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TUTOR: DR. CALANDRELLI, MATIAS PRESENTAN: DR. VICARIO DIEGO

Infarto Renal Agudo. TUTOR: DR. CALANDRELLI, MATIAS PRESENTAN: DR. VICARIO DIEGO DR. CHIOCCONI LUIS. Caso Problema : Hombre de 47 años con abdomen agudo

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TUTOR: DR. CALANDRELLI, MATIAS PRESENTAN: DR. VICARIO DIEGO

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  1. Infarto Renal Agudo TUTOR: DR. CALANDRELLI, MATIAS PRESENTAN: DR. VICARIO DIEGO DR. CHIOCCONI LUIS

  2. Caso Problema: Hombre de 47 años con abdomen agudo Enfermedad Actual: Paciente de 47 años ingresa por guardia por dolor abdominal difuso de 48 horas de evolución, que se intensifica en las últimas horas en flanco izquierdo, intensidad 10/10, dolor tipo lacerante. Dolor que no cede con AINES. Afebril, sin náuseas ni vómitos.

  3. Antecedentes Personales: • HTA diagnosticada hace 9 años (abandonó edicación) • Tabaquista de 42 p/y • Consumidor de marihuana actualmente • Cocaína dejo hace 5 años Examen Físico: Signos Vitales: PA: 130/90 mmHg, FC: 100 lpm, FR: 20 cpm, T: 36 ºC

  4. Abdomen: RHA conservados. Blando, depresible doloroso a predomino Flanco Izquierdo. No se palpan visceromegalias. Miembros: tono, trofismo, fuerza y temperatura conservados.  Pulsos periféricos presentes y simétricos. Genitourinario: Diuresis positiva, PPL negativo. Resto de examen físico sin alteraciones.

  5. Laboratorio Orina Completa Normal

  6. Imágenes: TC abdomen y pelvis c/c oral y e.v. (01/12/2010) TC Abdomen y Pelvis c/c oral y EV: El riñón izquierdo presenta en el sector lateral de su tercio medio un segmento que no realza con el contraste EV.

  7. TC Abdomen c/c EV: InfartoRenal Infarto renal

  8. ECO Doppler renal: (02/12/2010) Doppler renal bilateral dentro parámetrosnormales. Se evidencia un ligero aumento de la ecogenicidad de un sector segmentario del parénquima renal de tercio medio del riñón izquierdo. ECO Cardiograma: (02/12/2010) • Hipertrofia concéntrica VI • Fracción de eyección 58% • Dilatación leve AI ECO Cardiograma Transesofagico(02/12/2010) • Dilatación Ao ascendente, cayado y Ao descendente con enfermedad ateromatosa grado III Se descarta fuente cardioembólica.

  9. Evolución: durante la internación el paciente permanece asintomático, con tendencia a la hipertensión leve. Interpretación: Infarto renal de probable etiología tromboembólica. Se decide tratamiento con antiagregante plaquetario, estatinas y antihipertensivos.

  10. Se otorga egreso Sanatorial para continuar estudio en ambulatorio. Pendiente: Descartar trombofilias Indicaciones de egreso: • Dieta hiposódica • Losartan 50 mg / día • AAS 100 mg / día • Atorvastatina 20 mg / día • Tramadol 50 mg / día • Diclofenac 75 mg / día

  11. En consulta ambulatoria, el hematólogo decide iniciar ACO (RIN 2,18) Controles de TA: entre 120/70 – 150/100 mmHg Laboratorio: Uremia: 27 mg/dl, Creatinina: 1,20mg/dl Perfil Lipidico: LDL: 86 HDL: 46, Colesterol: 147 Ac. Urico: 4,8

  12. Trombofilia: • Homocisteinemia: 126 • Proteina C reactiva: normal • Proteina S: normal Anticoagulante Lupico: levemente aumentado Ac anticardiolipina IgG 19 IgM 25 (elevado) Proteinograma por electroforesis: normal

  13. El paciente completo 3 meses de terapia ACO permaneciendo asintomático, con pruebas de función renal normales y sin evidencias de nuevos episodios de embolia.

  14. Definición: Infarto Renal • Es la oclusión de la rama principal o segmentarias de la/las arterias renales, generando así isquemia y necrosis. • Incidencia de 0,007%-1,4% • 2-5% de embolización sistémicas Hoxie, HJ, Coggin, CB. Renal Infarction: Statistical study of two hundred and five cases and detailed report of an unusual case. Arch Intern Med 1940; 65:587 Domanovits H, Paulis M, Nikfardjam M, Meron G, K?rkciyan I, Bankier AA, Laggner AN Medicine (Baltimore). 1999;78(6):386-94.

  15. Clínica: Dolor Abdominal Puede tener :-Nauseas/ vomitos -Fiebre LAB: Leucocitosis, LDH, disfunción renal. Orina: hematuria (macro y/o microscópica). Estudios por imágenes: Tc abdomen c/c Ecodoppler vasos renales Angiografía Gold standard Domanovits H, Paulis M, Nikfardjam M, Meron G, K?rkciyan I, Bankier AA, Laggner AN Medicine (Baltimore). 1999;78(6):386-94.

  16. Dx diferenciales • Colico ureteral • Pielonefritis • Traumatismo lumbar • Isquemia mesenterica • Colico biliar • Colecistitis • Obstruccion urinaria • Carcinoma Renal • Diseccion aortica

  17. Causas • F.A • Estenosis mitral • Antecedente de embolia previa • HTA • Cardiopatia isquemica • Trombofilias • Enf antifosfolipidicas • Cancer • Domanovits H, Paulis M, Nikfardjam M, Meron G, K?rkciyan I, Bankier AA, Laggner AN Medicine (Baltimore). 1999;78(6):386-94.

  18. Tratamiento: • Fibrinolisis local o sistemica • Cirugia de revascularizacion (Traumatico, Obst bilateral o monorreno) • ACO • Antiagregacion

  19. Acute renal infarction. Clinical characteristics of 17 patients.Domanovits H, Paulis M, Nikfardjam M, Meron G, K?rkciyan I, Bankier AA, Laggner ANMedicine (Baltimore). 1999;78(6):386-94. • We analyzed the medical records of patients with an established diagnosis of acute renal infarction to identify predictive parameters of this rare disease. Seventeen patients (8 male) who were admitted to our emergency department between May 1994 and January 1998 were diagnosed by contrast-enhanced computed tomography (CT) as having acute renal infarction (0.007% of all patients). We screened the records of the 17 patients for a history with increased risk for thromboembolism, clinical symptoms, and urine and blood laboratory results known to be associated with acute renal infarction. A history with increased risk for thromboembolism with 1 or more risk factors was found in 14 of 17 patients (82%); risk factors were atrial fibrillation (n = 11), previous embolism (n = 6), mitral stenosis (n = 6), hypertension (n = 9), and ischemic cardiac disease (n = 7). All patients reported persisting pain predominantly from the flank (n = 11), abdomen (n = 4), and lower back (n = 2). On admission, elevated serum lactate dehydrogenase was found in 16 (94%) patients, and hematuria was found in 12 (71%) of 17 patients. After 24 hours all patients showed an elevated serum lactate dehydrogenase, and 14 (82%) had a positive test for hematuria. Our findings suggest that in all patients presenting with the triad--high risk of a thromboembolic event, persisting flank/abdominal/lower back pain, elevated serum levels of lactate dehydrogenase and/or hematuria within 24 hours after pain onset--contrast-enhanced CT should be performed as soon as possible to rule out or to prove acute renal infarction.

  20. Acute renal embolism. Forty-four cases of renal infarction in patients with atrial fibrillation.Hazanov N, Somin M, Attali M, Beilinson N, Thaler M, Mouallem M, Maor Y, Zaks N, Malnick SMedicine (Baltimore). 2004;83(5):292-9. Examinaron HC de todos los pacientes admitidos en Kaplan Medical Center and Sheba Medical Center in central Israel desde el1984 hasta 2002 que tuvieron Dx de infarto renal y FA. • Se identificaron 44 casos de embolia renal: 23 mujeres y 21 hombres, con edad promedio 69.5 +/- 12.6 años • 9 pacientes estaban siendo tratados con warfarina, 6 (66%) (INR)<1.8 • Con la TC se diagnostico 12/15 cases (80%); ecografia, 3/27 cases (11%). La Angiografia fue positiva 10/10 casos (100%). • La mortalidad a los 30-dias fue de 11.4%. • La embolia renal se Dx en mayores de 60 años y eventos embolicos previos. • La mayoria que estaba ACO estaba fuera de rango. Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel

  21. Blood pressure and renal outcomes in patients with kidney infarction and hypertension.Paris B, Bobrie G, Rossignol P, Le Coz S, Chedid A, Plouin PFJ Hypertens. 2006;24(8):1649-54. • OBJECTIVE: To assess the causes and frequency of kidney infarction associated with hypertension, and the blood pressure and renal function outcomes. METHODS: We analyzed the records of patients with kidney infarction documented by angiography and referred to a hypertension unit. RESULTS: Spontaneous kidney infarction was documented in 55 of 18,287 patients and was associated with renal artery disease in 41 cases. Twenty-five patients had a longstanding history of hypertension at referral, and 30 patients presented with acute hypertension. Patients with acute hypertension were more likely to report a history of lumbar pain and to develop malignant hypertension than patients with longstanding hypertension; they also had higher plasma renin concentrations. Data for long-term follow-up after referral were available for 36 patients, including 15 patients who underwent surgery or renal artery angioplasty. From referral to most recent follow-up, the blood pressure decreased from 176/111 to 143/89 mmHg in patients with longstanding hypertension, and from 183/111 to 127/80 mmHg in those with acute hypertension (P = 0.007/0.041 for between-group differences). Three patients with acute hypertension had normal blood pressure without treatment at follow-up. Patients with long-term follow-up displayed no change in the glomerular filtration rate. CONCLUSION: Kidney infarction is a rare cause of hypertension, usually associated with renal artery lesions. In cases of kidney infarction with acute hypertension, the blood pressure outcome is favorable following intervention and/or medication, and hypertension may resolve spontaneously. Universit? Paris-Descartes, Facult? de M?decine, Paris, France.

  22. Gracias

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