Unusual causes of Hematuria in dialysis patients: Diagnostic dilemma, risks and management
A 63-year-old man suffering from ESRD on maintenance HD for the past 2 years, was admitted with right flank pain and intermittent hematuria for one month. Previous ultrasound showed bilaterally small kidneys, each measuring about 6 cm. There was a fall of hemoglobin of 3 g/dL with development of postural symptoms and he also noticed a new onset mass in the right upper abdomen. Patient had a session of HD about a week back. On examination, he was pale, heart rate was 90/min, respiratory rate 18/min and his blood pressure was 130/90 mmHg. Abdomen was soft, non-tender, a 10 × 12 cm hard palpable lump was occupying the right hypochondrium and lumbar regions. There was no free fluid in the abdomen. Abdominal ultrasound revealed heteroechoic mass in the right kidney with multiple septations. Abdominal CT scan revealed a 10 × 10.3 × 11 cm well-defined predominantly hypodense mass with mean density of 19 HU, replacing the upper and mid-pole of the right kidney. There was peripheral wall enhancement with solid enhancing component within it (56 HU). Multiple enhancing septae were seen within it. Right renal vein and inferior venacava were normal []. Blood investigation revealed hemoglobin of 8.3 g/dL, hematocrit 28%, platelets 1,24000 /μL, INR 1.06, albumin 3.8, urea 73mg/dL, creatinine 8.4 mg/dL and serum potassium of 6.2 mEq/dl. The patient received 2 units of packed red blood cells during hemodialysis. On considering all available reports, a diagnosis of right renal mass, probably of renal cell carcinoma was made. He underwent open right radical nephrectomy and gross specimen revealed a solid renal mass []. On cutting the specimen whole pelvicalyceal system (PCS) was filled with blood clots [] and no growth was detected in PCS []. A detailed histopathological evaluation revealed changes of chronic glomerulonephritis with no evidence of malignancy, vascular malformations or PAN. Postoperatively, the patient is on HD and awaiting renal transplantation.