Unilateral renal shutdown: uncommon complication of polycystic disease PETER TADROS, MD, FRCP[C]
Hemorrhage within a polycystic kidney is a rare cause of acute renal shutdown. This paper presents such a case and reviews the causes and the radiologic methods used in making ,the diagnosis. Case report
A 44-year-old man presented with left-sided abdominal pain of acute onset. The pain was constant and nonradiating. There was no previous or family history of renal disease, and no previous history of pertinent medical or surgical problems. The results of initial urinalysis were normal except for the presence in the urine of a few erythrocytes. The hemoglobin concentration was 15.8 g/dl, the blood urea nitrogen concentration 11 mmol/l (31 mg/dl) and the serum creatinine concentration 159 .mol/1 (1.8 mg/dl). Intravenous pyelography demonstrated no function on the left side; both kidneys were seen to be enlarged, and there was some flattening of the calyces on the right side (Fig. 1). At cystoscopy no Reprint requests to: Dr. Peter Tadros, Department of radiology, Hotel Dieu of St. Joseph, 1030 Ouellette Ave., Windsor, Ont. N9A lEl
urine was seen coming from the left ureter. The retrograde examination showed a normal left ureter, with some compression externally of the renal pelvis; the calyces were noted to be flattened and to have lost their cupping (Fig. 2). A left ureteric catheter was left in situ for 48 hours, during which time there was no output of urine from the left kidney. The patient was referred for further radiologic investigation. Abdominal aortography revealed that the main renal arteries were patent. A selective left renal arteriogram displayed a reduction in the size and number of intrarenal branches and multiple round translucent areas within the renal parenchyma (Fig. 3). Since the renal vein did not opacify, venography (both inferior venocavography and left renal vein studies) was performed. No venous occlusion was demonstrated. An operation disclosed multiple cysts within the left kidney. Near the hilus were two large cysts containing relatively fresh blood; these were evacuated and marsupialized After the operation diuresis occurred; approximately 800 ml of urine was passed every 8 hours. The blood urea nitrogen concentration was 5.0 mmol/l (14 mg/dl) and
FIG. 1-Intravenous pyelogram: no function on left, splaying and flattening of calyces on right, and enlargement of both kidneys.
the serum creatinine concentration 124 .mol/l (1.4 mg/dl) 48 hours after the operation. The return of function of the left kidney is demonstrated in Fig. 4. Discussion The common causes for nonvisualization or nonfunction of one kidney noted with intravenous pyelography are: * Obstruction of the ureter by a calculus, a stricture or a neoplasm.
FIG. 2-Left retrograde cystoscopy shows no obstruction of ureter but external compression of renal pelvis and loss of cupping of calyces.
CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
597
* Destruction of the kidney or venous obstruction due to a neoplasm. * Trauma, giving rise to "fractured kidney". * Vascular causes: renal artery occlusion, secondary to either thromboembolism or stenosis; arteriovenous malformation or fistula; and renal vein obstruction, due to either a tumour or thrombosis. Uncommon causes include: * Unknown previous nephrectomy. * Congenital absence of the kidney. * Destruction of the kidney by tuberculosis or other severe infections, such as xanthogranulomatosis. * Multicystic disease.1'2 The recent literature does not include polycystic disease as a cause
of unilateral renal shutdown. The reason for the shutdown, bleeding into renal cysts so that the renal pelvis of an already compromised kidney is compressed, is not unknown,3 but is not widely recognized. A glance at the common causes of unilateral renal shutdown will explain the rationale of the investigations in such cases. In any patient in whom renal function is absent or markedly decreased unilaterally, cystoscopy with a retrograde examination should be carried out to exclude postrenal obstructive uropathy. The absence of a ureteral lesion should then lead to arteriographic investigations. If the renal vein is not visualized (as may be the case for delayed films with selective renal artery catheterization), then venography is indicated to exclude venous obstruction. In conclusion, bleeding into cysts in a polycystic kidney should be considered as a cause of unilateral nonfunction. My thanks to Dr. D. McLeod for referring this patient, to Ms. B. Hudacek for secretarial help and to Dr. D.R. Feore for the photography. References 1. REEDER MM, FELSON B: Gamuts in
Radiology, Audiovisual Radiology, Cincinnati, Ohio, 1975, H-22 2. PETEASNICK JP, PATEL 5K:
FIG 3 Nephrographic phase of selective left renal arteriogram: many round translucent areas.
Angio-
graphic evaluation of the non-visualizing kidney. J Roentgenol Radium Ther Nuci Med 119: 757, 1973 3. HAMBURGER J, ROYER P: Nephrology,
Saunders, Philadelphia, 1968
The other side of depression.
Anairanil Antidepressant
Indications and Clinical Uses Anatranil (clomipramine hydrochloride) is indicated in the drug treatment of depressive illness, including manic depresuive psychosis, depressed phase, and involutional melancholia. Anafranil tppears to have a mild sedative effect which may he helpful in atleviating the anxiety component often accompanying depression. ContraIndications Anatranil should not be given in conjunction with or within fourteen days of treatment with a monoamine oxidase inhihitor. Combined therapyof this type could lead to theappearance of serious hypertensive crises and death may occur. Anafranil is contraindicated in patientswith existing liver damageand should not be administered to patients with a history ot blood dyscrasias. Anatranil is contraindicated in patients who have shown hypersensitivity to the drug. Anatranit is contraindicated in patients with glaucoma, as the condition may be aggravated due to the atropine-tike effects of the drug. Use/n Pregnancy: The safety of use in pregnant women has not been established. Therefore, Anafranil should not be administered to women of childbearing potential, particularly during the first trimester of pregnancy, unless, in the opinion of the physician, the eopected benefit to the patient outweighs the potential risk to the fetus. Warnings The following warnings apply to Anafranil and other tricyctic antidepressant agents: Tricyclicagents may lower the convulsive threshold and should, therefore, be used with caution in patients with convulsive disorders. Electrocardiographic studies suggest that Anafranil should not be used in the presence of pronounced cardiac or circulatory failure, recent myocardial infarction or ischaemic heart disease. Anafranil also has a hypotensive action which maybe detrimental in these circumstances. The drug should, therefore, be used with caution in patients who are susceptible to hypotensive episodes. Tricyclic agents may produce urinary retention and should be used with caution in patients with urinary pathology, particularly in the presence of prostatic hypertrophy. Particularly in the elderly and in hospitalized patients the tricyclic antidepressants may give rise to paralytic ileus and therefore appropriate measures should be taken if constipation occurs. Anafranil should be kept in a safe place, well out of the reach of children. Precautions In seriouslydepressed patients the possibility of suicide should be borne in mind and may persist until significant remission occurs. Therefore, these patients should be carefully supervised during treatment with Anafranil, and hospitalization or concomitantelectro-convulsive therapy maybe required. Activation of latent schizophrenia or aggravation of existing psychotic manifestations in schizohrenic patients may occur; patientswith manic-depressive tendencies may enperience hypomanic or manic shifts: and hyperactive or agitated patients may become over-stimulated. A reduction in dose or discontinoation of Anafranil should be considered under these circumstances. Since Anafranil may produce sedation, particularly during the initial phase of therapy, patients should be cautioned about the danger of engaging in activities requiring mental alertness, judgement and physical coordination. It shout d be borne in mind that Anafranil may block the pharmacological effects of hypotensive drugs, such as guanethidine and similar agents. Caution should be observed in prescribing Anafranil in hyperthyroid patients or in patients receiving thyroid medication conjointly. Transient cardiac orrhythmias have occured in rare instances in patients who have been receiving other tricyclic compounds concomitantly with thyroid medication. Obstructive jaundice and bone marrow depression with agranulocytosis have been reported. Periodic blood cell counts and liver function tests are recommended in patients receiving treatment with Anafranil over prolonged periods. Adverse Reactions The following adverse reactions have been reported with Anatranil or other tricyclic antidepressants: Central Nervous System Effects: drowsiness, fatigue, insomnia, entrapyramidal effects such as tremor and ataxia, headache, anorexia and convulsions. Peripheral neuropathy has also been reported with tricyclic compounds. Behavioural Effects: agitation, excitement, hypomania or manic episodes, activation of psychosis, confusion, disturbed concentration, visual hallucinalions. Autonomic Nervous System Effects: dry mouth, blurred vision, difficulty with accommodation, constipation, paralytic bus, disturbances of micturition, excessive sweating, nausea and vomiting. CardiovascularEffects: hypotensiun, particularly orthoslalic hyputensior with associated vertigo, tachycardia, syncope, arrhythmia, asystole, EKG changes (including flattening or inversion of T wave) and disturhances in cardiac conduction.
Haematological and OtherToxic Effects: agranulocytosis has been re-
p4 A'
ported; it represents a hypersensitivity reaction. Ensinophilia may also occur. Obstructive jaundice, allergic skin reactions, pholxsensitizatixn, occasional dislurhances of appetite, abdominal pain, changes in libido, and weight gain. Dosage and Administration EXCEPT IN ELDERLY PATIENTS AND ADOLESCENTS: One tablet (25 mg) 3 times daily initially, increase up to six tablets (150 mg) daily, or more, as required. Dosage in excess of 200mg daily is not usually recommended for office patients. Occasiovally in more severe hospitalized patients, dosages up to 300 mg may be required IN ELDERLY PATIENTSAND ADOLESCENTS: 20to 30mg daily, increased by 10mg daily, if necessary, depending on tolerance and response. Availability Each pale yellow, sugar-coated lenticular tablet branded (Geigy) contains 25mg clomipramine hydrochloride. Alsoavailable in pale yellow, triangular sugar-coated tablets branded (Geigy), containing 10mg clomipramine hydrochloride. In boffles of 50 and 500. Product Monograph available to physicians and pharmacists on request.
References:
1. Rompel, H.: The Treatment of Depression, Med. Proc. 13, 631, (1967) 2. Clarke, F.C.: The Treatment of Depression in General Practice. S. Atr. Med. J.43, 23, (1969) 3. Lasich, A.J.: Clinical Evaluation of a New Anti-Depressant (Anafranil), Med. Proc. 14, 312(1968)
FIG. 4-Intravenous pyelogram after operation return of function of left kidney 10 minutes after injection of contrast material; note changes of polycystic disease 598 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
Geigy Dorval, P.O. H9S iBi
G-7004R
Hemorrhage within a polycystic kidney is a rare cause of acute renal shutdown. This paper presents such a case and reviews the causes and the radiologic methods used in making ,the diagnosis. Case report
A 44-year-old man presented with left-sided abdominal pain of acute onset. The pain was constant and nonradiating. There was no previous or family history of renal disease, and no previous history of pertinent medical or surgical problems. The results of initial urinalysis were normal except for the presence in the urine of a few erythrocytes. The hemoglobin concentration was 15.8 g/dl, the blood urea nitrogen concentration 11 mmol/l (31 mg/dl) and the serum creatinine concentration 159 .mol/1 (1.8 mg/dl). Intravenous pyelography demonstrated no function on the left side; both kidneys were seen to be enlarged, and there was some flattening of the calyces on the right side (Fig. 1). At cystoscopy no Reprint requests to: Dr. Peter Tadros, Department of radiology, Hotel Dieu of St. Joseph, 1030 Ouellette Ave., Windsor, Ont. N9A lEl
urine was seen coming from the left ureter. The retrograde examination showed a normal left ureter, with some compression externally of the renal pelvis; the calyces were noted to be flattened and to have lost their cupping (Fig. 2). A left ureteric catheter was left in situ for 48 hours, during which time there was no output of urine from the left kidney. The patient was referred for further radiologic investigation. Abdominal aortography revealed that the main renal arteries were patent. A selective left renal arteriogram displayed a reduction in the size and number of intrarenal branches and multiple round translucent areas within the renal parenchyma (Fig. 3). Since the renal vein did not opacify, venography (both inferior venocavography and left renal vein studies) was performed. No venous occlusion was demonstrated. An operation disclosed multiple cysts within the left kidney. Near the hilus were two large cysts containing relatively fresh blood; these were evacuated and marsupialized After the operation diuresis occurred; approximately 800 ml of urine was passed every 8 hours. The blood urea nitrogen concentration was 5.0 mmol/l (14 mg/dl) and
FIG. 1-Intravenous pyelogram: no function on left, splaying and flattening of calyces on right, and enlargement of both kidneys.
the serum creatinine concentration 124 .mol/l (1.4 mg/dl) 48 hours after the operation. The return of function of the left kidney is demonstrated in Fig. 4. Discussion The common causes for nonvisualization or nonfunction of one kidney noted with intravenous pyelography are: * Obstruction of the ureter by a calculus, a stricture or a neoplasm.
FIG. 2-Left retrograde cystoscopy shows no obstruction of ureter but external compression of renal pelvis and loss of cupping of calyces.
CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
597
* Destruction of the kidney or venous obstruction due to a neoplasm. * Trauma, giving rise to "fractured kidney". * Vascular causes: renal artery occlusion, secondary to either thromboembolism or stenosis; arteriovenous malformation or fistula; and renal vein obstruction, due to either a tumour or thrombosis. Uncommon causes include: * Unknown previous nephrectomy. * Congenital absence of the kidney. * Destruction of the kidney by tuberculosis or other severe infections, such as xanthogranulomatosis. * Multicystic disease.1'2 The recent literature does not include polycystic disease as a cause
of unilateral renal shutdown. The reason for the shutdown, bleeding into renal cysts so that the renal pelvis of an already compromised kidney is compressed, is not unknown,3 but is not widely recognized. A glance at the common causes of unilateral renal shutdown will explain the rationale of the investigations in such cases. In any patient in whom renal function is absent or markedly decreased unilaterally, cystoscopy with a retrograde examination should be carried out to exclude postrenal obstructive uropathy. The absence of a ureteral lesion should then lead to arteriographic investigations. If the renal vein is not visualized (as may be the case for delayed films with selective renal artery catheterization), then venography is indicated to exclude venous obstruction. In conclusion, bleeding into cysts in a polycystic kidney should be considered as a cause of unilateral nonfunction. My thanks to Dr. D. McLeod for referring this patient, to Ms. B. Hudacek for secretarial help and to Dr. D.R. Feore for the photography. References 1. REEDER MM, FELSON B: Gamuts in
Radiology, Audiovisual Radiology, Cincinnati, Ohio, 1975, H-22 2. PETEASNICK JP, PATEL 5K:
FIG 3 Nephrographic phase of selective left renal arteriogram: many round translucent areas.
Angio-
graphic evaluation of the non-visualizing kidney. J Roentgenol Radium Ther Nuci Med 119: 757, 1973 3. HAMBURGER J, ROYER P: Nephrology,
Saunders, Philadelphia, 1968
The other side of depression.
Anairanil Antidepressant
Indications and Clinical Uses Anatranil (clomipramine hydrochloride) is indicated in the drug treatment of depressive illness, including manic depresuive psychosis, depressed phase, and involutional melancholia. Anafranil tppears to have a mild sedative effect which may he helpful in atleviating the anxiety component often accompanying depression. ContraIndications Anatranil should not be given in conjunction with or within fourteen days of treatment with a monoamine oxidase inhihitor. Combined therapyof this type could lead to theappearance of serious hypertensive crises and death may occur. Anafranil is contraindicated in patientswith existing liver damageand should not be administered to patients with a history ot blood dyscrasias. Anatranil is contraindicated in patients who have shown hypersensitivity to the drug. Anatranit is contraindicated in patients with glaucoma, as the condition may be aggravated due to the atropine-tike effects of the drug. Use/n Pregnancy: The safety of use in pregnant women has not been established. Therefore, Anafranil should not be administered to women of childbearing potential, particularly during the first trimester of pregnancy, unless, in the opinion of the physician, the eopected benefit to the patient outweighs the potential risk to the fetus. Warnings The following warnings apply to Anafranil and other tricyctic antidepressant agents: Tricyclicagents may lower the convulsive threshold and should, therefore, be used with caution in patients with convulsive disorders. Electrocardiographic studies suggest that Anafranil should not be used in the presence of pronounced cardiac or circulatory failure, recent myocardial infarction or ischaemic heart disease. Anafranil also has a hypotensive action which maybe detrimental in these circumstances. The drug should, therefore, be used with caution in patients who are susceptible to hypotensive episodes. Tricyclic agents may produce urinary retention and should be used with caution in patients with urinary pathology, particularly in the presence of prostatic hypertrophy. Particularly in the elderly and in hospitalized patients the tricyclic antidepressants may give rise to paralytic ileus and therefore appropriate measures should be taken if constipation occurs. Anafranil should be kept in a safe place, well out of the reach of children. Precautions In seriouslydepressed patients the possibility of suicide should be borne in mind and may persist until significant remission occurs. Therefore, these patients should be carefully supervised during treatment with Anafranil, and hospitalization or concomitantelectro-convulsive therapy maybe required. Activation of latent schizophrenia or aggravation of existing psychotic manifestations in schizohrenic patients may occur; patientswith manic-depressive tendencies may enperience hypomanic or manic shifts: and hyperactive or agitated patients may become over-stimulated. A reduction in dose or discontinoation of Anafranil should be considered under these circumstances. Since Anafranil may produce sedation, particularly during the initial phase of therapy, patients should be cautioned about the danger of engaging in activities requiring mental alertness, judgement and physical coordination. It shout d be borne in mind that Anafranil may block the pharmacological effects of hypotensive drugs, such as guanethidine and similar agents. Caution should be observed in prescribing Anafranil in hyperthyroid patients or in patients receiving thyroid medication conjointly. Transient cardiac orrhythmias have occured in rare instances in patients who have been receiving other tricyclic compounds concomitantly with thyroid medication. Obstructive jaundice and bone marrow depression with agranulocytosis have been reported. Periodic blood cell counts and liver function tests are recommended in patients receiving treatment with Anafranil over prolonged periods. Adverse Reactions The following adverse reactions have been reported with Anatranil or other tricyclic antidepressants: Central Nervous System Effects: drowsiness, fatigue, insomnia, entrapyramidal effects such as tremor and ataxia, headache, anorexia and convulsions. Peripheral neuropathy has also been reported with tricyclic compounds. Behavioural Effects: agitation, excitement, hypomania or manic episodes, activation of psychosis, confusion, disturbed concentration, visual hallucinalions. Autonomic Nervous System Effects: dry mouth, blurred vision, difficulty with accommodation, constipation, paralytic bus, disturbances of micturition, excessive sweating, nausea and vomiting. CardiovascularEffects: hypotensiun, particularly orthoslalic hyputensior with associated vertigo, tachycardia, syncope, arrhythmia, asystole, EKG changes (including flattening or inversion of T wave) and disturhances in cardiac conduction.
Haematological and OtherToxic Effects: agranulocytosis has been re-
p4 A'
ported; it represents a hypersensitivity reaction. Ensinophilia may also occur. Obstructive jaundice, allergic skin reactions, pholxsensitizatixn, occasional dislurhances of appetite, abdominal pain, changes in libido, and weight gain. Dosage and Administration EXCEPT IN ELDERLY PATIENTS AND ADOLESCENTS: One tablet (25 mg) 3 times daily initially, increase up to six tablets (150 mg) daily, or more, as required. Dosage in excess of 200mg daily is not usually recommended for office patients. Occasiovally in more severe hospitalized patients, dosages up to 300 mg may be required IN ELDERLY PATIENTSAND ADOLESCENTS: 20to 30mg daily, increased by 10mg daily, if necessary, depending on tolerance and response. Availability Each pale yellow, sugar-coated lenticular tablet branded (Geigy) contains 25mg clomipramine hydrochloride. Alsoavailable in pale yellow, triangular sugar-coated tablets branded (Geigy), containing 10mg clomipramine hydrochloride. In boffles of 50 and 500. Product Monograph available to physicians and pharmacists on request.
References:
1. Rompel, H.: The Treatment of Depression, Med. Proc. 13, 631, (1967) 2. Clarke, F.C.: The Treatment of Depression in General Practice. S. Atr. Med. J.43, 23, (1969) 3. Lasich, A.J.: Clinical Evaluation of a New Anti-Depressant (Anafranil), Med. Proc. 14, 312(1968)
FIG. 4-Intravenous pyelogram after operation return of function of left kidney 10 minutes after injection of contrast material; note changes of polycystic disease 598 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
Geigy Dorval, P.O. H9S iBi
G-7004R
