A 55-year-old Caucasian woman initially presented to one of Cleveland Clinic’s regional outpatient urology clinics with gross hematuria and an obstructing right ureteral stone. After discussion with the patient regarding management options, including watchful waiting and lithotripsy, it was decided that the patient should undergo ureteroscopy.

She was found to have a moderate to severely dilated ureter up to the kidney and blood coagulum throughout the kidney, but no active bleeding was noted. A 6 mm calcium oxalate stone was extracted from the right distal ureter, after which a JJ stent was placed in the right kidney.

The patient later presented on post-operative day 2 with gross hematuria and tenderness of the right flank. On admission, she had a computed tomography (CT) scan of the abdomen and pelvis that showed significant right hydronephrosis.

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The renal pelvis and calyces, as well as the urinary bladder, were filled with high attenuation material suggestive of blood products. Because of anemia on admission (hemoglobin level of 6.8 g/L), she received a transfusion of two units of blood and transferred to the Cleveland Clinic main campus for further evaluation. A repeat CT scan showed an arteriovenous malformation (AVM) in the anterior interpolar region of the right kidney that was likely congenital.

Given this finding along with increasing hematuria, the patient underwent a bilateral selective renal angiogram with subselective coil embolization of the inferior anterior segmental artery and two interlobar arteries in the mid zone. This resulted in an improvement of her hematuria.

Due to concern for recurrence of bleeding, the patient had a repeat CT angiogram (CTA) two weeks later for a persistent large AVM in the right kidney, for which she had successful coiling and alcohol embolization. During this time, her creatinine level increased from a baseline of 0.8 mg/dL to 1.2 mg/dL.

One month later, the patient was seen by her primary care physician (PCP) for new onset hypertension. Her usual blood pressure measurements were 140/80 mm Hg, but her BP was higher since her procedures. At the PCP visit, BP was 183/106 mmHg. She was started on amlodipine 5 mg; this was later increased to 10 mg as her BP remained elevated. She was then referred to the nephrology department.

Prior to her visit to the nephrology department, the patient had a CTA that showed significant improvement in the right kidney AVM. There was a new wedge-shaped hypoperfused small area in the right renal parenchyma from her second embolization (Figure).

She had a small multifocal web-like stenosis in the distal right artery consistent with fibromuscular dysplasia (FMD). The patient also had a mag3 function scan showing that the left kidney contribution to total renal function was 71% and the right kidney contribution was 29%. Her creatinine level returned to her baseline of 0.8mg/dL.