What is the management of right renal (kidney) infarction?

From the Guidelines

Management of right renal infarction requires prompt diagnosis and treatment to preserve kidney function, and according to the most recent guidelines 1, angiography with eventual super-selective angioembolization should be considered as the first choice in hemodynamically stable or stabilized patients with solitary kidney and moderate or severe renal trauma with arterial contrast extravasation on CT-scan.

Initial Management

Initial management includes supportive care to maintain renal perfusion, monitoring renal function with daily creatinine measurements, and managing electrolyte imbalances.

• Pain control with intravenous opioids or NSAIDs is important.
• Blood pressure management is crucial, typically with ACE inhibitors like lisinopril (10-40 mg daily) or ARBs.

Angioembolization

Angioembolization allows continuation of non-operative management (NOM) if after the procedure patients recover from a hemodynamic point of view, and when no other indications for laparotomy exist 1.

• The success rate of angioembolization in blunt renal trauma ranges from 63% to 100% 1.
• Angioembolization has lower complication rates compared with surgery 1.

Non-Operative Management (NOM)

NOM should be the treatment of choice for all hemodynamically stable or stabilized minor, moderate, and severe lesions 1.

• Accurate classification of the degree of injury and associated injuries with CT-scan with intravenous contrast and delayed urographic phases is mandatory.
• Isolated urinary extravasation, in itself, is not an absolute contraindication to NOM in absence of other indications for laparotomy.

Endovascular Intervention

For cases diagnosed within 24 hours of symptom onset with large vessel occlusion, endovascular intervention with catheter-directed thrombolysis using tPA or mechanical thrombectomy may be considered.

• The underlying cause (atrial fibrillation, hypercoagulable state, aortic dissection, etc.) must be identified and treated.
• Renal infarction causes tissue ischemia and necrosis, and prompt treatment aims to limit the extent of permanent damage and prevent complications like chronic kidney disease, hypertension, and recurrent thrombotic events.

From the Research

Management of Right Renal Infarction

• The management of right renal infarction involves the use of anticoagulants to prevent further clotting and improve renal function 2.
• The choice of anticoagulant depends on the patient's renal function, with unfractionated heparin (UFH) being preferred in patients with severe renal insufficiency 3, 4.
• Low-molecular-weight heparin (LMWH) may be used in patients with mild to moderate renal insufficiency, but its use is limited in patients with severe renal insufficiency due to bioaccumulation 4, 5.
• The use of anticoagulants in patients with end-stage renal disease requires careful consideration, with UFH being the most commonly used agent for anticoagulation of the hemodialysis extracorporeal circuit 5.
• In patients undergoing continuous renal replacement therapy (CRRT), the choice of anticoagulant should be determined by patient characteristics, local expertise, and ease of monitoring, with regional citrate anticoagulation (RCA) being recommended over UFH in patients without contraindications to citrate 6.

Anticoagulation Strategies

• UFH is the most commonly used anticoagulant in patients with renal insufficiency, but its use is associated with an increased risk of bleeding complications 3, 5.
• LMWH may be used as an alternative to UFH in patients with mild to moderate renal insufficiency, but its use requires careful monitoring of anti-Xa levels to prevent bioaccumulation 4.
• RCA is a promising anticoagulant strategy in patients undergoing CRRT, with a lower risk of bleeding complications compared to UFH 6.
• The use of thrombin antagonists and platelet inhibiting agents as anticoagulants in patients with renal insufficiency is limited by the lack of clinical data and the potential for adverse effects 6.

Clinical Considerations

• Patients with right renal infarction should be evaluated for underlying conditions that may have contributed to the development of the infarction, such as atrial fibrillation or renal artery stenosis 2.
• Laboratory tests, including lactate dehydrogenase levels, should be performed to confirm the diagnosis of renal infarction and to monitor renal function 2.
• Imaging studies, such as computed tomography (CT) scans, should be performed to confirm the diagnosis of renal infarction and to evaluate the extent of the infarction 2.