Traumatic Blunt Force Renal Injury in a Diseased Horseshoe Kidney with Successful Embolization to Treat Active Bleeding: A Case Report and Literature Review

Abstract

Background. Blunt force injuries in patients with preexisting kidney disease account for 19% of all kidney injuries, suggesting that diseased kidneys are more vulnerable than normal kidneys. When a horseshoe kidney (a rare anomaly: prevalence of 0.2%) is injured, treatment is challenging, especially when nonoperative management is desired. In high-grade blunt force normal kidney injury, nonoperative management has high succession rate (94.8%) with kidney-related complication (13.6%). Surgical reconstruction and preservation of a damaged horseshoe kidney is difficult because of variations in its vascular anatomy. We report successful nonoperative management of a blunt horseshoe kidney injury with active bleeding and review previous outcomes and complications. Case Presentation. A 57-year-old man had a head-on collision motorcycle road traffic accident. On arrival, blood pressure was 90/60 mmHg, pulse rate 140 bpm, and clear yellow urine output 200 ml. The patient was transiently responsive to fluid and blood component. Whole body computed tomography showed a high-volume retroperitoneal hematoma and multiple-lacerated lower pole of the kidney, compatible with preexisting horseshoe kidney disease with active contrast-enhanced extravasation from the accessory right renal artery. Embolization was performed. Renal function, transiently impaired after embolization, normalized on day 3. An infected hematoma found on day 7 was successfully controlled with antibiotics. His recovery was uneventful. At the 6-month follow-up, his serum creatinine level had returned to normal. The average age of blunt force horseshoe kidney injury is 31.75 years and occurred more common in male (87.5%). Conclusion. Diseased horseshoe kidneys are prone to injury even with low-velocity impact such as a road traffic accident speed<15 km/h. Embolization is considered the first choice for management, with its high clinical success rate leading to less need for surgical repair. Not removing a hematoma is likely to result in complications. If embolization fails to stop bleeding, life-saving surgical exploration should be mandated.

Horseshoe kidney: Morphologic features, embryologic and genetic etiologies, and surgical implications

“…Blunt force renal trauma is an uncommon cause of renal problems in patients with HSK, and maybe associated with complications due to the typically complex vasculature organization involving branches from the aorta, mesenteric arteries and/or the common iliac arteries (Cortese et al, 2017; Voelzke & Leddy, 2014). As with kidneys of normal configuration, blunt trauma has been known to cause vascular injury, laceration of the renal parenchyma and retroperitoneal hematomas in HSK (Cortese et al, 2017; Murphey et al, 1996; Dominguez & Ekeh, 2011; Paragi et al, 2011; Krutsri et al, 2020; Daudia et al, 1999; Trottier et al, 2009; Escudero et al, 2012).…”

Case report: Conservative management of a blunt trauma to a horseshoe kidney

“…This makes the quick and correct diagnosis of horseshoe kidney injuries of utmost importance to carry out adequate treatment. We report a case in which a traumatically disrupted horseshoe kidney was quickly recognized and successfully managed using conservative techniques, which we feel was crucial given the higher risk of renal parenchyma loss in operative exploration of mispositioned kidneys with anomalous vascular supply [5].…”