1. ABC Advanced Bleeding Care Case: Spontaneous Kidney Rupture Santiago Ramón Leal-Noval

2. © TPWG May 2004 ABC Advanced Bleeding Care 2 Patient  Male, age 71  Antecedents: -Hypertension -COPD -Obesity -Atrial fibrillation -on oral anticoagulant prophylaxis with acenocumarol  Admitted to hospital with severe pain in the upper left back area  No associated fever or urinary symptoms

3. © TPWG May 2004 ABC Advanced Bleeding Care 3 Image Diagnosis  Ultrasound and CT showed: A left renal mass, suggesting abscess or haematoma extending through left perirenal area, affecting lateral fascia

4. © TPWG May 2004 ABC Advanced Bleeding Care 4 Diagnostic Puncture  CT-guided puncture/aspiration performed  Compatible with bleeding

5. © TPWG May 2004 ABC Advanced Bleeding Care 5 Lab Data at Admission Creatinine: 1.4 mg/dL Haemoglobin: 149 g/L Haematocrit: 0.43 L/L Platelets:248 x 10 9 /L Coagulation: PT: 25 (11 – 16 sec) INR:2.02(0.90 – 1.3) APTT:30(22 – 34 sec)

6. © TPWG May 2004 ABC Advanced Bleeding Care 6 Patient Management  Immediate withdrawal of oral anticoagulants (acenocumarol)  Vitamin K: 10 mg i.v.  Patient clinically stable  Further evolution observed

7. © TPWG May 2004 ABC Advanced Bleeding Care 7 Evolution 24 Hours Later Renal function impairment: Creatinine: 3 mg/dL Anaemia: 100 g/L Haematocrit: 0.31 L/L Platelets: 264 x 10 9 /L Coagulation: PT: 15 (11 – 16 sec) INR: 1.16(0.90 – 1.3) APTT: 23 (22 – 34 sec)

8. © TPWG May 2004 ABC Advanced Bleeding Care 8 Evolution 48 Hours Later  Patient suddenly presents severe pain in the upper left back area extending to left flank and back  No haemodynamic instability

9. © TPWG May 2004 ABC Advanced Bleeding Care 9 Lab Data Creatinine: 4.20 mg/dL Haemoglobin: 6.5 g/L Hb Haematocrit: 0.19 L/L Platelets:178 x 10 9 /L Coagulation: PT: 12 (12 – 14 sec) INR:1.06(0.90 – 1.3) APTT:26(22 – 34 sec)

10. © TPWG May 2004 ABC Advanced Bleeding Care 10 Kidney, sectioned in two halves Treatment: Urgent Surgical Left Nephrectomy II Haematoma

11. © TPWG May 2004 ABC Advanced Bleeding Care 11 Transfusions Total transfusion required during surgery: -4 RBC intraoperative -5 RBC in ICU due to persistent anaemia

12. © TPWG May 2004 ABC Advanced Bleeding Care 12 Clinical Evolution Anaemia persists despite transfusion: Haemoglobin: 80 g/L Haematocrit: 0.25 L/L Platelets: 308 x 10 9 /L Coagulation: PT: 11.6 (11 – 16 sec) INR: 1 APTT: 23 (22 – 34 sec)

13. © TPWG May 2004 ABC Advanced Bleeding Care 13 Possible Alternatives to Avoid Multi-transfusion  Recombinant activated FVII (rFVIIa)  Aprotinin