Nephroprotection in Acute Kidney Injury caused by Renal Artery Thrombosis
The paper presents the results of nephroprotection in acute kidney injury (AKI) caused by renal artery thrombosis. Nephroprotection performed due to successful diagnostics and endovascular intervention. Diagnostics was based on patient`s complaints and anamnesis, ultrasonography combined with renal power Doppler analysis, using a duplex scanner. In all 11 cases was identified renal artery thrombosis in solitary functioning kidney, the second one was either wrinkled or absent. After verification of anuria cause endovascular intervention was immediately performed, including tromboaspiration, balloon angioplasty and local thrombolysis threw intraarterial catheter. The duration of anuria before intervention was from 5 to7 days. In all cases renal function recovered in a few days, renal replacement therapy was not required.
Introduction. One of the infrequent, but significant and unrecognized causes of AKI is renal artery thromboembolism. Usually, AKI manifestated by anuria, develops only in the cases when occlusion of renal artery is bilateral or in a solitary functioning kidney. The main features of this disease are the difficulties in diagnostics and late beginning of treatment, with long-term anuria, for 5-7 days. A common protocol for diagnostics and treatment of renal artery thrombosis is absent. As methods for screening are recommended intravenous urography, radionuclide renography, contrast- enhanced computed tomography. Until recently, for suspected renal artery thrombosis patients were prescribed anticoagulant therapy and renal replacement therapy with hemodialysis, which became chronic, because of irreversible renal disfunction. Surgical treatment is only effective in the early hours. Outcome is often unfavorable. There is a high probability of hemorrhagic complications. For this reason, we decided to share with our successful experience of diagnostics and nephroprotection in AKI, caused by renal artery thrombosis solitary functioning kidney. In all cases the main sign of disease was anuria, pain in the lower back and significant elevation of serum urea, creatinine and potassium (azotemia and hyperkaliemia). As a rule, the contrlateral kidney was nonfunctional, more often was shrunken, probably due to previously undiagnosed thrombosis, or absent.
Material and methods. There were analyzed 11 cases of AKI , caused by renal artery thrombosis solitary functioning kidney from 2011 till 2013 year. Patients were treated in the ICU of Donetsk National Medical University, based on Resuscitation Centre of Donetsk regional clinical unit. Age ranged from 58 to 73 years. Most of the patients have a history, associated with a high risk of thromboembolism. In all cases, thrombosis developed on the background of atherosclerosis, coronary heart disease, persistent atrial fibrillation or atrial flutter. One of the main complaints was abdominal or lower back pain, not as intense as in renal colic, but requiring long-term use of analgesics (including NSAIDs). These complaints were accompanied by hypertensive crises, transient ischemic attack, myocardial infarction in history.
Results and discussion. Renal ultrasound sonography was performed in all patients before admission in ICU. This examination was uninformative to diagnose renal artery thrombosis. Because of absence of obstruction, patients were directed by nephrologist to ICU for hemodialysis treatment in connection with anuria for 5 — 6 days and high levels of serum urea (40 ± 6,2 mmol /l), creatinine (980 ± 10,3 mkmol /l) and potassium (6,7 ± 0,3 mmol / l). Condition was diagnosed as interstitial nephritis after NSAIDs treatment. Doppler sonography with duplex scanning revealed the ultrasound signs of atherosclerosis of the abdominal aorta, left renal artery thrombosis. After these data were recieved, the endovascular intervention was urgently provided. Renal artery catheterization, thromboaspiration, selective thrombolysis (Actilize 50 mg, twice during one hour), balloon angioplasty, renal artery stenting were performed. To avoid the nephrotoxic effect of rentgencontrast for the renal parenchyma, acetylcysteine was infused intravenously after intervention and for 2-3 days after it. Intravenous infusion of heparin at a dose of 600 to 800 U / h under the control of coagulation parameters (aPTT target level — 60-80 s) was continued. Heparin combined with clopidogrel (75 mg / day). Warfarin was prescribed after restoration of diuresis, when reaching the target INR (2.5-3.5). Renal function recovered in all patients without renal replacement therapy. Conclusion.Timely diagnostics of renal artery thrombosis with Doppler ultrasound scanning and endovascular intervention including renal artery catheterization, thromboaspiration, selective thrombolysis , balloon angioplasty are nephroprotective measures. Renal function recover in a few days without renal replacement therapy. In these cases AKI is diagnosed as prerenal.
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