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Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00177-3
10.1016/j.eucr.2024.102823
102823
Inflammation and Infection
Acute renal infarction mimicking renal colic: A case report and review of the literature
Motaouakil Abdessamade a.motaouakil@gmail.com
a⁎
okieyeh Yacoub Ahmed Jacob_2017@hotmail.com
b
EL Moudane Anouar anouarelmoudane@gmail.com
b
Barki Ali alibarki@hotmail.com
b
a Mohammed The First University, Faculty of Medicine and Pharmacy, Oujda, Morocco
b Mohammed I University Oujda Faculty of Medicine and Pharmacy, Oujda, Morocco
⁎ Corresponding author. a.motaouakil@gmail.com
13 8 2024
9 2024
13 8 2024
56 1028236 7 2024
4 8 2024
11 8 2024
© 2024 Published by Elsevier Inc.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Renal infarction is a rare pathology, which can be life-threatening for the kidney. Its low incidence and non-specific clinical manifestations make it difficult to diagnose, often resulting in delayed or misdiagnosis. Contrast-enhanced CT has a role to play in early positive diagnosis, enabling rapid and effective management. We report the case of a right renal infarction simulating renal colic, with a review of the literature.

Keywords

Renal infarction
Renal colic
CT scan with contrast injection
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pmc1 Introduction

Acute renal infarction is a severe medical emergency with the potential to cause irreversible kidney damage. It is a rare condition, difficult to diagnose due to its low incidence and atypical clinical presentation.1 In 1940, Hoxie and Coggin reported an incidence of 1.4 % in a post-mortem study.2 This study was published at a time when imaging techniques had not yet been developed, suggesting that the affection is largely under-diagnosed. We present a case of renal infarction in a patient with valvular heart disease, where the patient presented with a non-specific clinical presentation, that of renal colic, and unremarkable laboratory markers. Our case demonstrates the value of abdominopelvic CT with contrast injection in the positive diagnosis of this pathology.

2 Case presentation

The patient was a 42-year-old women with a 7-year history of mitral stenosis, on Acenocoumarol with poor compliance. She reported that she had stopped anticoagulant treatment 6 months previously, without consulting her cardiologist.

She was admitted to the emergency department with acute right renal colic, which had been present for 24 hours. She had no history of urinary lithiasis. Her family history was non-contributory and no known drug allergies were documented.

On admission, her vital signs were normal, with blood pressure 110/80 mmHg, heart rate 81 beats/minute and temperature 36.9 °C. Physical examination revealed no fever, nausea, vomiting, diarrhea or macroscopic hematuria. Urine dipstick revealed microscopic hematuria. Laboratory results were unremarkable, with the exception of a lactate dehydrogenase (LDH) level of 1041 U/L. cytological and bacteriological examination of urine was sterile.

Abdominopelvic ultrasound revealed no pathology. Due to the persistence of the symptomatology without any obvious etiology, an abdominopelvic CT scan without contrast injection was requested and found to be normal.

An additional CT scan with contrast was therefore performed, showing a complete opacification defect of the right renal artery, associated with the presence of hypodense right renal lesions, not enhanced after contrast medium injection, involving the entire upper pole and the middle part of the right kidney, with persistent partial enhancement of the lower pole, in favour of renal infarction (Fig. 1).Fig. 1 CT appearance of the right renal infarction.

Fig. 1

The patient was hospitalized and treated with an unfractionated heparin anticoagulant and analgesics. Follow-up was marked by normal renal function and, on the follow-up CT scan, repermeabilization of the renal artery with persistence of sequelae in the renal parenchyma (Fig. 2).Fig. 2 Follow-up CT scan showing persistent sequellar lesions in the right kidney.

Fig. 2

3 Discussion

Often unrecognized and difficult to diagnose, renal infarction remains an infrequent event.1

It occurs in patients with emboligenic heart disease, such as atrial fibrillation, mitral or aortic valve disease, cardiomyopathy or acute coronary syndrome. Other non-cardiac origins have been identified such as septic emboli, unstable aortic atherosclerotic plaque or renal artery stenosis.2

The clinical presentation of renal infarction is variable, but frequently involves sudden-onset pain in the lumbar fossa, radiating to the external genitalia, leading to the initial suggestion of renal colic. Fever or vomiting may be associated.2

Biologically, an elevated LDH level appears to be a more sensitive indicator,1 although it is not specific to renal infarction, as this intracellular enzyme is released during a variety of tissue necroses.

Many biological markers of varying specificity have been suggested to aid the diagnosis of renal infarction.1

Faced with this non-specific clinical and biological presentation, radiological imaging plays a crucial role in the positive and early diagnosis of renal infarction. Although a wide range of tests are available, few of them offer significant diagnostic advances.

Abdominopelvic CT with contrast injection increases sensitivity in the diagnosis of renal infarcts.3 After contrast injection, the infarcted area appears as a hypodense, triangular lesion with sharp edges and vascular topography.1 However, the definitive diagnosis of renal infarction is always confirmed by renal arteriography.4

Thus, when faced with a case of renal colic, it is best to initially perform an abdominopelvic CT scan without injection to exclude urinary lithiasis. In the event of a normal result, as in our patient's case, an additional contrast injection should be performed to detect a possible renal infarction, thus contributing to faster diagnostic management.

No consensus has been reached on the treatment of renal infarction, but its management is generally based on effective anticoagulation, with or without thrombolysis, followed by long-term antivitamin K therapy to limit the risk of recurrence. Surgical revascularization may also be proposed.

Prompt and effective management can preserve the renal parenchyma and thus maintain renal function. In practice, the impact on renal function is usually minimal even when there is a flare-up of acute renal failure, which resolves in the majority of cases.5 This means that, although renal function may be temporarily affected, it often recovers without significant sequelae.

4 Conclusion

Renal infarction, although rare, should be suspected in patients presenting with symptoms of renal colic without evidence of urinary lithiasis. In such cases, contrast injection should always be considered when a patient with unexplained renal colic presents with an unremarkable CT scan, especially if the patient has cardiovascular risk factors. Detailed imaging with contrast injection is essential for accurate diagnosis and effective management.

CRediT authorship contribution statement

Abdessamade Motaouakil: Writing – review & editing, Writing – original draft, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Ahmed okieyeh Yacoub: Methodology, Investigation, Funding acquisition. Anouar EL Moudane: Visualization, Methodology. Ali Barki: Writing – review & editing, Writing – original draft, Supervision.
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References

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