Spontaneous Page Kidney as a Complication of a Pancreatic Pseudocyst.

A 58-year-old man with a history of hypertension and alcohol dependence presented to the emergency department with complaints of severe left-sided abdominal pain and flank pain that began 1 week before admission. On further questioning, the patient endorsed recent heavy alcohol use.

In the emergency department, the patient was afebrile, tachycardic, and hypertensive to 170/130 mm Hg. On physical examination, there was a significant amount of left upper quadrant tenderness to soft palpation and left-sided costovertebral tenderness was present. Laboratory test results were significant for an elevated creatinine (1.47 mg/dL), leukocytosis (white blood count of 11,500), and a lipase of 464. Urinalysis was negative. Abdominal and pelvic computed tomography showed acute pancreatitis (pancreatic ductal dilatation and peripancreatic edema) with pancreatic cyst formation and a confluent left renal subcapsular pseudocyst/cystic structure causing a mass effect on the left renal parenchyma (Figures 1 and 2).

Figure 1.

Abdominal/pelvic computed tomography axial view with findings of a pancreatic cyst formation with a confluent large 11 × 8.5 × 11 cm left renal subcapsular cystic structure causing a mass effect on the left renal parenchyma.

Figure 2.

Coronal plane image of pancreatic cyst formation with left renal subcapsular cystic structure causes Page kidney.

Supportive management of acute pancreatitis was initiated with fluid resuscitation and pain control. Gastroenterology was consulted for endoscopic ultrasound (EUS), which revealed a dilated pancreatic duct in the tail of the pancreas (3 mm) along with parenchymal changes consistent with inflammation; further findings revealed an associated retroperitoneal fluid collection measuring 11 × 10 cm. The collection contained organized parenchymal tissue, which appeared to be in the left kidney. EUS-guided drainage was considered but was not performed because of the native kidney parenchyma obstructing the needle trajectory. In addition, the patient was started on an angiotensin-converting enzyme inhibitor with subsequent improvement in his hypertension and was scheduled for a repeat abdominal computed tomography in 3 months to re-evaluate the left renal subcapsular cyst for a decrease in size of the collection.

Page kidney is a condition that results in the development of secondary hypertension from external compressive forces to the renal parenchyma.[1,2] In our patient, the development of Page kidney was secondary to the extension of a pancreatic pseudocyst in the setting of acute alcoholic pancreatitis. Management involves both medical and invasive treatment modalities with the main therapeutic strategy directed at controlling hypertension. Although angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are not typically initiated for blood pressure control in the setting of acute kidney injury, Page kidney is a unique scenario in which these 2 medications should be considered as first-line. Although asymptomatic pancreatic pseudocysts are followed with surveillance, invasive interventions such as EUS-guided drainage or interventional radiology-assisted percutaneous drainage can be considered in those associated with large, symptomatic, or persistent collections with refractory hypertension.[2,3]

DISCLOSURES

Author contributions: R. Sharma: acquisition of data, drafting of the manuscript, and critical revision of the manuscript. B. Attarha: acquisition of data, drafting of the manuscript, and revision of the manuscript. K. Rechcigl: acquisition of data, drafting of the manuscript. W. Aung: acquisition of data, drafting of the manuscript, and critical revision of the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for publication of this case report.