Wedge-Shaped Low-Density Lesion on Sonography of the Kidney in Advanced Cirrhotic Patient

Takanobu Sakemi, MD, Department of Internal Medicine, Saga Medical School, Nabeshima, Saga 849 (Japan) Dear Sir, Progressive oliguric renal failure commonly complicates the course of patients with advanced cirrhosis. Cirrhotic patients have been reported to show a characteristic renal circulatory disturbance, such as renal vasoc-onstriction leading to severely reduced renal blood flow and reduced glomerular filtration rate. We report on a cirrhotic patient who developed acute renal failure (ARF), associated with the occurrence of lower back pain and wedge-shaped low-density area on sonography of the kidney. A 57-year-old woman was admitted to another hospital because of further examination of ascites on June 19, 1989. She was diagnosed as having advanced liver cirrhosis with ascites and esophageal varices. On July 12, she developed acute cholecystitis, demonstrating a fever of 40 °C and a jaudice and received antipyretics for 3 days and antibiotics for 5 days. Two days later, she noticed lower back pain and macrohematuria, followed by oliguria and rapid increase in serum creatinine and thereby underwent hemodialysis (HD). She was transferred to our hospital because of further examination of ARF on July 25 (the 12th clinical day). Physical examination on admission revealed distended abdomen with tenderness and fluctuation. Blood pressure was 112/52 mm Hg. There was a dull pain over the bilateral costovertebral angles. There was no pitting edema on her extremities. Urine volume was < IOO ml per day. Protein and occult blood in urine were positively detected; the sediment contained numerous red blood cells and many hyaline and granular casts. Urine sodium was 74 mEq/1 and potassium 30.5 mEq/1. Fractional excretion of urinary sodium (FENa) was 3.9%. The hemoglobin level was 7.4 g/dl; white blood cell count 1,700/μl and platelet count 45,000/μl. Blood urea nitrogens was 44.9 mg/dl and serum creatinine 8.1 mg/dl. Total bilirubin was 1.3 mg/dl, aspartate aminotransferase 24 U/l, alanine aminotransferase 8 U/l. Total protein was 6.2 g/dl, albumin 3.3 g/dl, IgG 2,468 mg/dl, IgA 138 mg/dl and IgM 282 mg/dl. HD was performed 9 times during the following 3 weeks and discontinued thereafter because of the increase in urine output and fall in serum creatinine. The first renal sonography performed on the second hospital day revealed enlarged kidneys with the wedge-shaped low-density area in the left