THE JOURNAL OF UROLOGY
109, May
Copyright © 1973 by The Williams & Wilkins Co.
SPONTANEOUS RUPTURE OF THE KIDNEY: A COMPLICATION OF
ANTICOAGULATION-REPORT OF 2 CASES
IGNACIO LUNA, ROBERT L. LEADBETTER
Since Bonet first reported on it, the possibility
of spontaneous rupture of the kidney has been
questioned.'· 2 Wunderlich 3 recognized and classi-
fied the disease, and in 1910 Coenen 4 suggested
the term Wunderlich's disease.
Conditions linked to the pathogenesis of spon-
taneous hematoma include chronic nephritis, neo-
plasm, infarct, aneurysm, arteriosclerosis, poly-
arteritis nodosa, alterations in the clotting
mechanism 5 and complications of anticoagulant
therapy. 6 • 7
In the American literature, only Hibner has
reported on spontaneous renal rupture secondary
to anticoagulant therapy. 6 Herein we report on 2
cases that occurred as complications of anticoagu-
lant therapy.
CASE REPORTS
Case 1. G. B. H., a white man, had been dis-
charged from the hospital 24 hours before we saw
him, after being treated for congestive heart fail-
ure, arteriosclerosis, diabetes mellitus and obe-
sity. He had been given digoxin, furosemide,
phenformin hydrochloride and sodium warfarin.
Twelve hours prior to the current hospitalization,
he was awakened by a severe, sharp, lower ab-
dominal and flank pain. He denied a history of
trauma.
Shortly after hospitalization his blood pressure
dropped to 80/0. The patient was cold and
clammy with a thready, irregular pulse and was in
obvious hypovolemic shock. Pertinent physical
findings were a few coarse rales on both lung bases
and a markedly distended, rigid abdomen with a
non-pulsatile mass in the left flank. Bowel sounds
were absent, no abnormal bruits were heard and
Accepted for publication September 15, 1972.
1 Valtonen, E. J.: Spontaneous rupture of an appar-
ently normal kidney; some criticism concerning this
diagnosis. Brit. J. Urol., 38: 484, 1966.
2 Polky, H. J. and Vynalek, W. J.: Spontaneous
nontraumatic perirenal and renal hematomas. Arch.
Surg., 26: 196, 1933.
'Wunderlich, C. R.: Handbuch der Pathologie und
Therapie, 2nd ed. Stuttgart: Edner & Seubert, 1856.
• Coenen: Das Perirenale Hamatom. Beitr. z. Klin.
Chir., 70: 494, 1910.
'Uson, A. C., Knappenberger, S. T. and Melicow, M.
M.: Nontraumatic perirenal hematomas: a report based
on 7 cases. J. Urol., 81: 388, 1959.
• Hibner, R. W.: Spontaneous rupture of the kidney
with massive hemorrhage. A complication of anticoagu-
lation. Amer. J. Surg., 118: 637, 1969.
7 Klinger, M. E., Tanenbaum, B. and Elguezabal, A.:
Pseudo-tumors of the kidney secondary to anticoagulant
therapy. J. Urol., 106: 507, 1971.
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Vol.
Printed in U.S.A.
AND DONALD R. GILBERT
there was a slight diminution in the tension of the
pedal pulses.
Initial laboratory studies revealed hemoglobin
12.4 gm., blood urea nitrogen (BUN) 32 mg. per
cent, glucose 328 mg. per cent, sodium 134 mg.,
potassium 6.3 mEq., carbon dioxide 17, chloride
98 mEq., urine positive for ketones and blood and
prothrombin time-patient 32, control 15, 15 per
cent. The excretory urogram (IVP) was suggestive
of a huge left renal shadow with poor function as
compared to the right (fig. 1). Haziness of the left
psoas margin made us suspicious of retroperito-
neal hemorrhage secondary to vascular or renal
pathology.
After the patient was stabilized, exploration
was performed. A huge hematoma was seen,
which included the left kidney, and there was
evidence of continuing active bleeding. We feared
a bleeding malignancy precipitated by anticoagu-
lation and thus we performed a nephrectomy (fig.
2). The operative and immediately postoperative
course was relatively stable. Ten hours later
sudden cardiac and respiratory arrest developed
and the patient died despite vigorous resuscitative
measures. An autopsy was denied.
Gross examination showed loss of renal pa-
renchymal and perirenal boundaries. The area of
rupture could not be identified because of marked
distortion and damage done by the hematoma.
Case 2. T. M., a 51-year-old white woman, was
hospitalized because of severe and progressive
pain in both lower extremities 4 days in duration.
Pertinent physical findings were bilateral calf
tenderness, a positive Homans' sign and vein
varicosities. No edema, discoloration or abnor-
mality in pedal pulsations was found. Initial
coagulation studies were considered normal and
the patient was placed on heparin and sodium
warfarin therapy. She responded satisfactorily.
On the third day prothrombin time was patient
31, control 13, 13 per cent; fibrinogen level 100 mg.
per cent, and Lee and White coagulation time 15
minutes, 30 seconds. Heparin was discontinued.
On the seventh day severe anterior chest pains
and right flank pains developed. The patient was
in obvious shock and required massive infusions
and vasopressors to stabilize her condition. The
chest x-ray revealed a straddling density of the
right lung with discoid atelectasis. On the eighth
day, the patient became increasing dyspneic; the
abdomen was distended and rigid with absent
bowel sounds and rebound tenderness was pres-
ent. A right flank mass was palpated, with bluish
skin discoloration. The transperitoneal tap was
positive. On exploration, the right kidney was
 SPONTANEOUS RUPTURE OF KIDNEY
FIG. 1. Huge left renal shadow with poor visualization and function.
FIG. 2. Gross specimen shows hemorrhage through
Gerota's fascia.
found embedded in a large mass of freshly clotted
blood with disruption of the renal cortex measur-
ing 2.5 by 1 cm. and actively bleeding. Since we
were unable to control bleeding, a nephrectomy
was done with concomitant venacaval plication.
Convalescence was stormy but the patient re-
covered.
DISCl'SSION
In both of these cases the patient was thought to
be at a reasonable therapeutic range of anticoagu-
lation. Rodman stated that bleeding does not
always correlate with the prothrombin complex
levels. 8 Low levels of prothrombin may
not necessarily produce bleeding; continuous
bleeding can occur at ranges considered safe, that
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is 20 to 30 per cent. 9 Roos and van Joost found
that the prothrombin time of 70 per cent in their
patients with bleeding was within the therapeutic
range. 10
The use of prothrombin-depressing agents
arises from the fact that bishydroxycoumarin
produces severe bleeding disorders in cattle. 11 It is
presumed to cause some functional disturbance of
the capillary endothelium with a reduction of
platelet adhesiveness without thrombocytopenia
even during prolonged therapy. 11 - 13 The urinary
tract is the most common single source of bleed-
ing, being reported in almost 40 per cent of
patients on long-term sodium ·warfarin therapy. 11
- We are making no attempt to speculate on the
mechanism for capsular and parenchymal disrup-
tion. We want only to emphasize the role of
anticoagulant therapy and the secondary disturb-
ance it produces, 11 - 13
SUMMARY
We have presented 2 cases of spontaneous
kidney rupture presumably secondary to an-
ticoagulant therapy. Nephrectomy was performed
in both cases. To our knowledge, intrarenal hem-
orrhage causing renal rupture is an uncommon
complication of anticoagulation therapy and has
previously been reported only once.
210 Brooks Street, Charleston, West Virginia
25301 (D.R. G.)
9 Zenteno-Alanis, G. H., Corvera, J. and Mateos, J.
H.: Subdural hematoma of the posterior fossa as a
complication of anticoagulant therapy. Presentation of a
case. Neurology, 18: 1133, 1968.
10 Roos, J. and Joost, M. E., van: The cause of
bleeding during anticoagulant treatment. Acta Med.
Scand., 178: 129, 1965.
11 Zweifier, A. J., Coon, W. W. and Willis, P. W., III:
Bleeding during oral anticoagulation therapy. Amer.
Heart eJ., 71: 118, 1966.
12 Spooner, M. and Meyer, 0. 0.: The effect of
dicumarol (3, 3' -methylenebis [4-hydroxycoumarin)) on
platelet adhesiveness. Amer. eJ. PhysioL, 142: 279, 1944.
13 M. A.: The significance of
Datients v;j.th the
s~and .. ;_62: 339) 1958.