CASE 26: LOIN PAIN AND HAEMATURIA
History
A 46-year-old woman presents to the emergency department with a 2-day history of
right-sided loin pain and macroscopic haematuria. The pain is continuous and dull in
character. Over the past 10 years she has had previous episodes of loin pain which have
occurred on both sides and resolved spontaneously over a few days. She has never passed
any stones. She was noted to be mildly hypertensive during her three pregnancies. She has
no other significant medical history. Her father died of a subarachnoid haemorrhage, aged
48 years. Her father’s brother has had a kidney transplant. She has no siblings. Her three
children, aged 17, 14 and 10 years, are well. She works as a teacher and neither smokes
nor drinks alcohol.
Examination
On examination she is afebrile. Her pulse is regular at 76/min and her blood pressure is
135/105 mmHg. Examination of the cardiovascular and respiratory systems is otherwise
unremarkable. On palpation of her abdomen, ballottable masses are palpable in each flank.
The right-sided mass is tender to palpation. Percussion note is resonant over the masses.
Neurological examination is normal. Funduscopy shows arteriovenous nipping and silver-
wiring of the retinal vessels.
NormalHaemoglobin 14.3 g/dL 11.7–15.7 g/dL
White cell count 5.2% 109 /L 3.5–11.0% 109 /L
Platelets 206 % 109 /L 150–440% 109 /L
Sodium 138 mmol/L 135–145 mmol/L
Potassium 4.3 mmol/L 3.5–5.0 mmol/L
Urea 10.2 mmol/L 2.5–6.7 mmol/L
Creatinine 146 &mol/L 70–120&mol/L
Albumin 42 g/L 35–50 g/LUrinalysis:'protein;'''blood
Urine microscopy:#200 red cells; 10 white cells; no organisms
Abdominal X-ray: no intra-abdominal calcification seenINVESTIGATIONS
Questions
- What is the diagnosis?
- How would you proceed to manage and investigate this patient?