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Kidney360
Kidney360
KIDNEY
Kidney360
Kidney360
2641-7650
American Society of Nephrology

39207894
K360-2024-000444
10.34067/KID.0000000000000500
00023
3
Clinical Images in Nephrology and Dialysis
Acute Kidney Injury and Ascites in a Patient with a History of Cervical Cancer
https://orcid.org/0000-0002-2651-1509
Ono Keisuke 1
https://orcid.org/0000-0002-7646-6638
Matsumoto Hironori 2
https://orcid.org/0000-0003-2047-4900
Komagata Yoshinori 1
1 Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
2 Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Tokyo, Japan
Correspondence: Dr. Keisuke Ono, email: onoxkeisuke@gmail.com
8 2024
29 8 2024
5 8 12261227
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Nephrology
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Visual Abstract

AKI
OPEN-ACCESSTRUE
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pmcCase Description

A 59-year-old woman presented with a chief concern of abdominal pain. At the age of 40, she had a history of cervical cancer for which she had undergone surgery, chemotherapy, and radiation therapy. Physical examination showed no evidence of generalized edema, including leg edema, but a computed tomography scan revealed massive ascites (Figure 1). Blood tests showed no liver dysfunction, and chest imaging showed no pleural effusion. After admission, her serum creatinine increased from 0.70 (mg/dl, 0.65–1.07) to 2.67 in 3 days. The patient was transferred to our tertiary care center for further examination. At our hospital, a paracentesis to remove ascitic fluid was performed, and dense yellow fluid was drained (Figure 2). The creatinine level in the ascites was 8.73 (mg/dl), which was higher than the serum creatinine level of 2.94 (mg/dl) on the same day. Computed tomography scan with contrast injected into the bladder showed a perforated area on the left side of the posterior wall of the bladder (Figure 3), suggesting that the patient had a bladder rupture. The elevated serum creatinine was believed to be a pseudo-AKI because of the reabsorption of creatinine by urinary leakage into the peritoneal cavity. After drainage of 3000 ml of ascites fluid and placement of an indwelling urinary catheter, serum creatinine decreased from 3.82 (mg/dl) to 0.90 (mg/dl) in 24 hours. The indwelling urinary catheter was removed 3 weeks after implantation. Three weeks after bladder catheter removal, the serum creatinine was 0.75 (mg/dl), and there was no recurrence of bladder perforation.

Figure 1 CT image of the abdomen before paracentesis to remove ascitic fluid. A large amount of ascites is observed. CT, computed tomography.

Figure 2 Drainage of ascites fluid. Dense yellow fluid is seen.

Figure 3 CT scan image after injection of a contrast fluid into the bladder, showing a partial leakage from the left side of the posterior wall of the bladder.

Discussion

Bladder rupture has both traumatic and nontraumatic causes, and nontraumatic ruptures are rare.1 Of the nontraumatic types, there is spontaneous rupture of the bladder due to radiotherapy, which can occur more than 30 years after treatment.2 On the other hand, it has also been reported to occur in relatively short periods of time, such as within a year.3 Therefore, caution should be taken at any point after radiation treatment. The recommended treatment of bladder injury is to maintain urinary drainage for 2–3 weeks, and in this case, an indwelling bladder catheter was placed accordingly.4 Although it has been reported that bladder rupture can result in pseudo-AKI, it is extremely rare,5 and moreover, it is difficult to recall when the cause of bladder injury was long ago, as in this case. Although nephrologists first think of hepatorenal syndrome as a cause of AKI with ascites, the possibility of bladder rupture should also be kept in mind, especially in patients receiving radiation therapy in the pelvic region.

Teaching Points

A bladder perforation can occur as a complication in patients treated with pelvic radiotherapy.

Urinary leakage into the peritoneal cavity can result in increased serum creatinine levels due to diffusion through the peritoneum.

Bladder perforation should be considered in the differential diagnosis of AKI patients with ascites.

Acknowledgments

Informed consent was obtained from the patient.

We would like to express our sincere gratitude to Dr. Kenshiro Kiuchi (Department of Obstetrics and Gynecology, Kyorin University School of Medicine), who worked with us and gave us helpful advice. We would also like to express our appreciation to the urology department at Kyorin University School of Medicine for their cooperation in the practice.

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/A582.

Funding

None.

Author Contributions

Conceptualization: Hironori Matsumoto, Keisuke Ono.

Writing – original draft: Keisuke Ono.

Writing – review & editing: Yoshinori Komagata, Hironori Matsumoto.
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References

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2. Lobo N Kulkarni M Hughes S Nair R Khan MS Thurairaja R . Urologic complications following pelvic radiotherapy. Urology 2018;122 :1–9. doi:10.1016/j.urology.2018.07.017 30036617
3. Watanabe Y Yamazaki S Yokoyama H , . A rare case of recurrent generalized peritonitis caused by spontaneous urinary bladder rupture after radiotherapy: a case report and literature review. Medicines (Basel). 2021;8 (11 ):67. doi:10.3390/medicines8110067 34822364
4. Bryk DJ Zhao LC . Guideline of guidelines: a review of urological trauma guidelines. BJU Int. 2016;117 (2 ):226–234. doi:10.1111/bju.13040 25600513
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