Retroperitoneal Hematoma in a Patient with Advanced Chronic Kidney Disease Receiving Warfarin Therapy

Abstract

A 73-year-old man with chronic kidney disease stage G5 was admitted to our hospital because of a worsening kidney dysfunction. He had undergone prosthetic valve replacement of the mitral valve 5 years previously and was currently taking warfarin. He showed excessive anticoagulation on admission, with a prothrombin time-international normalized ratio (PT-INR) of 3.91. The use of warfarin was ceased and PT-INR decreased to 2.1. Since the patient would need renal replacement therapy, he underwent arteriovenous fistula surgery for hemodialysis access on day 16. However, on day 18, he suddenly complained of lumbago and went into shock. His blood pressure dropped to 73/49 mmHg, and the hemoglobin level fell to 4.9 g/dL.Computed tomography revealed a huge retroperitoneal hematoma. Emergent lumbar artery embolization was performed on two consecutive days; however, the bleeding persisted, with subsequent development of abdominal compartment syndrome with impaired respiratory and cardiovascular function, and the patient died. Autopsy revealed a hematoma measuring 30×20×20 cm involving the psoas muscle and external iliac artery; the hematoma was covered with fibrous tissue instead of muscle. The psoas muscle is supplied by the internal iliac artery; however, a collapsed artery could not be confirmed in our patient. The closest major artery to the hematoma was located at the intersection of the psoas muscle and the external iliac artery. All arteries showed severe atherosclerosis. In patients with advanced chronic kidney disease, anticoagulant therapy should be administered carefully, and the etiology of retroperitoneal hematoma should be further investigated.

A rare life-threatening disease: unilateral kidney compressed by huge chronic spontaneous retroperitoneal hemorrhage

“…It is reported that spontaneous retroperitoneal hemorrhage may result from abdominal vascular rupture, rheumatologic disease, renal tumors, lumbar artery or venous rupture in anticoagulant administered and hemodialysis patients. 5 , 6 , 9 , 10 We must be wary of spontaneous retroperitoneal hemorrhage if these patients present with flank pain, anemia, and hemodynamic instability.…”

“…The major indications of operation include hemodynamic instability, abdominal compartment syndromes, and impaired respiratory and cardiovascular functions, but the latter two often mean treatment failure. 10 Therefore, once the diagnosis has been confirmed, intervention must be started because early diagnosis and appropriate treatment can decrease the mortality and morbidity. 9 …”

Rehabilitation training following retroperitoneal haemorrhage: A case report and review of the literature

“…Renal failure and dialysis. Although RPH in renal failure and patients on dialysis has generally been reported as individual cases, several such reports have been published in the literature (10)(11)(12)(13). In particular, the incidence of RPH is high in patients undergoing chronic haemodialysis, while also receiving anticoagulant therapy (14).…”

Warfarin-induced spontaneous retroperitoneal hemorrhage from the renal vein: A rare case with an uncommon etiology

“…Only a few case reports have been published on the fatality of SRH. 11,12 We report a case of warfarin-induced SRH from the renal vein that we initially managed conservatively, followed by embolization of the right renal artery later during hospital stay, with good recovery.…”