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Complete post-operative resolution of "temporary" end-stage kidney disease secondary to aortic dissection without static renal artery obstruction: a case study.
BMC Nephrol 2019; 20(1):368BN

Abstract

BACKGROUND

Acute kidney injury (AKI), which may progress to end-stage kidney disease (ESKD), is a potential complication of aortic dissection. Notably, in all reported ESKD cases secondary to aortic dissection, imaging evidence of static obstruction of the renal arteries always shows either renal artery stenosis or extension of the dissection into the renal arteries.

CASE PRESENTATION

We present the case of a 58-year-old man with hypertension who was diagnosed with a Stanford type B aortic dissection and treated with medications alone because there were no obvious findings indicative of dissection involving the renal arteries. He had AKI, which unexpectedly progressed to ESKD, without any radiological evidence of direct involvement of the renal arteries. Thus, we failed to attribute the ESKD to the dissection and hesitated to perform any surgical intervention. Nevertheless, the patient's hormonal levels, fractional excretion values, ankle brachial indices, and Doppler resistive indices seemed to indirectly suggest kidney malperfusion and implied renal artery hypo-perfusion. However, abdominal computed tomography imaging only revealed progressive thrombotic obstruction of the false lumen and compression of the true lumen in the descending thoracic aorta, despite the absence of anatomical blockage of renal artery perfusion. Later, signs of peripheral malperfusion, such as intermittent claudication, necessitated surgical intervention; a graft replacement of the aorta was performed. Post-operatively, the patient completely recovered after 3 months of haemodialysis, and the markers that had pre-operatively suggested decreased renal bloodstream normalised with recovery of kidney function.

CONCLUSIONS

To the best of our knowledge, this is the first report of severe AKI, secondary to aortic dissection, without direct renal artery obstruction, which progressed to "temporary" ESKD and was resolved following surgery. This case suggests that only coarctation above the renal artery branches following an aortic dissection can progress AKI to ESKD, despite the absence of radiological evidence confirming an obvious anatomical blockage. Further, indirect markers suggestive of decreased renal blood flow, such as ankle brachial indices, renal artery resistive indices, urinary excretion fractions, and hormonal changes, are useful for evaluating concomitant AKI and may indicate the need for surgical intervention after a Stanford type B aortic dissection.

Authors+Show Affiliations

Department of Urology, Takashimadaira Chuo General Hospital, 1-73-1 Takashimadaira, Itabashi, Tokyo, 175-0082, Japan.Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. aokada-tky@umin.ac.jp.Department of Nephrology, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan.Department of Cardiovascular Surgery, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan.Department of Cardiovascular Surgery, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan.Department of Cardiovascular Surgery, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan.Department of Nephrology, Fujieda Municipal General Hospital, 4-1-11 Surugadai, Fujieda, Shizuoka, 426-8677, Japan.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31615429

Citation

Mukaiyama, Yoshihiro, et al. "Complete Post-operative Resolution of "temporary" End-stage Kidney Disease Secondary to Aortic Dissection Without Static Renal Artery Obstruction: a Case Study." BMC Nephrology, vol. 20, no. 1, 2019, p. 368.
Mukaiyama Y, Okada A, Kawakatsu Y, et al. Complete post-operative resolution of "temporary" end-stage kidney disease secondary to aortic dissection without static renal artery obstruction: a case study. BMC Nephrol. 2019;20(1):368.
Mukaiyama, Y., Okada, A., Kawakatsu, Y., Akuzawa, S., Suzuki, K., Ishigami, N., & Yamamoto, T. (2019). Complete post-operative resolution of "temporary" end-stage kidney disease secondary to aortic dissection without static renal artery obstruction: a case study. BMC Nephrology, 20(1), p. 368. doi:10.1186/s12882-019-1559-8.
Mukaiyama Y, et al. Complete Post-operative Resolution of "temporary" End-stage Kidney Disease Secondary to Aortic Dissection Without Static Renal Artery Obstruction: a Case Study. BMC Nephrol. 2019 Oct 15;20(1):368. PubMed PMID: 31615429.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Complete post-operative resolution of "temporary" end-stage kidney disease secondary to aortic dissection without static renal artery obstruction: a case study. AU - Mukaiyama,Yoshihiro, AU - Okada,Akira, AU - Kawakatsu,Yutaro, AU - Akuzawa,Satoshi, AU - Suzuki,Kazuchika, AU - Ishigami,Naoyuki, AU - Yamamoto,Tatsuo, Y1 - 2019/10/15/ PY - 2018/12/09/received PY - 2019/09/16/accepted PY - 2019/10/17/entrez PY - 2019/10/17/pubmed PY - 2019/10/17/medline KW - Acute kidney injury KW - Aortic dissection KW - Dynamic obstruction KW - End-stage kidney disease KW - Static obstruction KW - Surgery KW - Upstream aortic constriction SP - 368 EP - 368 JF - BMC nephrology JO - BMC Nephrol VL - 20 IS - 1 N2 - BACKGROUND: Acute kidney injury (AKI), which may progress to end-stage kidney disease (ESKD), is a potential complication of aortic dissection. Notably, in all reported ESKD cases secondary to aortic dissection, imaging evidence of static obstruction of the renal arteries always shows either renal artery stenosis or extension of the dissection into the renal arteries. CASE PRESENTATION: We present the case of a 58-year-old man with hypertension who was diagnosed with a Stanford type B aortic dissection and treated with medications alone because there were no obvious findings indicative of dissection involving the renal arteries. He had AKI, which unexpectedly progressed to ESKD, without any radiological evidence of direct involvement of the renal arteries. Thus, we failed to attribute the ESKD to the dissection and hesitated to perform any surgical intervention. Nevertheless, the patient's hormonal levels, fractional excretion values, ankle brachial indices, and Doppler resistive indices seemed to indirectly suggest kidney malperfusion and implied renal artery hypo-perfusion. However, abdominal computed tomography imaging only revealed progressive thrombotic obstruction of the false lumen and compression of the true lumen in the descending thoracic aorta, despite the absence of anatomical blockage of renal artery perfusion. Later, signs of peripheral malperfusion, such as intermittent claudication, necessitated surgical intervention; a graft replacement of the aorta was performed. Post-operatively, the patient completely recovered after 3 months of haemodialysis, and the markers that had pre-operatively suggested decreased renal bloodstream normalised with recovery of kidney function. CONCLUSIONS: To the best of our knowledge, this is the first report of severe AKI, secondary to aortic dissection, without direct renal artery obstruction, which progressed to "temporary" ESKD and was resolved following surgery. This case suggests that only coarctation above the renal artery branches following an aortic dissection can progress AKI to ESKD, despite the absence of radiological evidence confirming an obvious anatomical blockage. Further, indirect markers suggestive of decreased renal blood flow, such as ankle brachial indices, renal artery resistive indices, urinary excretion fractions, and hormonal changes, are useful for evaluating concomitant AKI and may indicate the need for surgical intervention after a Stanford type B aortic dissection. SN - 1471-2369 UR - https://www.unboundmedicine.com/medline/citation/31615429/Complete_post-operative_resolution_of_"temporary"_end-stage_kidney_disease_secondary_to_aortic_dissection_without_static_renal_artery_obstruction:_a_case_study L2 - https://www.biomedcentral.com/1471-2369/20/368 DB - PRIME DP - Unbound Medicine ER -