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• W2019940186 abstract "A 52-year-old woman was evaluated for right flank discomfort for 2 months and for newly developed hypertension. She had experienced a motor scooter accident with blunt trauma to her right flank 3 years ago. Her family history was unremarkable. On physical examination, her blood pressure was 162/98 mm Hg and pulse rate was 74 per minute. A palpable firm mass over the right costovertebral angle was noted without percussion tenderness. The remainder of her physical examination was unrevealing. Urinalysis revealed mild proteinuria (1+) without hematuria or pyuria. Laboratory investigations were notable for mild anemia (hemoglobin 11.2 g per 100 ml), hypokalemia (potassium 3.2 mmol/l), high plasma activity of renin (2.3, 0.2–0.7 ng/l/sec) and aldosterone (714.9, 98.9–664.8 mmol/l). Abdominal plain film showed an unexpected huge opaque mass around the right flank region (Figure 1). The use of enalapril (20 mg daily) led to a reduction of blood pressure to 130/80 mm Hg on average. What is the cause of her hypertension? A solitary renal mass with peripheral rim calcifications on ultrasonography can occur in both benign and malignant conditions, most commonly in renal cysts and neoplasms.1.Israel G.M. Bosniak M.A. An update of the Bosniak renal cyst classification system.Urology. 2005; 66: 484-488Abstract Full Text Full Text PDF PubMed Scopus (299) Google Scholar Computed tomography can discriminate these underlying causes more precisely and, in this case, showed a huge eggshell-like calcified cystic mass (6.2 × 8.5 × 12.5 cm) with an internal homogeneous low density and no enhancement adjacent to her right kidney, suggestive of chronic subcapsular organizing hematoma rather than renal malignancies or infections (Figure 2). The hematoma compressed and distorted the right renal parenchyma without hilar involvement. The traumatic history and hypertension associated with a compressed kidney and its excellent response to an angiotensin-converting enzyme inhibitor confirmed the diagnosis of ‘Page kidney’. Page kidney generally refers to hypertension secondary to any external renal compression by acute or chronic processes, first described by Page in 1939 in an animal model of hypertension created by wrapping kidneys in cellophane and clinically in 1955.2.Engel W.J. Page I.H. Hypertension due to renal compression resulting from subcapsular hematoma.J Urol. 1955; 73: 735-739Abstract Full Text PDF PubMed Scopus (94) Google Scholar There are many possible causes. Subcapsular or perinephric hematoma due to traumatic, iatrogenic, or spontaneous hemorrhage accounts for most cases, of which motor vehicle accidents are the leading cause. It is noteworthy that in the last two decades, iatrogenic causes have increasingly resulted from a complicated renal allograft biopsy or lithotripsy. Besides hematoma, non-bleeding etiologies have also been reported, including urinoma, large renal cyst, pararenal, and retroperitoneal lesions.3.Bakri R.S. Prime M. Haydar A. et al.Three ‘Pages’ in a chapter of accidents.Nephrol Dial Transplant. 2003; 18: 1917-1919Crossref PubMed Scopus (6) Google Scholar,4.McCune T.R. Stone W.J. Breyer J.A. Page kidney: case report and review of the literature.Am J Kidney Dis. 1991; 18: 593-599Abstract Full Text PDF PubMed Scopus (72) Google Scholar Hypertension, the hallmark of Page kidney, is believed to involve renal hypoperfusion and ischemia, consequently activating the renin–angiotensin–aldosterone system (RAAS). The resultant compression-induced interstitial nephritis may also contribute to the development of hypertension.5.Vanegas V. Ferrebuz A. Quiroz Y. et al.Hypertension in Page (cellophane-wrapped) kidney is due to interstitial nephritis.Kidney Int. 2005; 68: 1161-1170Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar A concomitant loss of renal function in varying degrees has been reported as another important complication, particularly after a biopsy of kidney allografts or a poorly functioning contralateral kidney. Hypokalemia with renal potassium wasting attributed to concurrent hyperaldosteronism can be present as a consequence of Page kidney.3.Bakri R.S. Prime M. Haydar A. et al.Three ‘Pages’ in a chapter of accidents.Nephrol Dial Transplant. 2003; 18: 1917-1919Crossref PubMed Scopus (6) Google Scholar,4.McCune T.R. Stone W.J. Breyer J.A. Page kidney: case report and review of the literature.Am J Kidney Dis. 1991; 18: 593-599Abstract Full Text PDF PubMed Scopus (72) Google Scholar The diagnosis of Page kidney is usually made after imaging. Computed tomography has allowed for an earlier and more accurate diagnosis than ultrasonography, in addition providing excellent views of the retroperitoneal space and a temporal resolution of hematoma. Conservative therapy with RAAS blockade and fluid control is generally sufficient to control associated hypertension, as in our patient.3.Bakri R.S. Prime M. Haydar A. et al.Three ‘Pages’ in a chapter of accidents.Nephrol Dial Transplant. 2003; 18: 1917-1919Crossref PubMed Scopus (6) Google Scholar Surgical interventions involving nephrectomy, evacuation of hematoma, and endoscopic or percutaneous drainage of hematoma are reserved for persistent or refractory hypertension, very large hematoma, and deteriorating renal function.6.Santucci R.A. Wessells H. Bartsch G. et al.Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee.BJU Int. 2004; 93: 937-954Crossref PubMed Scopus (266) Google Scholar In summary, Page kidney, an important but easily ignored cause of hyperreninemic hypertension, should be considered in the differential diagnosis of secondary hypertension. Use of CT scanning has allowed for earlier and accurate diagnoses. Conservative therapy with RAAS blockade is appropriate if there are no severe complications." @default.
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• W2019940186 title "The Case ∣ A hypertensive woman with an abnormal abdominal X-ray" @default.
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