Reverse PD-a rare cause of acute renal failure in a transplanted patient.

Sir

Spontaneous bladder rupture is a known cause of abdominal pain and acute renal failure [1]. Alcoholics and other substance abusers are particularly prone to developing this syndrome [2, 3]. Some patients may present with a history of pelvic surgery, irradiation or a tumor in the lower abdomen [4, 5]. If unrecognized, the mortality of this clinical entity is remarkably high [6]. We report a case of bladder rupture, probably spontaneous, in a young woman who had undergone renal transplantation twice due to congenital cystinosis. Bladder rupture is a pertinent differential diagnosis in transplanted patients with abdominal pain and sudden rise of creatinine.

A 29-year-old woman was admitted to our hospital because of acute abdominal pain and anuria. Clinical examination revealed a bloated abdomen with signs of ascites. There was marked suprapubic tenderness. Chemistry on admission showed acute renal failure (creatinine 3.4 mg/dL and blood urea nitrogen 49.6 mg/dL). On ultrasonographic imaging, an obvious postrenal cause could not be found but free fluid was present in the pelvis. A subsequent magnetic resonance imaging (MRI) peritoneography showed large amount of fluid in the peritoneal cavity as well as an irregularity in the bladder wall (see Figure 1). The kidney transplant was unremarkable. We performed a diagnostic ascitic tap and determined creatinine and urea in the intra-abdominal fluid. Both parameters were clearly elevated (creatinine 8.8 mg/dL and urea 69.8 mg/dL).

Fig. 1.

MRI peritoneography demonstrating irregularity on the bladder dome and large amount of fluid in the peritoneal cavity.

Rupture of the bladder wall was deemed the most likely cause. The patient was transferred to the urology department and underwent cystoscopy and micturition cystourethrography. A dehiscence at the left side of the ventral bladder wall with intraperitoneal leakage of contrast medium was demonstrated, in accordance with the MRI images. Median laparotomy was performed and the bladder wall could be repaired. The postoperative course was uneventful. At discharge, the renal function was normal.

A definite cause for the bladder rupture could not be established. The patient denied substance abuse or alcoholic binge drinking. After detailed questioning, she reported having carried her 5-year-old nephew the day before admission, which may have caused blunt trauma to the abdomen.

Bladder rupture, either spontaneous or traumatic, should be considered in patients with acute renal failure, abdominal pain and ascites. We speculate that her underlying metabolic disease may have predisposed our patient by cystine crystal accumulation in the bladder wall. To the best of our knowledge, this association has not been reported before.