Spontaneous parenchymal rupture of the kidney, a rare but life-threatening entity: a single-center experience
Nontraumatic, spontaneous parenchymal kidney rupture is a rare clinical entity that can cause extensive haemorrhage and lead to the development of a Wunderlich's syndrome. It has been previously described in patients with systemic lupus erythematosus (SLE) (1) or in patients with Castleman's Disease (2). Sometimes an incidental renal carcinoma can be found in the kidney. We report our experience of spontaneous rupture of the kidney without a clear cause, in a single high-volume center.
Materials and Methods
We retrospectively evaluated all the patients that reached our emergency department for a kidney rupture from January 2012 to December 2016. 62 patients experience a parenchymal kidney rupture due to a clear cause and 10 patients experience a spontaneous parenchymal kidney rupture without a clear cause. All patients with an anamnesis of abdominal trauma were excluded from the analysis. All patients were evaluated with an abdominal ultrasonography and then an abdominal computed tomography.
The mean age of the patients (four women and six men) was 52,1 years (range 18-69). All patients reached our emergency department with abdominal pain. 6 out of 10 patients experience a diffuse abdominal pain and 4 out of 10 patients experience a pain that simulated a renal colic, probably related to the occupation of the pelvis by blood clots. 5 out of 10 patients experience haematuria. 6 out of 10 patient experience a typical Wunderlich's syndrome with hypovolemic shock Stage 3 (marked tachycardia and tachypnea, low systolic blood pressure (mean 66,6 mmHG), confusion state, sweating with cool and pale skin. In the youngest patient the systolic blood pressure was 120 mmHG. Despite this the blood sample showed a lower hematocrit (Hemoglobin=6,7 g/dL). The mean hemoglobin level was 6,54 g/dL (range 5,8-7,1). All patients underwent blood transfusions. 6 out of 10 patients had a renal injury grade 3 (Fig.1) and 4 out of 10 patients had a renal injury grade 2. The management was conservative for seven patients. Three patients experience the embolization of a subsegmental renal artery. One patients with a renal injury grade 3 experienced an infected retroperitoneal abscess and required a surgical drainage.
A lot of conditions can cause a parenchymal kidney rupture (misunderstood renal cell cancer, acute purulent pyelonephritis secondary to stone, polycystic kidney disease, etc). Only few cases about spontaneous rupture of the kidney are reported in the scientific literature (3). The management of these patients is critical because the condition may go unrecognised in the early stages and can result in death. In our experience the youngest patient had a normal systolic blood pressure despite of the low levels of haemoglobin. It can be related to the high level of catecholamine that increased the blood pressure. In our experience the management was conservative but if the collecting system or the vascular pedicle are involved it is imperative to choose a surgical approach.
The spontaneous parenchymal kidney rupture is a rare but life-threatening entity. It is critical for clinicians in the Emergency Department to be aware of this entity to avoid diagnostic error. It is important to exclude all the causes of the kidney rupture. Moreover, in the young patients the condition can be misunderstood. In conclusion, we suggest to pay attention to old people that more probably can have consequences after a severe hemorrhage.
1- Ufuk F, Herek D. Life-threatening spontaneous kidney rupture in a rare case with systemic lupus erythematosus: Prompt diagnosis with computed tomography. Hemodial Int. 2016 Jan;20(1):E9-11.
2- Kremer A, Kremer V, Lee SK.Spontaneous kidney rupture with incidental renal cell cancer in patient with Castleman's disease. Urology. 2009 Oct;74(4):787-8.
3- Dangle P, Pandya L, Chehval M.Idiopathic non-traumatic spontaneous renal hemorrhage/laceration: a case report and review of the literature. W V Med J. 2012 Nov-Dec;108(6):24-6.Argomenti: cancro del rene