The Korean Journal of 2010; 29: 768～771 Case Report

1) Renal Pelvic Hematoma Induced by Delayed Re-bleeding After Renal

Dae-hong Jeon, M.D.1, Jong Woo Seo, M.D.1, Yeojin Kang, M.D.1, Dong Won Lee, M.D.1, Hyeon Jeong Lee, M.D.1, Hyun-Jung Kim, M.D.1, Se-Ho Chang, M.D.1, 2 and Dong Jun Park, M.D.1, 2

Department of Internal Medicine1, Gyeongsang National University School of Medicine, Institute of Health Science2, Jinju, Republic of Korea

Renal biopsy is a useful method for the diagnosis of disease. Complications may occur and are usually associated with bleeding. However, delayed recurrent bleeding is so rare. We report a case of renal pelvic hematoma and occurred by delayed re-bleeding after percutaneous needle renal biopsy. A 42-year-old woman was admitted to our institution via emergency room with gross and left flank pain, which had started on that day. Renal biopsy had been done 8 days earlier. Computed tomography (CT) angiography revealed left hydronephrosis caused by pelvic hematoma and we observed bloody urine in the left ureteral orifice on . Hydration, diuresis and double J stent insertion restored hydronephrosis and hematuria was disappeared. Even though renal pelvic hematoma by delayed bleeding occurs rarely after percutaneous needle kidney biopsy, we should consider this complication when delayed recurrent gross hematuria occurs after kidney biopsy.

Key Words: Biopsy, Hematuria, Hematoma

However, complications, although rare, may occur INTRODUCTION and the majority of these are related to bleeding. The common complications of percutaneous needle renal Renal biopsy is a useful method not only for the biopsy include hematuria, perinephric hematoma, arte- diagnosis of kidney disease, but also to determine riovenous fistula, aneurysm and infections. Microscopic treatment strategy and evaluate response to treat- hematuria almost always occurs in all patients, but ment1). Furthermore, the percutaneous approach using gross hematuria occurs in 5% to 9% of biopsy pati- real-time ultrasound guidance and automated biopsy ents3-6). On occasion, gross hematuria occurs days needles is the standard method of obtaining tissue in after the biopsy, but it resolves within a few days patients without contraindications. This procedure re- with resting in most cases3). We report a case of renal mains safe with a few risks to the patient and provides pelvic hematoma occurred by delayed re-bleeding adequate tissue for diagnosis in at least 95% of cases2). after percutaneous needle renal biopsy causing gross

Submitted: 3 August 2010, Revised: 30 August 2010 hematuria and hydronephrosis. Accepted: 30 August 2010 Correspondence: Dong Jun Park, M.D. CASE REPORT Department of Internal Medicine, Gyeongsang National University, College of Medicine, 92 Chiram-dong, Jinju, South Korea. A 42-year-old woman was admitted to our institu- Tel: 055)750-8739, Fax: 055)758-9122 tion via emergency room with gross hematuria and E-mail: [email protected] Dae-hong Jeon, et al.: Hydronephrosis after Renal Biopsy left flank pain, which had started on that day. She had signs were as follows: blood pressure (140/90 mmHg), undergone a percutaneous ultrasound-guided renal heart rate (95 beats per minute), body temperature biopsy 8 days earlier because of rapid aggravation of (36.7℃), and respiratory rate (21 times per minute). and increased , and There was mild at her conjunctivae and no subsequently experienced gross hematuria that stop- jaundice on her sclera. The chest examination re- ped spontaneously two days after biopsy. We had vealed no abnormal findings. There was no hepato- used 16G automated gun needle and gotten 3 pieces megaly or splenomegaly on the abdominal examination. of tissue. We had found no structural abnormality There was no skin lesion on whole body. Pretibial causing the gross hematuria on follow up kidney Dop- pitting edema was shown on the both legs. The peri- pler ultrasonography one day after biopsy (Fig. 1). pheral WBC count was 17,470/mm3 (neutrophils: 78.7 She was discharged without gross hematuria after %, lymphoid cells: 13.6%, and monocytes: 2.8%). hydration and bed rest. Her hemoglobin was 11.5 mg/ The hemoglobin level was 10.8 g/dL and the platelet dL, BUN and creatinine levels were 35.5 mg/dL and count was 449,000/mm3. Her hepatitis B surface anti- 3.5 mg/dL, respectively at the day of discharge. Final gen and antibody were negative and positive, respec- results of her renal biopsy revealed diabetic nephro- tively. Antibody against hepatitis C antigen was nega- pathy. tive. Blood test showed as follows: total protein (5.4 On re-admission, she had abrupt gross hematuria g/dL), albumin (2.2 g/dL), sodium (138.8 mmol/L), with clotting and progressive left flank pain. Her vital potassium (4.2 mmol/L), chloride (110.8 mmol/L),

tCO2 (18 mmol/L), calcium (8.3 mg/dL), phosphorus (4.6 mg/dL), glucose (240 mg/dL), BUN (31.5 mg/ dL), and creatinine (3.8 mg/dL). There was no ab- normality on routine laboratory finding. We observed bloody urine in the left ureteral orifice on cystoscopy. Abdominal computed tomography an- giography showed a 2.2×2.7 cm hematoma in the left renal pelvis, with resulting hydronephrosis (Fig. 2). We started infusion of normal saline and used furo- semide to increase urine output. We also inserted a Fig. 1. Ultrasonography. There were no structural abnor- double J stent into the left to reduce the hy- malities such as perirenal hematoma, aneurysm and arterio-venous fistula to induce bleeding. dronephrosis and maintain urine flow. The gross he-

Fig. 2. Contrast enhanced CT angiography. Contrast enhanced CT angiography showed mild left hydronephrosis and high density signal considered as hematoma of 2.2×2.7 cm in diameter at the left renal pelvis (arrows). The Korean Journal of Nephrology 2010; 29: 768～771 maturia and flank pain stopped 4 days after admis- ding 8 days after percutaneous renal biopsy. We ex- sion. Her creatinine level increased to 6.8 mg/dL 5 amined CT angiography in spite of her being afraid of days after admission because of occurrence of radio- radiocontrast induced nephropathy (RCIN) to evaluate contrast-induced acute renal failure, with maintaining definite cause of delayed and recurrent gross hema- her urine output. Double J stent was removed one turia because we could not explain cause of gross month later on urology outpatient department (OPD) hematuria. after confirmation of absence of left renal hydroneph- Factors that have been found to predispose to com- rosis and restoration of creatinine level to 4.1 mg/dL. plications after PRB include renal insufficiency (1.2 mg/dL), poorly controlled (diastolic BP; DISCUSSION 90 to 110 mmHg), and a prolonged bleeding time5, 10). Whittier et al proposed that only serum creatinine at We report a rare case of hydronephrosis by renal baseline can be predictive of a complication. Patients pelvic hematoma occurred by delayed re-bleeding with a serum creatinine 5.0 mg/dL were 2.3 times as after renal biopsy. We have successfully treated this likely to have a complication7). Patients with advanced complication by hydration, enhancing diuresis and renal insufficiency (estimated GFR of 40 mL/min) double J insertion. have a six-fold increase in risk of severe bleeding Although percutaneous renal biopsy (PRB) is ex- postoperatively, and even those with mild levels of tremely safe, it is reported that clinically significant renal insufficiency (estimated GFR of 61 to 80 mL/ complications are seen in 7.4% of biopsies2). The se- min) have a two fold increase in the risk of serious verity of complications by PRB is usually divided into postoperative bleeding compared with patients with two groups. Minor complications were defined as normal renal function after adjusting for measures of those resulting in gross hematuria and/or perinephric coagulation status and platelet function11). Only the hematoma but spontaneously resolving without the risk factor of bleeding in our patient was moderate need for further intervention. Major complications renal insufficiency. Her blood pressure was well cont- were those resulting in the need for an intervention, rolled and she has no abnormality of coagulopathy. such as a transfusion of blood products or invasive We cannot explain exactly why delayed re-bleeding procedure (radiographic or surgical), and those re- occurred and made pelvic hematoma in our case. sulting in acute renal obstruction or failure, septicemia, Because we had confirmed that gross hematuria spon- or death7). taneously stopped 2 days after renal biopsy and she It is known that these complications commonly could not find gross hematuria until re-admission by occurred within 24 hours, especially in the case of herself, it is not prudent to consider that persistent serious complications. Whittier et al7) demonstrated gross hematuria existed continuously even after her that the complication was identified within 12 hours discharge. In addition, we could not find any struc- of the procedure in 85% of cases and 89% of compli- tural abnormalities to induce re-bleeding such as cations were apparent within 24 hours. In patients peri-renal hematoma and arteriovenous fistula on with major complications, the complication was identi- Doppler USG of kidney checked one day after initial fied within 24 hours in 91% of . Likewise, gross hematuria. Her sudden onset flank pain and Marwah et al.8) and Jones et al.9) found that the major finding of gross hematuria on re-admission day also complications were identified in >90% of cases within demonstrate that there was sudden onset of re- the first few hours of post-biopsy observation. How- bleeding on re-admission day. ever, there has been no report of delayed renal blee- In this case, delayed bleeding after renal biopsy is Dae-hong Jeon, et al.: Hydronephrosis after Renal Biopsy a cause of gross hematuria and pelvic hematoma ac- 5) Diaz-Buxo JA, Donadio JV Jr: Complications of percu- companied by hydronephrosis. Delayed gross hema- taneous renal biopsy: An analysis of 1,000 consecutive biopsies. Clin Nephrol 4:223-227, 1975 turia after kidney biopsy is rare, but must be evaluated 6) Slotkin EA, Madsen PO: Complications of renal biopsy: prudently. Even though renal pelvic hematoma by Incidence in 5,000 reported cases. J Urol 87:13-15, delayed bleeding occurs rarely after percutaneous 1962 needle kidney biopsy, we should consider this compli- 7) Whittier WL, Korbet SM: Timing of complications in percutaneous renal biopsy. 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