed papillary cell carcinoma and the mid pole revealed clear cell papillary RCC. Her allograft function was stable at around 40ml/min/1.73m2 for the last decade and so nephron sparing therapy was considered to be the most suitable option. She underwent cryoablation of both the lesions on two separate occasions one month apart. Post procedure she did well and maintained her renal function. Follow up MRI in 12 months did not show any evidence of recurrence. RCC in allograft is a rare entity. Traditional treatment involves radical nephrectomy. More recently nephron conserving options such as nephron sparing surgery, cryoablation, radiofrequency ablation have been successfully employed to treat small localized solitary tumors, especially in Caucasians with sparse literature in other races. To the best of our knowledge, this is first case report in United States on successful use of nephron sparing treatment of renal cancer in allograft of African American recipient. Other uniqueness to our case was the presence of two unique foci of cancer of varying histology. Papillary cell carcinoma and clear cell papillary renal cell carcinoma are considered as two distinct pathologies. There is lack of literature on the effectiveness of nephron sparing lesion in treating papillary cell variety. Our case highlights the effectiveness of nephron sparing cryoablative procedure in treatment of small renal allograft lesions with relative preservation of renal function.
128 MASSIVE PNEUMOPERITONEUM IN PATIENTS ON CHRONIC PERITONEAL DIALYSIS Vanya Grover, Chelsea Estrada, William Weber, Cheryl Laveglia, Heesuck Suh, Nand K. Wadhwa. Division of Nephrology, SUNY, Stony Brook, New York, USA. Massive pneumoperitoneum (PP) is a rare complication in peritoneal dialysis patients on automated peritoneal dialysis (APD). We encountered two patients with massive PP due to a faulty APD technique presenting as acute abdomen. First patient was a 68 year-old woman with ESRD on APD who was admitted with diffuse abdominal pain. She was afebrile and her abdomen was distended and diffusely tender. She was diagnosed acute peritonitis and was empirically treated with antibiotics. The peritoneal fluid revealed a cell count of 411WBC per mcL with 2% neutrophils. Gram stain and cultures were negative. APD was resumed and within 24 hours her abdominal pain resolved. She was discharged home without antibiotics. Ten days later she developed a similar episode. A computed tomography (CT) revealed massive free intraperitoneal air. APD was resumed and her abdominal pain subsided. Again peritoneal fluid was negative. The second patient was a 48 year-old man with ESRD on APD who was admitted with distended abdomen for one week. He was afebrile and abdomen was distended but non-tender. The peritoneal fluid was negative. CT of the abdomen revealed PP. APD was resumed and his abdominal distension subsided. PP without peritonitis in PD patients less likely indicates intraabdominal etiology needing surgical interventions. Deviation from the PD procedure should be considered in differential diagnoses. In both patients after reviewing the APD procedure, the cause of PP was found to be same faulty technique with an introduction of air from the APD set before initiating PD. After retraining of these patients for the APD procedure, no further episode of PP occurred. We suggest that in patients with massive PP, the technique of APD should be evaluated including retraining if needed to prevent its recurrence.
Am J Kidney Dis. 2014;63(5):A1-A121
125 ACUTE KIDNEY INJURY WITH PAPILLARY NECROSIS IN A CASE OF POST STEM CELL TRANSPLANT: A CASE REPORT Roveena Goveas, Zeenat Bhat, Wayne State University School of Medicine & Detroit Medical Center, Detroit, MI, USA Renal papillary necrosis is usually associated with conditions that lead to ischemia of the medullary pyramids. Its presentation in the absence of well-known risk factors is rare. 54year old Caucasian female with essential thrombocytopenia and myelofibrosis, was initially managed with chlorambucil, hydroxyurea and ruxolitinib and underwent a splenectomy. She was admitted for allogenic stem cell transplant, received anti thymocyte globulin, cellcept and tacrolimus for immunosupression, induction with Busulfan, Fludarabine and total body irradiation, and failed to engraft. On day 44 of allogenic stem cell transplant she developed acute kidney injury. Her creatinine trended up from 0.4 to 1.8. She denied dysuria, flank tenderness and hematuria. Denied use of non-steroidal antiinflammatory drugs in the recent past. She was treated with cefepime for febrile neutropenia and was on acyclovir for herpes infection. On examination she was normotensive, tachycardic. Renal US showed mild left hydronephrosis with dilated calyces containing echogenic debris which were suggestive of papillary necrosis. She had no known history of sickle cell hemoglobinopathies, diabetes mellitus or any history suggestive of vasculitis. Urine cultures were negative. Urinalysis showed hematuria. Given her immune compromised status and appearance of debris in renal ultrasound, fungal infection was considered and ruled out. She slowly recovered her renal functions with supportive care. Papillary necrosis characterized by coagulative necrosis of the renal medullary pyramids and papillae, is caused by conditions that induce ischemia of these structures. It is usually seen in patients with sickle cell disease, pyelonephritis, diabetes mellitus, and analgesic nephropathy. In our case we were not able to identify a definitive cause; she lacked common risk factors such as diabetes mellitus but could have been multifactorial. Most likely cause for papillary necrosis in this case was ischemic injury sustained from sepsis, altered renal hemodynamic leading to decreased renal perfusion and total body irradiation, as a contributory factor.
126 CARBON DIOXIDE (CO2) ANGIOGRAPHY IN THE DIAGNOSIS OF FIBROMUSCULAR DYSPLASIA (FMD): A CASE REPORT. Roveena Goveas, Humayun Ashraf, Noreen Rossi, John Flack, James Sondheimer. Wayne State University School of Medicine & Detroit Medical Center, Detroit, Michigan,USA. Middle aged females presenting with accelerated hypertension (HTN) pose a diagnostic challenge due to overlap between atherosclerotic lesions and FMD of the renal artery. A 45 year old Caucasian woman presented with complaints of headache, blurred vision, nausea, vomiting along with difficulty maintaining balance. She had no personal history but a strong family history of HTN. She was in hypertensive emergency with BP 300/175 mmHg. Physical exam revealed an S4 gallop, bilateral optic disc edema, flame hemorrhages and cotton wool spots. She had increased muscular tone, hyper reflexia, extensor plantar reflex on the right and dysmetria of the left upper extremity. Intravenous nicardipine was initiated. MRI showed two acute ischemic infarcts in the corona radiata and subacute hemorrhages in the left cerebellar hemisphere. Laboratory data showed creatinine 6.8 mg/dL (baseline of around 1.8 mg/dL), platelet count 145K/mm3 with anisocytosis. She was hemodialyzed acutely. Workup for secondary HTN was pursued. Renal artery duplex was negative. Nonetheless, CO2 angiography was performed and revealed bilateral lesions compatible with FMD. She underwent successful bilateral angioplasty after which her BP improved. She is currently on amlodipine, lisinopril and labetalol with good BP control, and partial recovery of renal function, creatinine 3.6 mg/dL. FMD should be suspected in middle aged females presenting with accelerated HTN. Unlike atherosclerotic disease in which angioplasty does not improve outcome compared with medical therapy, angioplasty may provide benefit in FMD. Our case highlights benefit of accurately diagnosing FMD in middle aged females and its subsequent treatment.
A50
127 NEPHRON SPARING THERAPY FOR INCIDENTAL DE NOVO RENAL CELL CARCINOMA (RCC) IN A KIDNEY ALLOGRAFT 15 YEARS AFTER TRANSPLANATATION: CASE REPORT Roveena Goveas, Mona Doshi, Wayne State University School of Medicine & Detroit Medical Center, Detroit, Michigan, USA. We report a case of a kidney transplant recipient who developed two foci of renal carcinomas of varying histology that were successfully treated with cryoablation and minimal loss of graft function. 49 year old African American lady status post deceased donor renal transplant 15 years ago who was noted to have abnormal urine analysis at a routine clinic visit. Subsequent work up including an MRI revealed two lesions over the transplanted kidney, a 2.3 cm lesion in the mid to upper pole and a 1.7 cm lesion in the mid to lower pole, both of which had features suspicious for renal malignancy. A CT guided biopsy of the upper pole lesion showed papillary cell carcinoma and the mid pole revealed clear cell papillary RCC. Her allograft function was stable at around 40ml/min/1.73m2 for the last decade and so nephron sparing therapy was considered to be the most suitable option. She underwent cryoablation of both the lesions on two separate occasions one month apart. Post procedure she did well and maintained her renal function. Follow up MRI in 12 months did not show any evidence of recurrence. RCC in allograft is a rare entity. Traditional treatment involves radical nephrectomy. More recently nephron conserving options such as nephron sparing surgery, cryoablation, radiofrequency ablation have been successfully employed to treat small localized solitary tumors, especially in Caucasians with sparse literature in other races. To the best of our knowledge, this is first case report in United States on successful use of nephron sparing treatment of renal cancer in allograft of African American recipient. Other uniqueness to our case was the presence of two unique foci of cancer of varying histology. Papillary cell carcinoma and clear cell papillary renal cell carcinoma are considered as two distinct pathologies. There is lack of literature on the effectiveness of nephron sparing lesion in treating papillary cell variety. Our case highlights the effectiveness of nephron sparing cryoablative procedure in treatment of small renal allograft lesions with relative preservation of renal function.
128 MASSIVE PNEUMOPERITONEUM IN PATIENTS ON CHRONIC PERITONEAL DIALYSIS Vanya Grover, Chelsea Estrada, William Weber, Cheryl Laveglia, Heesuck Suh, Nand K. Wadhwa. Division of Nephrology, SUNY, Stony Brook, New York, USA. Massive pneumoperitoneum (PP) is a rare complication in peritoneal dialysis patients on automated peritoneal dialysis (APD). We encountered two patients with massive PP due to a faulty APD technique presenting as acute abdomen. First patient was a 68 year-old woman with ESRD on APD who was admitted with diffuse abdominal pain. She was afebrile and her abdomen was distended and diffusely tender. She was diagnosed acute peritonitis and was empirically treated with antibiotics. The peritoneal fluid revealed a cell count of 411WBC per mcL with 2% neutrophils. Gram stain and cultures were negative. APD was resumed and within 24 hours her abdominal pain resolved. She was discharged home without antibiotics. Ten days later she developed a similar episode. A computed tomography (CT) revealed massive free intraperitoneal air. APD was resumed and her abdominal pain subsided. Again peritoneal fluid was negative. The second patient was a 48 year-old man with ESRD on APD who was admitted with distended abdomen for one week. He was afebrile and abdomen was distended but non-tender. The peritoneal fluid was negative. CT of the abdomen revealed PP. APD was resumed and his abdominal distension subsided. PP without peritonitis in PD patients less likely indicates intraabdominal etiology needing surgical interventions. Deviation from the PD procedure should be considered in differential diagnoses. In both patients after reviewing the APD procedure, the cause of PP was found to be same faulty technique with an introduction of air from the APD set before initiating PD. After retraining of these patients for the APD procedure, no further episode of PP occurred. We suggest that in patients with massive PP, the technique of APD should be evaluated including retraining if needed to prevent its recurrence.
Am J Kidney Dis. 2014;63(5):A1-A121