From the Guidelines
Management of renal infarction in the emergency department should prioritize non-operative management (NOM) in hemodynamically stable patients, with a focus on aggressive pain control, anticoagulation, and supportive care to maintain renal perfusion, as recommended by the most recent guidelines 1. The initial management includes aggressive pain control with IV opioids, anticoagulation with unfractionated heparin, and supportive care with IV fluids to maintain renal perfusion.
- Diagnostic workup should include a complete blood count, comprehensive metabolic panel, lactate dehydrogenase, urinalysis, and contrast-enhanced CT scan which is the gold standard for diagnosis.
- For cases diagnosed within 24 hours of symptom onset, consider endovascular intervention with intra-arterial thrombolysis using tissue plasminogen activator (tPA) or mechanical thrombectomy, as suggested by recent studies 1.
- Blood pressure management is crucial, aiming for normal to slightly elevated pressures to maintain renal perfusion.
- Patients require admission for continued anticoagulation and transition to oral anticoagulants for at least 3-6 months.
- The underlying cause of the infarction must be identified and addressed, with cardioembolic sources being most common, followed by hypercoagulable states and renal artery dissection or thrombosis.
- Early nephrology and vascular surgery consultation is recommended for all cases of renal infarction, as emphasized by recent guidelines 1.
- In cases of hemodynamic instability, immediate intervention with surgery or angioembolization may be necessary, as indicated by the guidelines 1.
- The use of angiography and selective angioembolization should be considered in cases of arterial contrast extravasation, gross non-self-limiting hematuria, or other indications, as suggested by recent studies 1.
From the Research
Management of Renal Infarction in the Emergency Department
The management of renal infarction in the Emergency Department (ED) involves prompt diagnosis and treatment to prevent long-term kidney damage and other complications.
- Diagnosis of renal infarction is often delayed or missed due to its non-specific presentation and rarity 2, 3, 4.
- Clinical characteristics that can suggest an early diagnosis of renal infarction include flank and/or abdominal pain, elevated serum lactate dehydrogenase level, and proteinuria 3.
- Treatment of renal infarction may include anticoagulation with heparin and warfarin, thrombolytic therapy with urokinase, and antiplatelet agents 5, 3, 6.
- Early contrast-enhanced computerized tomography scan should be considered for high-risk patients to aid in diagnosis 2.
- Patients with renal infarction should be followed by functional studies rather than serum creatinine level 2.
Treatment Options
- Medical treatment with coumadin, heparin, and thrombolytics may be used to treat renal infarction 3.
- Reperfusion therapy may be effective in saving the affected kidney if initiated promptly 4.
- Low-molecular-weight heparin (LMWH) may be used to treat renal infarction, especially in patients with risk factors for thromboembolism 6.
Important Considerations
- Renal infarction can lead to acute kidney injury, new-onset estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m^2, end-stage renal disease, and death despite aggressive treatment 5.
- A high index of suspicion is required for early diagnosis of renal infarction, especially in patients with risk factors for thromboembolism 2, 3, 6.
- Concurrent injuries or thromboembolism in other foci should be noticed and evaluated in patients with renal infarction 2.