A fatal misdiagnosis of page kidney - case report

Page kidney is a condition where external compression of the renal artery and renal parenchyma leads to subsequent ischaemia and activation of renin-angiotensin-aldosterone axis. A 42-year-old female with hirsutism, hypertension and diabetes was diagnosed with a right adrenal mass and underwent laparoscopic adrenalectomy. Her hypertension worsened postoperatively and was managed medically. Subsequently she developed a right flank pain on the fifth postoperative day and died suddenly the next day. Autopsy revealed a pale body with cushingoid appearance. Surgical scars were healthy. Internal examination of the abdomen revealed a haemoperitoneum of 500 ml together with a large subcapsular haematoma measuring 1000 ml surrounding the right kidney, compressing the right renal artery. Kidneys were pale and the right kidney was soft and friable. Cortical surface of the right kidney demonstrated a possible surgical puncture site with an overlying thrombus together with a contused inferior vena cava. Other organs were pale but appeared otherwise normal. Histology revealed diffuse cortical necrosis of right kidney and features of adult respiratory distress syndrome in the lungs. Haemorrhagic shock following laparoscopic adrenalectomy for right adrenal tumor was declared as the cause of death, contributed by the development of the Page kidney. Trauma of several aetiologies including laparoscopic abdominal surgery may contribute to Page kidney. It presents with flank pain, hypertension and renal mass. Since postoperative blood loss usually manifests as hypotension, resulting hypertension may mislead the attending clinicians. Once diagnosed, it can be managed with surgical drainage and antihypertensives.