MO355: Recovering From a Renal Vascular Catastrophe

Abstract

BACKGROUND AND AIMS Bilateral acute renal artery thrombosis (BARAT) is a rare and catastrophic condition. This diagnosis is often delayed or unrecognized and the true incidence may be underestimated. To the best of our knowledge, only three cases are reported in literature—all treated conservatively. We present two cases of BARAT who recovered kidney function under conservative approach. METHOD Data was obtained from the electronical medical record. RESULTS: Case 1:A 73-year-old male with no history of cardiac disease, hypertension or recent trauma was admitted with right flank pain and vomiting. He had severe hypertension (204/103 mmHg), anuria with acute kidney injury (AKI) and elevated lactate dehydrogenase (LDH). He started haemodialysis on admission. Renal computerized tomography (CT) angiogram showed bilateral arterial thrombosis—left renal artery was totally occluded and partial occlusion of the right renal artery with slight enhancement of the corresponding kidney (Fig. 1). Vascular surgery posed no surgical indication and systemic anticoagulation with low molecular weight heparin (LMWH) was started. A thorough screening for occult neoplasm and hypercoagulable state causes was negative. He was independent from dialysis 54 days after. Currently (6 months after), he is on stage 3b chronic kidney disease (CKD) with a serum creatinine (sCr) 2.19 mg/dL. Case 2: A 65-year-old female was admitted with dyspnea associated with right lumbar pain, severe hypertension (230/140 mmHg), peripheral edema and pulmonary congestion. Her prior history included heavy smoking and atherosclerotic artery disease with placement of aortoiliac stent 20 years before. She had no history of atrial fibrillation. She was admitted with de novo cardiac insufficiency with a mild reduction of left ventricular ejection fraction. After admission, she developed anuric AKI with refractory fluid overload and started dialysis. CT angiogram showed a large aortic thrombus that occluded both renal arteries. The right principal renal artery was occluded but the kidney had partial reperfusion from an accessory artery (Fig. 2). The left renal artery was totally occluded. Vascular surgery posed no surgical indication and the patient started LMWH. She was independent from haemodialysis 30 days after. She has currently a stage 4 CKD with sCr 3.2 mg/dL. CONCLUSION There are currently no guidelines on both the acute and long-term management of BARAT. The few reported cases of BARAT were all treated conservatively with systemic anticoagulation and had late but consistent kidney function recovery. This suggests that renal parenchyma could still be viable after BARAT. Could early revascularization therapies accelerate recovery and minimize irreversible damage? In both cases, a cause was not found. Much is still unknown about the pathophysiology, and further research is warranted.