Maruyama Takashi, Abe Masanori, Furukawa Tetsuya, Kobayashi Shinichiro, Yoshida Yoshinori, Noda Hiroko, Okada Kazuyoshi, Soma Masayoshi
Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Japan.
Intern Med. 2016;55(9):1153-8. doi: 10.2169/internalmedicine.55.5811. Epub 2016 May 1.
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.
一名73岁的慢性肾脏病G5期男性因肾功能恶化入住我院。他5年前接受了二尖瓣人工瓣膜置换术，目前正在服用华法林。入院时他出现抗凝过度，凝血酶原时间-国际标准化比值（PT-INR）为3.91。停用华法林后，PT-INR降至2.1。由于患者需要肾脏替代治疗，他在第16天接受了动静脉内瘘手术以建立血液透析通路。然而，在第18天，他突然诉腰痛并陷入休克。他的血压降至73/49 mmHg，血红蛋白水平降至4.9 g/dL。计算机断层扫描显示巨大的腹膜后血肿。连续两天进行了紧急腰动脉栓塞；然而，出血持续存在，随后发展为伴有呼吸和心血管功能受损的腹腔间隔室综合征，患者死亡。尸检发现一个大小为30×20×20 cm的血肿，累及腰大肌和髂外动脉；血肿被纤维组织而非肌肉覆盖。腰大肌由髂内动脉供血；然而，在我们的患者中未确认有塌陷的动脉。与血肿最接近的主要动脉位于腰大肌与髂外动脉的交汇处。所有动脉均显示严重的动脉粥样硬化。对于晚期慢性肾脏病患者，应谨慎给予抗凝治疗，并应进一步调查腹膜后血肿的病因。
