Case of the week 신장내과 R2 이재연

Case 1 C.C.) Rt abdomen pain o/s 내원 1 달전 Hematuria o/s 내원 1 일전 P.I. ) 11852528 신 O 천 (M/52) adm. 2006- 11- 24 C.C.) Rt abdomen pain o/s 내원 1 달전 Hematuria o/s 내원 1 일전 P.I. ) ’94년 r/o GN ESRD로 HD start AVF occlusion 으로 수 차례 angioplasty , 02 년 AVF op 재시행 ’01년 11월 Rt abdominal pain 있어 개인병원 방문, Rt renal mass 의심되어 전원 , abdomen CT에서 both kidney의 multiple small cyst 와 cyst rupture의한 Rt renal hematoma 소견 보여 항생제 및 conservative Mx 후 퇴원함 이후 AVF occlusion 으로 수 차례 angioplasty 시행 받음

’06년 7월 , 갑자기 Lt flank pain 이 발생하여 응급실 내원 CT 촬영 결과 Known acquired cystic kidney disease에 Lt renal hematoma 발생하여 bleeding control 및 conservative Mx 후 비뇨기과 상의결과 elective nephrectomy 고려하기로 하고 퇴원함. ‘06년 9월 recurrent AV graft site infection 과 occlusion 으로 warfarin 복용 시작함 ’06년 10월 중순부터 Rt abdominal pain 있고 내원 전일 혈뇨 발생하여 응급실로 내원함

PMHx) DM/ HTN/ pul. Tb/ hepatitis(-/+/-/-) HTN: ’89년 CKD 진단 시 같이 진단 Op Hx) AVF op.: ‘94. 12, ‘02. 3 , ’06.11 d/t recurrent AVF obstruction PHx) alcohol (-) smoking (-)

Review of system Physical examination General fever(-) chill(-) malaise(-) GI A/N/V/D/C(+/-/-/-/-) diffuse abdominal pain(+): both (Rt.>Lt.) GU Urine output<10cc/day hematuria(+) voiding difficulty(-) Physical examination V/S 120/70mmHg- 74회/min- 18회/min- 36.7°C Chest CBS without crackle RHB without murmur Abd soft and flat abdomen abdominal Td/ RTd (+ / -) : Rt. flank area Rt abdominal palpable mass(+) B/Ext CVA tenderness ( + / - ) pitting edema(-/-) Rt. arm AVF site thrill & bruit: good

Initial lab finding CBC/DC 7530/mm3- 6.4g/dL-20.0%-268K(seg 68.7%) PT/PTT 3.55(INR) / 65.9 sec. Chemistry TB/DB 0.5/ 0.2 mg/dL AST/ALT 29/ 16 U/L ALP/GGT 64/ 6 mg/dL Prot/alb 7.0/ 3.7 g/dL LD/CK 302/ 2.5 U/L Glucose 104 mg/dL BUN/Cr 52/ 11.8 mg/dL Na/K/Cl 138/5.3/99 mmol/L CRP: 1.7 mg/dL EKG N.S.R

Chest PA

Abd CT ( 06-7-8) Hemorrhage at Lt perirenal space

Initial problem lists 1. Rt. Flank pain & hematuria Acquired cystic kidney disease, s/p Lt cyst rupture 2. ESRD on HD

Initial assessement & plan 1.R/o Recurred vessel rupture of acquired cystic kidney disease p) f/u Abdomen CT (이전 CT와 비교) CBC/DC f/u  transfusion if need pain 양상 관찰, HR 관찰 Wafarin medication 중단 Vit K supply 2. ESRD on HD p) HD without heparin

HD 2 Hb level 1g/dL 이상 감소 HR 증가 소견 응급 CT시행

Right renal hemorrhage with large perirenal hematoma Abdomen CT ( 06-11-25) 06.7월 abdomen CT Right renal hemorrhage with large perirenal hematoma Acquired renal cystic disease Emergent embolization 결정!

Embolization Renal cystic artery중 2곳 embolization시행

f/u Abdomen CT (07-1-09)

Final diagnosis 1. Acquired cystic kidney disease with recurred cystic vessel rupture s/p embolization 2. ESRD on HD

Case 2 11180396 오O근 ( M/54) adm . 06-2-7 C.C.) diffuse abdominal pain o/s 1일 전 P.I.) ‘18년 전 Type 2 DM 진단 ‘10년 전부터 DM nephropathy ESRD로 CAPD 시행 CAPD Peritonitis로 2차례 입원 치료함 내원 1달 전 CAPD peritonitis 로 항생제 치료에 반응 없어 CAPD catheter 제거 후 HD로 전환함 17일 전에 퇴원 하여 동네 의원에서 HD 시행하며 경도의 diffuse abdominal pain 있어 항생제 치료 받음 내원 1일 전부터, diffuse abdominal pain 및 watery diarrhea 3-4회 있어 응급실 경유 입원.

PMHx) 당뇨병 : 18년전 진단, nateglinide 90mg tid 고혈압 : 10년전 진단 ,madipine 5mg qd cilazapril 2.5 mg qd 폐결핵 : 15년전 Pulmonay Tb.진단.약물 치료 후 완치 판정 B 형 간염 : 없음 수술력 : Lt. AV Fistula ( radiocephalic) 06-1-16 FHx) 특이사항 없음 PHx) 술(-), 담배 (-)

REVIEW OF SYSTEM General : general weakness (+) fever (-) chill (-) Skin : Itching (-) rash (-) H & N : sore throat(-) Resp. : cough(-) sputum(-) dyspnea(-) Cardiac : chest pain(-) orthopnea(-) G-I : abdominal pain(+) A/N/V/D/C(-/-/-/+/-) G-U : dysuria(-) frequency(-) nocturia(-) Endo. : polydipsia(-) polyuria(-) M-S : arthralgia(-) : both wrist, elbow, ankle

PHYSICAL EXAMINATION V/S : 130/70 mmHg - 78/min - 20/min - 36.5℃ Chest Clear breathing sound without crackle or wheezing Regular heart beat without murmur Abdomen Mild distended abdomen Hyperactive bowel sound Diffuse tenderness (+) or rebound tenderness (-) Back/Extremity CVA tenderness(-/-) Peripheral pitting edema(-/-) Lt. wrist ; thrill ( good)

PHYSICAL EXAMINATION Abdomen Mild distended abdomen Hyperactive bowel sound Diffuse tenderness (+) or rebound tenderness (-) Back/Extremity CVA tenderness(-/-) Peripheral pitting edema(-/-) Lt. wrist ; thrill ( good) , Nerology Knee DTR(++/++) , Motor & sensory intact

Laboratory Finding CBC/DC 10950 /mm3 - 9.1 g/dL - 27.6 % - 473000/㎣ (Seg. 80.9 %) Chemistry TB/DB 0.87/0.15 mg/dL T-cholesterol 152 mg/dL AST/ALT 48/12 U/L ALP 111 U/L Pro/ALB 5.9/2.3 g/dL BUN/Cr 20/7.6 mg/dL Glucose 165 mg/dL Na/K/Cl 136/3.2/94 mmol/L Ca/P/Mg 8.4/1.2/2.4 mg/dL Urinalysis Urine 없음

Chest PA

ABDOMEN SUPINE

ABDOMEN CT (03-5-21)

Initial problem lists 1. Abdominal pain & diarrhea Known CAPD peritonitis 2. ESRD on HD 3. Type 2 DM 4. Known acquired renal cystic disease

Initial assessement & plan 1.AGE, CAPD peritonitis p) stool culture, Widal test , ascites analysis ; cytology, gram stain, culture, chemistry abdominal CT if needed continue antibiotics 2. ESRD on HD p) HD 3. Type 2 DM p) continue current medication 4. Aquired renal cystic disease p) abdominal CT

Initial lab finding CBC/DC 10,950/mm3 - 9.1g/dL – 27.6% - 473K (seg 80.9 %) PT/PTT 1.05 (INR) 56c 33 sec. Chemistry TB/DB 0.87/ 0.15 mg/dL AST/ALT 48/ 12 U/L ALP/GGT 152/74 mg/dL Prot/alb 5.9/2.3 g/dL Glucose 165 mg/dL BUN/Cr 20/ 7.6 mg/dL Na/K/Cl 136/3.2/96 mmol/L CRP: 9.1 mg/dL ESR 42 mm/hr Widal O,H,A,B titer < 20 Stool culture : negative EKG N.S.R

Ascites L.D. 218 unit Amylase 26 RBC 270/m㎥ WBC 320/m㎥ Neutrophils 21 % Lymphocytes 44 Eosinophils 1 Mono 28 Histio 6 Protein 4300 mg/dL Glucose 170mg/dL CL 94 mmol Cytology within noma limit Gram stain not found Culture not found

Abdominal CT (06-2-8) RK, upper pole, large cyst with enhancing solid portion

Abdominal CT (06-2-8)

Further diagnostic plan Kidney MRI Bone scan

KIDNEY MRI – T1

RK, upper pole, large cyst with enhancing solid portion KIDNEY MRI – T1 enhanced RK, upper pole, large cyst with enhancing solid portion T1WI에서 renal parenchyma와 isosignal intensity를 보이고 T2WI에서 약간 높은 signal intensity를 보이며 enhancement가 비교적 잘 되는 lobulating solid portion을 가지고 있음

BONE SCAN - no metastatic bone lesion

Renal angioinfarction (06-3-28) lipiodol embolization

06-2-8 abd CT

Final diagnosis 1. Acquired cystic kidney disease with RCC s/p Right renal infarction and atrophy 2. AGE, CAPD peritonitis 3. ESRD on HD 3. Type 2 DM

Thank you !!