NDT Plus Advance Access originally published online on January 4, 2008
NDT Plus 2008 1(2):92-93; doi:10.1093/ndtplus/sfm035
© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
The rare event of exercise-induced dissection of the renal artery: successful long-term treatment by localized lysis
Gerald S. Braun1,
Ulrich Linsenmaier2,
Matthias N. Witt3 and
Holger Schmid3
1 Department of Nephrology and Immunology, Technical University of Aachen (RWTH), 52057 Aachen
2 Department of Radiology, University of Munich (LMU), 80336 Munich, Germany
3 Department of Nephrology, Medical Policlinic, University of Munich (LMU), 80336 Munich, Germany
Correspondence: Holger Schmid, Department of Nephrology, Medical Policlinic, University of Munich (LMU), Pettenkoferstrasse 8a, 80336 Munich, Germany. Tel: +49-89-51603511; Fax: +49-89-51604924; E-mail: holger.schmid{at}lrz.uni-muenchen.de
Key Words: kidney infarction • rt-PA • spontaneous dissection • sports
Received for publication December 4, 2007. Accepted for publication December 6, 2007.
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Case report
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A previously healthy 31-year-old man experienced a sudden onset
of severe left loin pain radiating into the left lower abdomen
during a side-movement, while performing a workout of the abdominal
muscles in a fitness club. He collapsed and was immediately
brought to our emergency department. Vital signs were blood
pressure 130/75 mmHg, heart rate 64/min, height 185 cm and weight
85 kg. The clinical examination was unremarkable. Relevant laboratory
parameters were a serum creatinine of 1.2 mg/dL, blood–urea
nitrogen of 15 mg/dL, creatinine kinase of 24 IU/L (25°C)
and a normal urinalysis. Abdominal CT revealed the absence of
perfusion of the lower and middle pole of the left kidney, corresponding
to an 80% perfusion deficit (
Figure 1A). Subsequent angiography
demonstrated a dissection and thrombotic occlusion of the left
renal artery (
Figure 1B). Multi-step local lysis was performed
within 6 h and on the following day, using 7 mg of recombinant
tissue–plasminogen activator (rt-PA), respectively. As
estimated by final angiography, perfusion could be essentially
restored (
Figure 1C). On Day 2, LDH rose to 1950 U/L (25°C),
demonstrating tissue damage, and serum creatinine was 1.5 mg/dL
but reached a steady state at 1.3 mg/dL during the next days.
Subsequently, blood pressure remained normal and the patient
was discharged on oral phenprocoumon for 6 months without antihypertensive
medication. At 6-month follow-up, blood pressure was 110/75
mmHg, serum creatinine was 1.0 mg/dl and creatinine clearance
was 95 mL/min. Doppler ultrasonography showed a renal arterial
resistive-index of 0.6 bilaterally, indicating the absence of
re-occlusion or re-stenosis. The lysed kidney had shrunk by
2 cm in length but
50% of its function was preserved, as demonstrated
by scintigraphic excretory testing (73% on the right, 27% on
the left kidney). At 5-year follow-up, blood pressure was 125/75
mmHg, serum creatinine was 1.1. mg/dl and creatinine clearance
was 131 mL/min. Renal ultrasound and Doppler sonography showed
an unchanged situation.
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Fig. 1 (A) Contrast-enhanced abdominal CT during the late venous phase showing a perfusion deficit of the middle and lower pole of the left kidney. (B) Digital substraction angiography (DSA) showing a corresponding perfusion deficit of the left kidney during the early filling phase. (C) Good reperfusion after the second cycle of local lysis with rt-PA.
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Discussion
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Renal artery dissection is a rare event that is usually caused
by blunt trauma or occurs in association with predisposing conditions
such as atherosclerosis, fibromuscular dysplasia, genetic connective
tissue disease, syphilis, tuberculosis and cocaine or amphetamine
consumption [
1–3]. On the other hand, sports or physical
exercise leading to renal artery dissection has been described
four times in the literature, i.e. with aerobics [
4], sit-ups
for abdominal muscle training [
3], triathlon [
2] and rope skipping
[
1]. The presumed mechanism is intimal tearing, by either direct
stretching of the artery by movement through muscular tension
or by forces of acceleration/deceleration [
2]. In these cases
and the present one, no predisposing condition was identified.
A continuum of a mechanism of acceleration/deceleration where
sport is on one side and trauma is at the other extreme is stressed
by two cases where dissection was associated with a jump from
a truck and aerobatic flight manoeuvres involving high
G-acceleration,
respectively [
2,
5]. In the setting of an infarcted kidney, arterial
hypertension does not usually develop immediately, but takes
months to years to develop [
3,
6]. Eventually, the decision for
removal of a damaged kidney is made [
2,
6]. Localized lysis has
a pre-emptive character by aiming to reverse the occlusion immediately.
Ideally it should be performed within the first hour. As demonstrated
in the literature and by the case presented herein, a lasting
partial function of the affected kidney can potentially be restored,
and development of arterial hypertension can be prevented after
5 years of follow-up [
7]. In the future, as more results of
long-term observations of treated patients become available,
the general usefulness of this promising approach may be better
estimated.
Conflict of interest statement. None declared.
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References
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- Tovbin D, Lantsberg S, Feldman L, et al. Unilateral acute renal cortical necrosis (ACN) following skipping with a rope. Nephrol Dial Transplant (2000) 15:415–418.[Free Full Text]
- Thomas MC, Walker RJ, Packer S. Running repairs: renal artery dissection following extreme exertion. Nephrol Dial Transplant (1999) 14:1258–1259.[Abstract/Free Full Text]
- Alamir A, Middendorf DF, Baker P, et al. Renal artery dissection causing renal infarction in otherwise healthy men. Am J Kidney Dis (1997) 30:851–855.[Web of Science][Medline]
- Montgomery JH, Moinuddin M, Buchignani JS, et al. Renal infarction after aerobics. Clin Nucl Med (1984) 9:664–665.[CrossRef][Web of Science][Medline]
- Beyer RW, Daily PO. Renal artery dissection associated with Gz acceleration. Aviat Space Environ Med (2004) 75:284–287.[Medline]
- Meyrier A, Rainfray M, Lacombe M. Delayed hypertension after blunt renal trauma. Am J Nephrol (1988) 8:108–111.[Web of Science][Medline]
- Klein RM, Niehues R, Hollenbeck M, et al. The local lysis therapy of spontaneous renal artery dissection with arterial thrombosis. Dtsch Med Wochenschr (1992) 117:1185–1190.[Medline]
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