林鉅棟、歸家豪、廖俊厚

天主教耕莘醫療財團法人耕莘醫院泌尿外科

Spontaneous retroperitoneal hemorrhage secondary to renal cyst rupture in a peritoneal dialysis patient with acquired cystic kidney disease: A case report

Chu-Tung Lin、Chia-Hao Kuei 、Chun-Hou Liao

Divisions of Urology, Department of Surgery, Cardinal Tien Hospital, New Taipei City, Taiwan

 

Introduction: Spontaneous retroperitoneal hemorrhage is a rare but life-threatening condition. Acquired cystic kidney disease (ACKD) occurs in patients who are on dialysis for end-stage renal disease (ESRD). Hemorrhagic renal cysts are the most frequent complication of patients with ACKD. Bleeding occasionally extending into the perinephric space causes perirenal hematoma, or retroperitoneal hemorrhage (RH). Presentation of perirenal hematoma and retroperitoneal 

hematoma in peritoneal dialysis (PD) patients with ACKD is exceedingly rare. We report a PD patient with ACKD who developed hemoperitoneum secondary to retroperitoneal hematoma and hemorrhagic renal cysts

Case description: A 46-year-old man with ESRD had been treated with peritoneal dialysis for 7 years. Medical records showed that he had no cysts at the start of peritoneal dialysis. The patient presented with persistent right flank pain on hour before visiting emergent department. His blood pressure was 79/59 mmHg and heart rate was 110 bpm and rhythmic. He denied diarrhea, vomiting and bloody stool. There was tenderness over abdomen and right flank. Laboratory values were as follows; white blood cells: 6.4 × 10³, hemoglobin: 7.9 g/dl, C-reactive protein: 3.8 mg/L. Coagulation profile and liver tests were within normal levels. Abdominal computed tomography revealed that a huge hematoma was at right perirenal and retroperitoneal area and bilateral atrophy kidney with multiple cysts. The patient was transfused with packed red blood cell and underwent right radical nephrectomy with presumptive diagnoses of renal cell cancer secondary to ACKD or cystic hematoma. Macroscopically, there was multiple cystic lesion with necrotic bleeding tissues. After nephrectomy, hemoperitoneum disappeared and the patient recovered completely.  

Conclusions: Approximately 50% of the patients with ACKD develop hemorrhagic renal cysts. When spontaneous retroperitoneal hemorrhage was in dialysis patients, the most common cause was cyst rupture in patients with ACKD. Most patients with hemorrhagic renal cysts were undergoing hemodialysis compared with PD. This has been explained that longer duration of hemodialsis with heparin anticoagulation may cause more severe cystic disease. Consequently, patients with long duration of dialysis should be under surveillance for ACKD development and associated bleeding risks.