Polyclonal gammopathy related to renal bleeding in a peritoneal dialysis patient
A-15-year-old girl was admitted with left flank pain and gross hematuria for several days. Four years ago, she was diagnosed as end-stage renal disease due to dysplastic kidneys which was multicystic dysplastic kidney in right side and was dysplastic kidney with severe hydronephrosis in left side. She underwent cadaveric kidney transplantation. However, because chronic allograft dysfunction has occurred, she has been undergoing peritoneal dialysis for 3 months. She had received oral immunosuppressant therapy during kidney transplantation state, and it was stopped when the peritoneal dialysis was started. Her blood pressure was 147/104 mmHg, heart rate was 112 beats/min and respiratory rate was 22 beats/min. She looked acutely ill and physical examination revealed severe tenderness on the left costovertebral angle, but no pitting edema. The laboratory findings on admission were hemoglobin 6.3 g/dL, hematocrit 18.7%, white blood cell count 5,640/µL (lymphocyte 78% neutrophil 17%) and platelet 144,000/µL. The blood chemistry showed total protein/albumin 6.8/2.6 g/dL, sodium/potassium 132/4.0 mmol/L, calcium/phosphorus 7.3/3.5 mg/dL, blood urea nitrogen/creatinine 43/13.1 mg/dL, erythrocyte sedimentation rate 53 mm/hr, and C-reactive protein 2.2 mg/dL. Coagulation blood test was prothrombin time 105%, partial thromboplastin time 30.5'', international normalized ratio 1.0. Her urine showed gross hematuria with blood clots and protein (4+) occult blood (3+) on dipstick. The analysis of dialysate was normal. Computerized tomography of her abdomen revealed encapsulated intrapelvic hematoma in the left kidney (). She was given red blood cell transfusion and with conservative therapy, flank pain and gross hematuria were improved. Follow-up serial hemoglobin level was remained and her blood pressure was maintained within the normal range. Follow-up abdominal computerized tomography showed as renal pelvic hematoma of the same size. She was discharged with improved condition. At the outpatient department, she had neither fever nor pain, but complained of intermittent gross hematuria with blood clot and her anemia was not improved. Ten days after discharge, follow-up laboratory findings showed a reversed albumino-globulin ratio (total protein, 6.6 g/dL; albumin, 1.9 g/dL; globulin, 4.7 g/dL; albumin/globulin ratio, 0.4) and this finding was sustained for two months in spite of no evidence of infection or inflammation. Serum electrophoresis was compatible with polyclonal gammopathy, which showed an increased component with alpha-1 and gamma fraction (). Thereafter, a massive gross hematuria was recurred and anemia was persisted. We performed the embolization of the left renal artery, two months after when the renal cystic hemorrhage began. The continuous bleeding was solved and also, albumino-globulin dissociation was normalized a month after renal artery embolization was done ().