American Journal of Kidney Diseases
Volume 52, Issue 4 , Pages 788-791, October 2008

Renal Infarction in a Patient With Spontaneous Dissection of Segmental Arteries: Diffusion-Weighted Magnetic Resonance Imaging

  • Yasuhiro Yamanouchi, MD, PhD

      Affiliations

    • Department of Nephrology, Shin-fuji Hospital, Shizuoka, Japan
    • Corresponding Author InformationAddress correspondence to Yasuhiro Yamanouchi, MD, PhD, Shin-fuji Hospital, 3900 Obuchi, Fuji, Shizuoka, 417-0801 Japan
    • ,
  • Kei Yamamoto, MD

      Affiliations

    • Department of Internal Medicine, Chigasaki Tokushukai Medical Center, Kanagawa, Japan
    • ,
  • Kazushige Noda, MD

      Affiliations

    • Department of Internal Medicine, Chigasaki Tokushukai Medical Center, Kanagawa, Japan
    • ,
  • Koji Tomori, MD, PhD

      Affiliations

    • Department of Nephrology, Chigasaki Tokushukai Medical Center, Kanagawa, Japan
    • ,
  • Takahiro Kinoshita, MD, PhD

      Affiliations

    • Department of Radiology, Chigasaki Tokushukai Medical Center, Kanagawa, Japan

Received 12 November 2007; accepted 11 July 2008. published online 27 August 2008.

Article Outline

 

Dissection of segmental renal arteries is rare and commonly associated with underlying arterial diseases. Arterial dissection usually results in renal infarction, but can be asymptomatic. When there are no symptoms, a diagnosis of arterial dissection leading to renal infarction may not be considered. Diffusion-weighted magnetic resonance imaging (DWI) has never been used to clinically diagnose renal infarction. We report a case of spontaneous segmental artery dissection with a nonspecific clinical presentation in which DWI was effective in confirming a diagnosis of acute renal infarction.

Back to Article Outline

Case Report 

Clinical History 

A previously healthy 48-year-old man presented to the emergency department with sudden-onset left epigastric and flank pain, as well as nausea and vomiting. His medical history included a prior cholecystectomy, but this was not believed to contribute to his present condition. He had no history of trauma.

On examination, the patient's temperature was 36.4°C and blood pressure was 122/70 mm Hg. He had agonizing epigastric and flank pain. He had no tenderness in the left costovertebral angle. Abdominal bruits were not heard. Urinalysis showed no red blood cells, protein, or white blood cells. Laboratory tests showed the following values: white blood cells, 5.5 × 103/μL (5.5 × 109/L) with a normal differential; hemoglobin, 15.2 g/dL (152 g/L); platelets, 209 × 103/μL (209 × 109/L); lactate dehydrogenase, 215 U/L; aspartate aminotransferase, 23 U/L; alanine aminotransferase, 27 U/L; C-reactive protein, 0.06 mg/dL; and serum creatinine, 0.71 mg/dL (62.8 μmol/L). Hemostasis test results were normal, and antinuclear antibody was negative.

Imaging Studies 

Enhanced abdominal computed tomography (CT) showed wedge-shaped low-density areas in the mid and lower left kidney (Fig 1). Although physical examination and laboratory findings did not show abnormalities, the patient was suspected to have an acute renal infarction and was admitted to the hospital. The patient was treated with systemic anticoagulation therapy using 10,000 IU/d of heparin.

DWI was performed to ensure that the renal infarction was acute and therefore contributed to the patient's symptoms. DWI showed an acute renal infarction in the mid and lower left kidney as a high-intensity area (Fig 2). Apparent diffusion coefficient maps can also confirm an acute renal infarction (data not shown) as a low-intensity area. Acute renal infarction was diagnosed. On day 2 of hospitalization, conventional angiography of the left renal artery showed narrowing in the anterior and posterior segments (Fig 3). CT during renal arteriography (angio-CT), in which an angiography catheter was placed in the left renal artery and CT was performed after injection of contrast, confirmed the narrowing, also showing thrombosis in part of the posterior segmental artery (Fig 4).

  • View full-size image.
  • Figure 4. 

    Angio–computed tomography shows (A) narrowing of the anterior segmental artery in the left kidney (arrowheads) with thrombosis of what is presumed to be the false lumen and (B) narrowing of the posterior segmental artery in the left kidney (arrows) with thrombosis of what was presumed to be the false lumen.

Diagnosis 

A diagnosis of renal segmental artery dissection was made.

Clinical Follow-up 

We tried to determine the reason for the dissection of the segmental arteries. Risks of renal infarction (Box 1) were ruled out in the present case in correlation with the patient's history, physical examination, and laboratory findings. We therefore established the diagnosis of spontaneous renal segmental artery dissection.

Box 1. Risk Factors for Renal Infarction
Renal arteriosclerosis
Vasculitis
Collagen disease
Malignant hypertension
Fibromuscular dysplasia
Segmental arterial mediolysis
Marfan syndrome
Ehlers-Danlos syndrome

The patient's pain subsided after a drip infusion with heparin on admission. Anticoagulation with intravenous heparin was followed by an oral anticoagulation drug on day 3 of hospitalization. The patient was discharged from the hospital on day 5 and remained asymptomatic.

Back to Article Outline

Discussion 

Complete or incomplete vascular occlusion of the renal artery or segmental branches causes renal infarction resulting in the development of acute onset of flank pain, typically accompanied by nausea and vomiting.

Most renal infarctions are caused by emboli attributed to atrial fibrillation or valvular disorders. Other causes of renal infarction include spontaneous isolated renal artery dissection,1, 2, 3, 4 as well as renal arteriosclerosis, vasculitis, collagen vascular disease, malignant hypertension, fibromuscular dysplasia, segmental arterial mediolysis, Marfan syndrome, and Ehlers-Danlos syndrome.5, 6 Furthermore, spontaneous isolated renal interlobular artery dissection is a rare disease observed in only a few patients.7, 8, 9, 10, 11 The natural history of both spontaneous isolated renal artery dissection and spontaneous isolated renal interlobular artery dissection is poorly understood.

Renal infarction should be considered in patients who report flank pain and present with increased blood pressure. Hematuria is also observed frequently, along with increased serum lactate dehydrogenase levels. To confirm the diagnosis of renal infarction, contrast-enhanced abdominal CT should be performed. If the computed tomographic scan shows a renal perfusion defect, conventional renal angiography, angio-CT, or computed tomographic angiography, can be used to confirm the diagnosis. The major differential diagnoses for this presentation are urolithiasis and acute pyelonephritis.

In the present case, the patient presented with the usual symptoms of sudden onset of flank pain, nausea, and vomiting. However, other typical clinical signs, including hypertension, hematuria, peripheral leukocytosis, and increased aspartate aminotransferase, lactate dehydrogenase, and C-reactive protein levels, were not observed. Furthermore, the patient did not have any of the common etiologic diseases, such as renal arteriosclerosis, vasculitis, collagen disease, malignant hypertension, fibromuscular dysplasia, segmental arterial mediolysis, and congenital disorders.

Although abdominal CT with contrast enhancement showed low-density areas in the lower poles of the left kidney, the absence of typical clinical signs made diagnosis difficult, and we could not rule out the possibility that the infarction was subacute and did not account for the patient's symptoms. DWI was used to make a definite diagnosis of acute renal infarction.

DWI is a magnetic resonance imaging technique sensitive to mobility in intravoxel water molecules that provides unique information that is dependent on the molecular motion of water. Its clinical importance has been established in the field of neuroimaging. Recent studies have already shown the potential value of this method in the evaluation of patients with various renal diseases, such as renal infection, pyonephrosis, tumors, and diffuse renal disease.12, 13, 14, 15, 16, 17, 18, 19 Although renal infarction with typical findings is diagnosed quickly, fewer findings, as in this case, make diagnosis difficult. DWI can clearly detect ischemic lesions early and show the acute phase of infarctions as high-intensity areas.

Antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker generally is used because plasma rennin activity is increased, leading to constriction of blood vessels and hypertension. Anticoagulation with intravenous heparin followed by oral warfarin is the optimal treatment regimen. Other therapies, such as thrombolysis, thrombectomy, and percutaneous transluminal angioplasty, can also be used if the patient has a contraindication to conventional anticoagulation therapy.17

In conclusion, we report a case of spontaneous isolated renal segmental artery dissection without obvious underlying cause. DWI showed acute renal segmental infarction in the lower pole of the left kidney as a high-intensity area. This was followed by detection of dissection of the segmental artery in the same region using digital subtraction angiography and computed tomographic angiography.

DWI is effective for confirming the diagnosis of acute renal segmental infarction in the absence of definitive laboratory findings.

Back to Article Outline

Acknowledgements 

Support: None.

Financial Disclosure: None.

Back to Article Outline

References 

  1. Sang HL, Han CL, Sung JO, et al. Percutaneous intervention of spontaneous renal artery dissection complicated with renal infarction: A case report and literature review. Catheter Cardiovasc Interv. 2003;60:335–338
  2. Shu W, Kei T, Naoto T, Yoshitomo K, Tatsuo S, Koushi A. Spontaneous multiple arterial dissections presenting with renal infarction and subarachnoid hemorrhage in a patient under treatment for infertility. Circ J. 2005;69:368–372
  3. Guérin E, Vandueren E, Dubois E, Delcour C, Wautrecht JC, Verhelst G. Spontaneous renal artery dissection in an otherwise healthy male. Acta Chir Belg. 2006;106:703–706
  4. Alamir A, Middendorf DF, Baker P, Nahman NS, Fontaine AB, Hebert LA. Renal artery dissection causing renal infarction in otherwise healthy men. Am J Kidney Dis. 1997;30:851–855
  5. Lacombe M. Isolated spontaneous dissection of the renal artery. J Vasc Surg. 2001;33:385–391
  6. Edwards BS, Stanson AW, Holley KE, Sheps SG. Isolated renal artery dissection: Presentation, evaluation, management and pathology. Mayo Clin Proc. 1982;57:564–571
  7. Bakir AA, Tatel SK, Schwartz MM, Lewis EJ. Isolated dissecting aneurysm of the renal artery. Am Heart J. 1978;96:92–96
  8. Perry MO. Spontaneous renal artery dissection. J Cardiovasc Surg. 1982;23:54–58
  9. Esayag-Tendler B, Yamase H, Ramsbay G, White WB. Accelerated hypertension with encephalopathy due to an isolated dissection of a renal artery branch vessel. Am J Kidney Dis. 1994;23:869–873
  10. Ramamoorthy SL, Vasquez JC, Taft PM, McGinn RF, Hye RJ. Nonoperative management of acute spontaneous renal artery dissection. Ann Vasc Surg. 2002;16:157–162
  11. Yukako K, Atsuhiro I, Tomoko Y, Osamu T, Matsuhiko H, Takao S. Left renal infarction due to dissecting aneurysm of the renal arterial branch. Jpn J Nephrol. 2003;45:695–700
  12. Cova M, Squillaci E, Stacul F, et al. Diffusion-weighted MRI in the evaluation of renal lesions: Preliminary results. BJR. 2004;77:851–857
  13. Namimoto T, Yamashita Y, Mitsuzaki K, Nakayama Y, Tang Y, Takahashi M. Measurement of the apparent diffusion coefficient in diffuse renal disease by diffusion-weighted echo-planar imaging. J Magn Reson Imaging. 1999;9:832–837
  14. Fukuda Y, Ohashi I, Hanafusa K, et al. Anisotropic diffusion in kidney: Apparent diffusion coefficient measurements for clinical use. J Magn Reson Imaging. 2000;11:156–160
  15. Toyoshima S, Noguchi K, Seto H, Shimizu M, Watanabe N. Functional evaluation of hydronephrosis by diffusion-weighted MR imaging. Acta Radiol. 2000;41:642–646
  16. Chan JHM, Tsui EYK, Luk SH, et al. MR diffusion-weighted imaging of kidney: Differentiation between hydronephrosis and pyonephrosis. J Clin Imaging. 2001;25:110–113
  17. Verswijvel G, Vandecaveye V, Gelin G, et al. Diffusion-weighted MR imaging in the evaluation of renal infection: Preliminary results. JBR-BTR. 2002;85:100–103
  18. Squillaci E, Manenti G, Di Stefano F, Miano R, Strigari L, Simonetti G. Diffusion-weighted MR imaging in the evaluation of renal tumours. J Exp Clin Cancer Res. 2004;23:39–45
  19. Squillaci E, Manenti G, Cova M, et al. Correlation of diffusion-weighted MR imaging with cellularity of renal tumours. Anticancer Res. 2004;24:4175–4179

 Originally published online as doi:10.1053/j.ajkd.2008.07.002 on August 26, 2008.

PII: S0272-6386(08)01102-5

doi:10.1053/j.ajkd.2008.07.002

American Journal of Kidney Diseases
Volume 52, Issue 4 , Pages 788-791, October 2008

Article Tools

* Image Usage & Resolution