Dear Editor,
Page kidney is a treatable cause of secondary hypertension caused by a subcapsular haematoma. Blunt trauma and renal biopsies are the main causes, although it can also be contributed by shock wave lithotripsy (SWL). We present a case of a patient with a favorable recovery after a SWL with nonsurgical management.
A 35-year-old woman with medullary sponge kidney without bleeding comorbidity and non-domiciliary treatment underwent SWL on bilateral renal lithiasis. 5.2-mm and 8-mm stones were located in interpolar and lower pole regions, respectively, in the right kidney (RK). In the left kidney (LK), there were 4-mm and 7-mm stones in the upper pole region.
One session of SWL with a Litotriptor Dornier Gemini was carried out in 75 min. 3400 shocks with an energy of 120 J in RK and 2300 shocks with an energy of 80 J in LK were delivered to the stones with adequate fragmentation. The procedure was well tolerated, without any complications.
One week later, the patient went to the hospital with a severe headache. Blood pressure at 180/100 mmHg was detected. Serum creatinine had not increased. Suspecting Page Kidney, ultrasound (US) was perfomed. US showed subcapsular haematoma of 18.5 mm thickness in the RK and a decrease in vascularization and resistive index of 0.8 (Fig. 1a). The patient was hospitalized where the Interventional Nephrology department administered antihypertensive treatment with enalapril 20 mg/24 h.
Fig. 1.
a Subcapsularhematoma after shockwave lithotripsy, and decrease of vascularization. b Full resolution of hematoma
The patient had a favorable evolution after 5 days of hospitalization, maintaining blood pressure in the normal range. Because of the absence of progression of the haematoma, the patient was discharged and monitored weekly. US showed a progressive resolution of haematoma, being completely resolved 2 months later (Fig. 1b). The resistive index in the Doppler US normalized. Antihypertensive treatment was interrupted and her blood pressure remained in the normal range.
In 1955, Irwin Page first described the occurrence of secondary hypertension due to a kidney parenchymal compression caused by a subcapsular haematoma. Hypertension can be considered idiopathic in many cases and probably it is frequently underdiagnosed. A sophisticated screening process is necessary for early diagnosis and treatment. Performing an US assessment of the kidney may be recommended after any kidney intervention to detect early complications [1].
Page kidney induced by SWL is a rare complication with an incidence rated around 0.5%. Several risk factors such as a history of hypertension, obesity and an age over 60 years have been reported [2]. There are no definitive guidelines for the management of Page kidney. Conservative treatment should be considered in clinically stable patients with improvements in the range of oral antihypertensives. However, surgical evacuation is usually required in the event of persistent hypertension, a very large haematoma or decreased renal function [3].
Conflict of interest
The authors declare that they have no competing interests.
Human and animal rights
All procedures performed in this case report were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from the participant included in this article.
References
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