When kidneys are too bright…a rare cause of shock

Abstract

A 70-year-old male known for hepatitis-B liver cirrhosis and hepatocellular carcinoma, on transplant list, was referred to our ICU team following a microwave ablation of a segment VIII hepatic lesion. Indeed, after the procedure, the patient complained of abdominal pain and developed severe shock. Examination revealed poor perfusion and firm-to-touch abdomen. Lactate was 7 mmol/l. An urgent bedside ultrasound showed new intraperitoneal fluid. CT-scan was performed to rule out hemorrhagic shock. The non-contrast CT showed ascites and diffuse bowel swelling, but no intraperitoneal blood (Fig. 1a). The contrast-enhanced phase ruled out hemorrhage and showed marked hyperenhancement of the kidneys (Fig. 1b). In this context, albeit non specific, this feature promptly suggested impaired venous return through the inferior vena cava (IVC). Subocclusion of the vessel in its perihepatic segment was confirmed on following images (Fig. 1c). The cause of this narrowing was edema associated with thermoablation (Fig. 1d). Despite angiography and dilation of the IVC and hepatic veins, the liver and kidney functions worsened and the patient needed urgent liver transplantation on the following day. He recovered after surgery. Liver thermoablation can rarely cause severe shock consecutive to acute IVC stenosis. Hyperenhancement of the kidneys can strongly suggest this diagnosis.