Case Report: Fatal Complications of BK Virus-Hemorrhagic Cystitis and Severe Cytokine Release Syndrome Following BK Virus-Specific T-Cells

BK virus (BKV)-hemorrhagic cystitis (HC) is a well-known and rarely fatal complication of hematopoietic stem cell transplantation (HSCT). Treatment for BKV-HC is limited, but virus-specific T-cells (VST) represent a promising therapeutic option feasible for use posttransplant. We report on the case of a 16-year-old male with dedicator of cytokinesis 8 (DOCK8) deficiency who underwent haploidentical HSCT complicated by severe BKV-HC, catastrophic renal hemorrhage, and VST-associated cytokine release syndrome (CRS). Gross hematuria refractory to multiple interventions began with initiation of posttransplant cyclophosphamide (PT/Cy). Complete left renal arterial embolization (day +43) was ultimately indicated to control intractable renal hemorrhage. Subsequent infusion of anti-BK VSTs was complicated by CRS and progressive multiorgan failure, with postmortem analysis confirming diagnosis of hepatic sinusoidal obstruction syndrome (SOS). This case illustrates opportunities for improvement in the management of severe BKV-HC posttransplant while highlighting rare and potentially life-threatening complications of BKV-HC and VST therapy.

A case of colonoscopy-induced Wunderlich's syndrome in a hemodialysis patient: coincidence or association?

Wunderlich syndrome, or spontaneous renal hemorrhage (SRH), is a rare condition encountered in patients undergoing chronic hemodialysis (HD) usually attributed to acquired cystic kidney disease (ACKD) among other causes. In the literature, colonoscopy is associated with splenic injuries, and renal hemorrhage has not been previously described. Management can range from conservative treatment to angiographic embolization or exploration and nephrectomy. Here we report an unusual case of a 54-year-old woman HD patient who presented with SRH within a few days of colonoscopy. The reason of SRH was rupture of an ACKD cyst. We assumed that colonoscopy was a provoking factor and elaborated hypotheses for its etiopathogenesis. The patient underwent successful left nephrectomy. The importance of this case lies in the fact that colonoscopy is not always an innocent procedure in HD patients, and could be complicated by renal cyst hemorrhage.

Comparison of transradial and transfemoral access for transcatheter arterial embolization of iatrogenic renal hemorrhage

Background There are few reports of renal artery embolization (RAE) via transradial access (TRA) for renal hemorrhage, and none have compared outcomes of RAE via TRA and transfemoral access (TFA). The objective was to compare technical and clinical outcomes in patients undergoing RAE via TRA or TFA for iatrogenic renal hemorrhage. Materials and methods This study included 45 RAE procedures (16 TRA and 29 TFA) for iatrogenic renal hemorrhage in 43 patients performed at a tertiary referral center between October 2018 and December 2020. Information regarding underlying diseases, coagulation status, angiographic and embolization procedure details, technical and clinical successes, and complications were retrospectively evaluated. Results There were no differences in demographics, underlying diseases, updated Charlson comorbidity scores, angiographic findings, and volume of contrast material between the TRA and TFA groups. By contrast, prothrombin time and international normalized ratio were significantly lower in the TRA than in the TFA group. Embolic materials differed significantly in the two groups. Procedure duration, fluoroscopy time, digital subtraction angiography number, and dose area product were slightly lower in the TRA than in the TFA group, but the differences were not statistically significant. Technical and clinical success rates in the TRA and TFA groups were 100% and 96.6%, and 100% and 96.6%, respectively. No patient in either group experienced procedure-related complications during a 4 week follow-up period. Conclusion RAE via TRA in the management of iatrogenic renal hemorrhage was safe and feasible, with similar procedure duration and radiation exposure to RAE via TFA. TRA may be an acceptable alternative to TFA in these patients.

Wunderlich syndrome (spontaneous renal hematoma) as a cause of acute abdomen: a case report

Spontaneous renal hemorrhage, also known as Wünderlich syndrome, is a rare condition that can be life-threatening and consists of the onset of sudden hemorrhage into the subcapsular and perirenal spaces. It can be lethal as it goes unnoticed and requires aggressive treatment. The entity lies mainly in neoplasms, the malignant ones being the most common. We present the case of a 63-year-old female patient with acute abdomen clinic, a diagnostic laparoscopy was performed and renal hematoma was evidenced as the cause of the symptoms. It was managed conservatively without any complications. We emphasize the importance of keeping in mind Wünderlich syndrome as a differential diagnosis to instigate early treatment for a better outcome.

Superselective Renal Artery Embolization Management of Post-percutaneous Nephrolithotomy Hemorrhage and Its Methods

Objective: The purpose of this study was to evaluate the therapeutic efficacy and safety of superselective renal arterial embolization (SRAE) in the treatment of patients with renal hemorrhage after percutaneous nephroscopy (PCNL). In addition, embolization techniques and embolization materials during operation were also worthy of further discussion.Methods: From February 2015 to December 2019, clinical data of 49 consecutive patients with renal hemorrhage after PCNL were retrospectively analyzed. Demographic and clinical data of patients were recorded, changes in serum creatinine values were analyzed, and the safety and efficacy of TAE were evaluated. Clinical experience was also recorded.Results: A total of 49 patients underwent angiography, of which 46 patients received SRAE due to positive hemorrhagic foci detected by angiography, and the technical success rate of 46 patients was 100%. Among the three patients who did not receive embolization, one patient underwent nephrectomy, and two patients improved with conservative treatment, with a clinical success rate of 98%. There was no statistically significant difference between serum creatinine before PCNL and 7 days after SRAE (101.6 ± 36.5 to 100.5 ± 27.1 μmol/L; P = 0.634), and no significant change was observed in serum creatinine at the last follow-up (99.4 ± 34 μmol/L, P = 0.076). No major complications occurred after embolization.Conclusions: SRAE is safe and effective in patients with renal hemorrhage after PCNL. The experience of interventional therapy and the choice of embolization materials in this study may provide certain benefits for the treatment of patients with renal hemorrhage after PCNL.

Transcatheter Arterial Embolization with N-butyl-2 Cyanoacrylate Glubrans 2 for the Treatment of Acute Renal Hemorrhage Under Coagulopathic Condition

Background:The efficacy and safety of transcatheter arterial embolization (TAE) using the N-butyl-2 cyanoacrylate (NBCA) Glubran2 in the treatment of acute renal hemorrhage (RH) under coagulopathic conditionsarestill no consensus.Methods: Between February 2014 and June 2019, 8 patients underwent TAE with the NBCA Glubran2 for acute RH under coagulopathic conditions. Coagulopathy was defined as abnormal values of prothrombin time and activated partial thromboplastin time and/or a reduced platelet count.Angiograms and medical records were retrospectively reviewed to determine technical/clinical success, complications and recurrent hemorrhage after TAE, and follow-up outcomes were assessed.Results: Of note, one patient presented with severe coagulopathy, and three presented with severe RH and hemodynamic instability. The NBCA Glubran2 was employed as a sole embolic material in sixpatients. In the remaining two patients, it was employed for secondary embolization.Under coagulopathic conditions, due to the use of the NBCA Glubran2, both technical success and clinical success for acute RH were achieved in all patients. Duringa mean follow-up time of 30.1 months (range, 3-84 months), neither persistent nor recurrent active hemorrhage required repeat endovascular or surgical treatment for hemostasis. No Glubran2related complications occurred mid-TAE pro-cedure. In addition, renal function information was available for all patients, and there was no significant difference between the serum creatinine levels [(83.8 ± 15.5) vs (85.8 ± 32.2) μmol/L] before and one week after Glubran2 embolization (p=0.89; CI, -34.5 to 30.5).Conclusions: The present findings suggest that TAE with the NBCA Glubran2 may be a safe alternative treatment for the management of RH under coagulopathic conditions. In particular, this method appears to be a potentially attractive alternative when con-ventional embolic materials fail in patients with ongoing hemodynamic instability or even under severe coagulopathic conditions.