Managing unplanned subcapital renal hemorrhage through multidisciplinary and hybrid methods: A strategy for addressing Wunderlich syndrome
A 26-year-old female patient, with a medical history of diabetes mellitus, diabetic nephropathy, and arterial hypertension, encountered a severe complication during a routine hemodialysis session. Sudden right-sided flank pain developed, leading to an urgent need for medical intervention.
The patient, who was undergoing hemodialysis three times a week due to end-stage renal disease, was quickly assessed by a multidisciplinary team. A decision was made for urgent management by the interventional radiology team, as the case presented symptoms reminiscent of Wunderlich syndrome – a rare and serious condition characterized by spontaneous renal bleeding without trauma.
The initial therapy included immediate renal arterial embolization using interventional radiology. Selective renal angiography was performed to identify the target vessel, and extravasation of the contrast agent was spotted in the lower sector. A coil was used to achieve successful embolization, helping to control the bleeding. However, an infiltration of the right psoas muscle was also observed.
On the second day following the embolization, the patient developed tachycardia and slight hypotension, and an urgent Uro-CT scan indicated a persistent hematoma and aggressive bleeding in the arterial phase. Recurrent bleeding required an emergency hemostatic nephrectomy despite temporary stabilization. A renal pedicle ligation was performed, followed by nephrectomy and placement of a drainage tube (Redon).
The postoperative course was characterized by good improvement, hemodynamic stability, cessation of deglobulization, preserved diuresis, and a drainage tube that only returned a few traces of sero-hematologic fluid. Laboratory workup showed hemoglobin at 6.5 g/dL, low sodium and potassium levels, high urea and creatinine levels, and normal coagulopathy profile.
The management plan included the immediate installation of 2 peripheral venous lines, fluid resuscitation, serial arterial blood gas analysis, insulin delivery based on capillary glucose levels, and blood transfusions. The patient was afebrile, conscious, and had stable hemodynamics but was pale and had right flank tenderness.
While the identity of the multidisciplinary team members involved in the treatment of patients with Wunderlich syndrome is not explicitly detailed in the available search results, in similar complex cases, multidisciplinary teams typically include specialists such as surgeons, internists, neurologists, diabetes and nutrition experts, and neurochirurgists working collaboratively to provide comprehensive care.
This case highlights the importance of a prompt and effective multidisciplinary response in managing rare and potentially life-threatening conditions like Wunderlich syndrome. The successful treatment of this patient underscores the value of interventional radiology and emergency surgery in such situations.
