A 58-year-old man with past medical history of cysteinuria and recurrent cysteine stones underwent percutaneous nephrolithotomy (PCNL) to remove a large calculusin the left kidney as well as placement of a double J ureteral stent. His right kidney is atrophic and non-functioning. The procedure went well with removal of most of the stone. However, on post-operative day 1 (POD1), he developed hypoxia. V/Q scan showed high probability for pulmonary embolism (PE). Heparin drip was started to treat PE. The next day (POD2), he became hypotensive and increasingly hypoxic. He required vasopressor support and intubation. Shortly after, his urine output decreased to less than 20 mL per hour. His urine has been bloody since the procedure. A chest X-ray showed new-onset large left-sided pleural effusion. A chest tube was placed with an immediate drain of 500 mL bloody fluid. Laboratory studies included the following: WBC 14.1×103/MCL;hemoglobin 6.9 g/dL (baseline 13.9 g/dL); platelet count 14.1×103/MCL; creatinine 5.2 (baseline 1.8 mg/dL pre-operatively à 2.8 mg/dL on POD1); BUN34 mg/dL; Na 135 mmol/L; K 4.4 mmol/L; chloride 102 mmol/L; CO2 18mmol/L; and calcium 8.3 mg/dL. Urinalysis was positive for blood, protein and leukocyte esterase. There were numerous RBCs and WBCs. Chest tube drainage was sent to measure the creatinine level, which was 5.9 mg/dL.

Figure 1. CT of the abdomen without contrast showing large subcapsular hematoma in the left kidney (arrow).

A computed tomography scan of the abdomen without contrast revealed an 11.6 x 4.4x 10.2 cm subcapsular and pericapsular collection in the left kidney along the posterior cortical margin, and sub acute hemorrhage within the left perirenal space and left posterior pararenal space (Figure 1). The right kidney was severely atrophic.

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