Simple Ex Vivo Porcine Kidney Model for Teaching Ultrasound-Guided Intervention.

OBJECTIVE. The purpose of this study is to describe the use of a novel, cost-effective, gelatin ex vivo porcine kidney model for renal interventions performed using ultrasound guidance. CONCLUSION. Percutaneous ultrasound-guided renal interventions are common procedures in radiology. Use of models helps trainees develop the hand-eye coordination needed to successfully perform interventional techniques. The gelatin ex vivo porcine kidney model can be used to educate trainees in proper technique before they perform such procedures on actual patients.

Resolution of multiorgan sarcoid-like reaction after treatment of renal cell carcinoma.

Sarcoid -like reactions (SLRs) can occur in several malignancies adjacent to primary tumour location or the draining lymph nodes. The presence of peritumoural and intratumoural SLR in patients suffering from renal cell carcinoma (RCC) has been reported in few instances. However, the association of RCC with SLR in spleen, liver and other organs in the absence of systemic sarcoidosis is very rare.We present an unusual case of a gentleman in his 30s, who presented with a lesion in the left kidney along with non-specific lesions (likely granulomatous) in liver, spleen and lungs. Partial Nnephrectomy specimen confirmed conventional/clear cell RCC. The histopathology revealed an extensive epithelioid granulomatous reaction affecting both peritumoural and intratumoural areas. Follow-up images demonstrated an almost complete resolution of lesions in the spleen, liver and lungs. Our case supports the hypothesis that non-caseating granulomas of SLR could be a manifestation of an immunologically mediated antitumour response.

Super-response to renal denervation in treatment-resistant essential hypertension.

Renal denervation may be indicated in patients with treatment-resistant essential hypertension to decrease sympathetic nervous activity and optimise blood pressure. We present the case of a woman in her 50s with long-standing essential hypertension, a previous transient ischaemic attack, obesity and a family history of cardiovascular disease, who presented with persistent 24-hour ambulatory hypertension despite ongoing lifestyle modifications and being on five antihypertensive agents with no evidence of an alternative primary aetiology. She had intermittent palpitations and blurring of vision alongside evidence of left ventricular hypertrophy on a CT scan. She underwent renal denervation, following which, not only was she able to cease all antihypertensive therapy but managed to maintain optimised blood pressure with subsequent reversal of left ventricular hypertrophy. Trials have demonstrated modest but inconsistent reductions in blood pressure whereas our case represents a 'super-response' likely due to a higher number of circumferential ablations in comparison to previous studies.

Eculizumab therapy and complement regulation in a case of resistant catastrophic antiphospholipid syndrome.

Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening form of antiphospholipid syndrome characterised by diffuse arterial and venous thrombosis, in the presence of positive antiphospholipid antibodies. The multiple sites of thrombosis in small, medium and large vessels progress to multiorgan failure, accounting for the high mortality rate associated with CAPS. Unregulated complement activation is increasingly recognised as critical to the pathogenesis of CAPS. Early diagnosis is essential to initiate prompt life-saving treatment with the triple therapy of anticoagulation, immunosuppression and either plasmapheresis or intravenous immunoglobulin. Among other immunosuppressive agents, eculizumab, a complement inhibitor has demonstrated efficacy in treatment-resistant cases.We report an instructive case of a woman presenting with both clinical and laboratory findings consistent with primary CAPS, resistant to initial treatment and responsive to eculizumab, with emphasis on genetic testing and implications for future therapy.

A Huge High-Flow Aneurysmal Renal Arteriovenous Malformation Treated With Endovascular Transcatheter Embolization.

Renal arteriovenous anomalies are uncommon. They are characterized by an abnormal vascular connection that usually bypasses the capillary bed. Most are acquired arteriovenous fistulas (AVF) while the rest are congenital or idiopathic arteriovenous malformations (AVM). AVF are usually caused by renal interventions, trauma, or neoplastic processes. They can lead to hypertension, heart failure, hematuria, and renal insufficiency. A 69-year-old woman presented with arrhythmia, tachycardia, mild ankle edema, and increasing fatigue. Right kidney color Doppler ultrasound confirmed the presence of a huge AVM with a blood flow of 9 L/minute and a dilated, 35 mm in diameter, right renal vein. Two months later, an attempt to embolize the AVM failed as the Amplatzer™ Vascular Plug II (Abbott Laboratories, Chicago, Illinois, United States) migrated to the pulmonary circulation and was later removed. Complete embolization was achieved by implanting two Amplatzer Vascular Plug IIs, various embolization coils, histoacryl glue, and lipiodol. Control angiography revealed significant stenosis in the right subclavian artery endovascular access, which was managed with BeGraft (Bentley InnoMed GmbH, Hechingen, Germany) and Zilver (Cook Group Incorporated, Bloomington, Indiana, United States) stents. The patient was discharged on the third postoperative day, all her symptoms resolved, and she reported eventual recovery. Three months later, the patient was operated on due to a 40x58 mm pseudoaneurysm at the right femoral access site. Thus, renal AVMs should be included as a potential alternative diagnosis for various symptoms such as hematuria and hypertension resistant to medication. Endovascular embolization is a less-invasive, safer, and more effective option than open surgery but has a risk of complications. Success requires fully occluding the shunted vessel, preventing embolic material migration, and preserving normal arterial branches. It depends on selecting adequate techniques and embolic materials individually, based on etiology and precise vascular anatomy assessment.

Endovascular Treatment of a Bilateral, Ruptured Angiomyolipoma in a Patient With Tuberous Sclerosis Complex.

A renal angiomyolipoma (AML) is a rare, usually benign tumor consisting of smooth muscle cells, abnormal blood vessels, and fat tissue. Although AMLs are often asymptomatic, they can present with flank pain, hematuria, and a palpable mass in the abdomen. A significant complication involves rupture and hemorrhage into the retroperitoneal cavity, which can be life-threatening. The treatment approach has evolved from surgical removal to more conservative management, such as nephron-sparing embolization and mammalian target of rapamycin (mTOR) inhibitors for tuberous sclerosis complex (TSC)-associated AML. In March 2024, a 36-year-old female patient diagnosed with TSC was admitted to our department and underwent several endovascular embolizations after a life-threatening hemorrhage from a ruptured multilocular AML. The treatment was successful, with complete exclusion of the AMLs from circulation and without any complications during the postoperative period. This case emphasizes the effectiveness of selective arterial embolization using the Onyx liquid embolic system in managing AMLs and highlights the importance of preserving renal function. Methods used in AML diagnosis include ultrasound and computed tomography scans, with magnetic resonance imaging and biopsy recommended in difficult cases. Treatment depends on aspects such as tumor size, symptoms, and patient's general condition, with options ranging from active surveillance for small, asymptomatic AMLs to more invasive procedures for larger, symptomatic tumors. The main goal is to minimize symptoms and preserve renal function.

Usefulness of selective percutaneous transluminal angioplasty using renal echo for a patient with bilateral renal artery stenosis and chronic renal failure.

A man in his 70s visited the hospital for chronic kidney disease with hypertension. He had anuria for several days before visiting the hospital. His creatinine level rose to 8.97 mg/dL (from 3 mg/dL) and his systemic blood pressure increased to 183 mm Hg. Other uraemic symptoms were also observed, and he was therefore admitted to the hospital and started continuous haemodiafiltration. MRI and angiography showed a highly stenotic lesion with calcification at the origin of the renal artery; a CT scan showed atrophy of the left kidney. Renal Doppler ultrasonography was performed and renal resistive indexes were: 0.92 for the left kidney and 0.68 for the right kidney. The viability of the right kidney was thought to be maintained, and percutaneous transluminal renal angioplasty (PTRA) for the right renal artery stenosis was performed; his creatinine level improved (3 mg/dL) and his systolic blood pressure decreased (120 mm Hg). We implanted a stent on the right stenotic lesion and the right renal artery blood flow improved. We experienced an effective PTRA for the right renal artery for bilateral renal artery stenosis. Although the indications of PTRA for renal artery stenosis are limited, the evaluation of renal function using ultrasonography could be a useful index for determining the culprit lesion.

Retained foreign body post-PCNL: an unusual complication and endoscopic management.

During this era of advanced and minimally invasive procedures for treating urolithiasis, percutaneous nephrolithotomy (PCNL) remains the primary choice for removing large renal calculi. While there are various known complications associated with PCNL, such as bleeding, sepsis and injury to neighboring organs, the occurrence of retained foreign bodies as a result of the procedure is rarely reported. In this case report, we present a unique instance of encrustation involving a retained guidewire sheath following PCNL, which was initially mistaken for a residual stone fragment in imaging studies. Fortunately, the foreign body was successfully removed using retrograde intrarenal surgery.

Preoperative renal embolisation in patients with polycystic kidney disease requiring incisional hernia repair after renal transplantation.

In the same way that renal transcatheter arterial embolisation (TAE) has demonstrated its effectiveness and safety compared with nephrectomy of the polycystic kidney at the time of transplantation, we propose that TAE can be a minimally invasive option in the surgical preparation for incisional hernia repair in order to reduce the compressive effect of the polycystic kidney, creating space and ensuring safe hernia repair. The objective of this article is to describe the first case in which TAE is used in advance of incisional hernia secondary to renal transplantation in patients with autosomal dominant polycystic kidney disease.

Cryoablation following neoadjuvant tyrosine kinase inhibitor as treatment of a T1a renal clear cell carcinoma in a patient with a solitary kidney.

The case is presented of a woman in her 60s with renal cell carcinoma in a solitary kidney with normal renal function. Because of the solitary kidney status, the management strategy described in acknowledged guidelines was not possible. The patient was treated with standard first-line tyrosine kinase inhibitor followed by percutaneous CT-guided cryoablation. Before and after the procedure the patient had normal kidney function. The treatment resulted in local cancer control, but a bone metastasis developed in the thoracic part of the spine.

Biopsy-proven fungal pyelonephritis complicating delayed graft function in a renal transplant patient.

Delayed graft function (DGF) is a common phenomenon following renal transplantation, which can be due to several factors. A rare cause includes invasive fungal infections, which can often be a challenge to diagnose. Nonetheless, prompt identification of such infections particularly within transplant patients is essential as they can lead to severe downstream sequelae, including graft loss and even death. We describe here a challenging case of fungal pyelonephritis complicating and potentially leading to DGF and further dialysis dependence within a renal transplant patient. Notably, we highlight the importance and clinical utility of biopsy to confirm the diagnosis, as investigations may be largely normal otherwise. Furthermore, we emphasise that with early identification of these infections, effective antifungal treatment can be commenced in a timely fashion leading to better patient outcomes and good graft function.

A Massive Renal Infarction Due to Atheroemboli: A Case Report.

The symptoms of acute renal infarction (ARI) caused by atheroemboli are vague, making it rare. Early diagnosis of renal infarction can be made through contrast-enhanced CT of the abdomen. However, diagnosing atheroemboli is more challenging. Kidney biopsy is the most accurate method to determine the cause, but it may not always be available in clinical settings. In cases where a thrombectomy is performed, white substances in thrombus aspiration or the patient's blood can suggest a diagnosis. Intervention is an effective technique, but there is controversy due to a lack of data, particularly in lobular artery infarction. We successfully treated one case using thrombus aspiration, and the specimens suggested atherosclerosis as the cause.

Renal artery stenosis stenting with unmasking and embolisation of a renal arteriovenous fistula.

A man in his 70s was presented to the emergency department with uncontrollable hypertension and worsening renal function on a background of atherosclerosis-related bilateral renal artery stenosis. Following progressive deterioration in renal function and refractory hypertension, the patient was referred to interventional radiology for consideration of renal artery stenting. Following stenting of the right renal artery, a large renal arteriovenous fistula became apparent, which required emergent embolisation. Both procedures were successful, with excellent clinical and radiological responses.

Rescue of an asymptomatic arterial occlusion after kidney transplant.

Arterial injury leading to vascular occlusion is a rare complication of kidney transplantation that requires urgent intervention to salvage the kidney and prevent graft loss. Occasionally, the recipient iliac vessels may be injured, resulting in acute ischaemia of the lower extremity in addition to loss of blood flow to the kidney transplant. In the case presented here, a 58-year-old man with chronic kidney disease secondary to IgA nephropathy underwent pre-emptive deceased donor renal transplantation complicated by an external iliac artery (EIA) dissection proximal to the transplant anastomosis. However, as a result of retrograde blood flow from collateral vessels, perfusion of the kidney and right lower extremity was initially preserved and early diagnosis was made after post-transplant ultrasound. This report reviews the aetiology, clinical features and therapeutic options for arterial injuries post-transplant. This case also highlights the importance of post-transplant vigilance and the value of routine postoperative ultrasound imaging.

Mechanical stress-related haemolysis in a paediatric haemodialysis patient.

Haemodialysis (HD) is a common kidney replacement therapy (KRT) used in the management of children with end-stage kidney disease (ESKD). We describe the case of a 2-year-old child who developed mechanical intraluminal haemolytic anaemia secondary to the acute angulation of the HD line. In contrast to reports of arteriovenous fistula-associated haemolysis, onset was insidious in nature and detected through review of subtle serial biochemical and haematological changes. Development of hyperbilirubinaemia during HD was modest due to the partial clearance of bilirubin via HD-enabled diffusion. The only persistent and consistent marker was the post-HD rise in lactate dehydrogenase in association with decreasing haemoglobin. We propose that mechanical stress-induced haemolysis should be considered in children on HD who develop unexplained or persistent anaemia with resistance to increasing doses of iron and erythropoiesis-stimulating agent supplementation.

Renal malakoplakia with invasion of the liver and diaphragm: a patient case and literature review.

Renal malakoplakia, a seldom seen chronic inflammatory condition, continues to elude medical, surgical, radiological and pathological specialists due to its mimicry of other renal pathologies and low incidence. The variable clinical manifestations and non-specific radiological findings of malakoplakia can be misleading, and ultimately require a pathological diagnosis. A literature review reveals an extremely low prevalence of renal malakoplakia, a handful of invasive renal malakoplakia cases and no reports of liver and diaphragmatic invasion. We present a case of a renal mass with liver and diaphragmatic invasion in a 59-year-old woman that deceived clinicians and radiologists until a pathological diagnosis of renal malakoplakia was performed. This case highlights the need of awareness for malakoplakia in the differential diagnosis for renal invasive and non-invasive masses. The need to await a surgical biopsy and pathological diagnosis is critical to ensure a correct diagnosis and avoid unnecessary surgery of the kidney.

Intrahepatic renal cell carcinoma implantation along a percutaneous biopsy and cryoablation probe tract.

A man in his 60s underwent percutaneous biopsy and cryoablation of a right upper pole clear cell renal cell carcinoma followed by repeat cryoablation 8 months later for possible residual disease. The patient was followed with imaging with documented stability for 19 months after repeat ablation. However, imaging at 32 months demonstrated intrahepatic nodular enhancing lesions along the initial percutaneous biopsy and ablation tract, consistent with metastatic implantation. The patient underwent repeat percutaneous biopsy and two rounds of microwave ablation for treatment of the intrahepatic implants, with no residual disease at 10 months postablation. While needle tract seeding is a known complication of percutaneous manipulation of various abdominopelvic malignancies, there have been no prior reports of intrahepatic metastatic implants related to percutaneous renal cell carcinoma ablation. Awareness of this potential complication is important for treatment planning, informed consent and surveillance. This report shares our experience of the management of intrahepatic metastatic implants.

Intraoperative indocyanine green fluorescence navigation in a robot-assisted partial nephrectomy for a large renal cell carcinoma in a horseshoe kidney.

A man in his 60s was referred to the urology department with an incidental finding of large 75 mm mass within a horseshoe kidney. CT imaging highlighted the well-known aberrant arterial anatomy seen in horseshoe kidney which often causes significant surgical challenges.After careful preoperative planning, the mass was resected successfully during a robot-assisted partial nephrectomy. Intraoperatively, indocyanine green fluorescence navigation helped to confirm arteries supplying area of resection were appropriately clamped, allowing for safe resection of the mass. Histology revealed a chromophobe renal cell carcinoma with clear margins. The patient was discharged on day 4 postoperatively and continues to be cancer free on routine surveillance imaging.

Ruptured angiomyolipoma, a novel entity for emergency physicians in the differential diagnosis of haemorrhagic shock in a female patient of reproductive age.

A woman in her 30s presented to the emergency department with acute onset, progressively worsening left-sided abdominal pain after exercise. She was found to be hypotensive and diaphoretic, with free intraperitoneal fluid detected on bedside point-of-care ultrasound. Resuscitation was initiated, a presumptive diagnosis of ruptured ectopic pregnancy was made, and obstetrics and gynaecology were consulted. Point-of-care urine pregnancy testing, however, was negative, and subsequent CT angiography of the patient's abdomen revealed an angiomyolipoma (AML) with active haemorrhage. Ultimately, embolisation was performed in the interventional radiology suite, with improvement of patient haemodynamics. Ruptured AML is a rare, life-threatening condition that needs to be included in the differential diagnosis of haemorrhagic shock in female patients of reproductive age presenting to the emergency department.

Successful rescue from kidney failure with delayed catheter-directed intervention after catastrophic bilateral kidney paradoxical thromboembolism.

A 62-year-old man presented with acute abdominal and flank pain, oligoanuria and severe acute kidney injury. Unenhanced CT imaging did not detect urolithiasis or hydronephrosis. There was an early blood pressure surge followed by an intense inflammatory response, with a rise in peripheral blood leucocytes and C reactive protein. His urinalysis was bland but the serum lactate dehydrogenase was markedly elevated. CT angiograms demonstrated multiple pulmonary emboli and bilateral renal artery thromboembolism, with occlusion of the left main renal artery. Despite an 88-hour delay from pain onset, catheter-directed thrombolysis and thromboaspiration of both renal arteries were successfully performed, allowing the patient to recover enough kidney function to cease haemodialysis. A patent foramen ovale with right-to-left shunting was discovered, and paradoxical embolism was suspected as the cause of renal infarction. The benefit of catheter-directed reperfusion after prolonged bilateral renal ischaemia is not easily predicted by the severity or duration of acute kidney injury alone.