Loin pain

Severe pain in the loin lasting several hours and which is recurring requires referral to investigate underlying cause. One of the systems that need to be investigated is the renal system. Pain originating from kidney disorders and renal colic (renal calculi) initially presents with loin pain and may radiate to the back or spread downwards to the iliac fossa, suprapubic area and in males into the scrotum. 

Other Systemic Effects. Edema of the scrotum and ankle, loin pains, thirst, and severe exhaustion were reported in a man who washed his hands with diesel fuel over several weeks (Crisp et al. 1979). Effects resulting from inhalation versus dermal exposure could not be distinguished in this case. 

Other Systemic Effects. Inhalation and/or dermal exposure to diesel fuel has been associated with edema in two individuals (Crisp et al. 1979 Reidenberg et al. 1964). In one of these cases, loin pains, thirst, and severe exhaustion were also reported (Crisp et al. 1979). Several case studies reported fever in children following acute ingestion of kerosene (Akamaguna and Odita 1983 Aldy et al. 1978 Dudin et al. 1991 Mahdi 1988 Majeed et al. 1981 Nouri and Al-Rahim 1970 Saksena 1969 St. John 1982 Subcommittee on Accidental Poisoning 1962). The effects of oral exposure to kerosene in children cannot be used to predict possible effects in adults or the effects of other fuel oils by this route without additional information. Similarly, it cannot be determined whether the effects of diesel fuel noted in humans would occur from exposure to other fuel oils or in the general population since limited information is available. 

Clinical manifestations occur in three phases. In the neurological stage, the patient appears intoxicated, with slurred speech, ataxia, stupor, and hallucinations, and may be comatose, with respiratory depression. The cardiopulmonary stage is delayed by 12-24 hours, when hypotension, tachycardia, muscle tenderness and congestive cardiac failure are seen. After 1-3 days the renal stage supervenes, with loin pain, crystalluria, oliguria and renal failure, as a result of calcium oxalate crystal deposition in the renal tract. Sequestration of calcium can cause profound hypocalcaemia, tetany, and cardiac arrhythmia. 

Acute Renal Failure with Severe Loin Pain and Patchy Renal Ischemia After Anaerobic Exercise.-... 

In this text, we emphasize that ALPE should always be considered in patients who complain of severe loin pain and nausea after sprinting in an athletics meeting, and while ALPE frequently develops in patients with renal hypouricemia, it also develops in those without it. 

In 1982, we classified exercise-related acute renal failure into two types myoglobinuric acute renal failure, as had previously been reported, and non-myoglobin-related acute renal failure (exercise-induced acute renal failure). In 2002, the latter was named ALPE (Acute renal failure with severe Loin pain and Patchy renal ischemia after anaerobic Exercise) [4]. The term acute kidney injury (AKI) has recently been proposed as a patho-physiologically more correct alternative to the term acute renal failure. Therefore, exercise-induced acute renal failure in this book may be replaced by exercise-induced acute kidney injury. 

Minimum rhabdomyolysis—non-myoglobinuric acute renal failure due to exercise-induced acute renal failure—ALPE (acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise) after sprint, short track event such as 200-m race, etc. 

The other type is non-myoglobinuric acute renal failure, in which intense exercise over a short period of time, such as sprinting, causes minimal rhabdomyolysis without myoglobinuria, i.e., acute renal failure syndrome with severe loin pain and patchy renal vasoconstriction [2]. A recent study showed that anaerobic exercise caused this syndrome, and proposed that Acute renal failure with severe Loin pain and Patchy renal ischemia after anaerobic Exercise (ALPE) (exercise-induced acute renal failure) was a new type of acute renal failure syndrome [4]. 

A 24-year-old man (Patient 3). This patient had flu-like symptoms, and took a mixed preparation consisting of bucetin at 120 mg and aspirin at 240 mg. After 15 h, he participated in a 200-m race in an athletics meeting (October 10, 1980). After 6h, he attended our hospital with nausea and bilateral loin pain. The severe pain, which made it impossible for him to drive a car, persisted for 2 days. His serum creatinine and urinary protein levels were 2.4mg/dl and 2+, respectively, 4 days after onset. The patient was negative for urinary occult blood, and his urinary sodium level was 99mEq/l. On the same day, drip infusion pyelography (DIP) revealed no ureteral... 

Severe loin pain severed hours after exercise. 

In relation to the term exercise-induced acute renal failure, this disorder was expressed as loin pain and acute renal failure after exercise (athletics meeting) in 1981 [24] (Fig. 24). Later, however, Nishimura and Takahara [25], Ishii et al. [26], and Nakamura et al. [27] named this disorder exercise-induced acute renal failure. Since then, this term has commonly been used [3]. 

Acute renal failure with severe loin pain... 

Fig. 24. A copy of the description of ALPE published in Igaku-No-Ayumi (J Clin Exp Med). Topics loin pain and acute renal failure after exercise (athletics meeting). When patients with this new syndrome come to an emergency room complaining of loin pain, they are often misdiagnosed as having radio-lucent urolithiasis. When a patient complains of severe loin pain after unaccustomed violent exercise at an athletics meeting or during summer bathing, in particular after taking a nonsteroidal anti-inflammatory drug (NSAID) for flu-like symptoms, this new syndrome should be suspected. In addition, the patient s serum creatinine level must be measured. (From [24], with permission)...

Some patients have nontypical ALPE. Some do not clearly remember having exercised [1,28,29], and others do not complain of loin pain [30,31]. In addition, others concurrently develop myoglobinuric acute renal failure and exercise-induced acute renal failure (ALPE), and show the characteristics of both disorders [32,33],... 

In the first patient and the fourth patient in our initial series (p. 7), the association of ALPE with anaerobic exercise had not yet been recognized, and their medical histories may have been insufficient, or the patients may not have reported intense exercise over a short duration. In acute renal failure patients with loin pain of unknown etiology, the presence or absence of anaerobic exercise should always be ascertained when taking their medical history. Erley et al. [28] did not comment on exercise in their study. However, when Sato et al. inquired about exercise in 1998 [34], Erley et al. reported that the patient had undertaken exercise. 

This patient was the first case in our series in which acute renal failure developed after an athletics meeting. After he had participated in a 200-m race, loin pain occurred, leading to acute renal failure. Delayed computed tomography (CT) showed diffuse to patchy contrast enhancement. The details are given in Chap. 2, Sect. 2. 

Patient No. Age (years) Sex Prodrome (flu-like symptoms) Analgesics Exercise Loin pain Duration of pain (days)... 

This patient was the first case in which ALPE developed in the presence of renal hypouricemia [3]. On September 26,1984, he participated in a 400-m race in a school athletics meeting. On September 27, nausea and vomiting occurred about 12 h later at 0100 hours, and then bilateral loin pain and abdominal pain developed. Because... 

This patient, who had autosomal dominant polycystic kidney disease (ADPKD), almost drowned and then developed ALPE. On July 20, 1990, he nearly drowned in the sea at 1500 hours, and was brought to our hospital by ambulance for dyspnea and severe loin pain at 1620 hours. On admission, metabolic acidosis was observed. His CRP, serum creatinine, CPK, amylase, and urinary protein levels were 1+, 1.5mg/dl, 116 U/l, 592IU/1 (derived from the salivary gland), and 2+, respectively. His body temperature was 37.7°C, and his blood pressure was 110/60 mmHg. His pulse and respiratory rate were 120/min and 22/min, respectively. Delayed CT 6h after the administration of contrast medium showed wedge-shaped contrast enhancement in the noncystic renal parenchyma (Fig. 34). On July 24, a bone scan with MDP revealed patchy lesions (Fig. 35). His serum creatinine level was 1.3 mg/dl, which had decreased to 1.0 mg/dl on July 27. The patient was then discharged. 

This patient, who had ADPKD, developed ALPE after a sprint. On October 1,1995, he participated in two 100-m races at an athletics meeting in the morning. After a few hours, severe loin pain occurred, and he attended our department the following morning. There were no other abnormal findings, and his blood pressure, pulse, and serum creatinine values were 120/66 mmHg, 64/min, and 1.6mg/dl (serum creatinine level before onset 0.9mg/dl), respectively. On October 2, delayed CT 4 and 24 h after the administration of contrast medium showed patchy lesions (Fig. 37). On October 14, his serum creatinine level returned to 1.1 mg/dl, and CT 4h after the administration of contrast medium showed no contrast enhancement. 

On June 13,1998, this patient participated in 100-m, 400-m, and 1500-m time-trial races at 1400 hours. Left loin pain occurred at 1600 hours. He considered that he had caught a cold, and took a commercially available drug for colds and an analgesic agent. Initially, pain was marked in the sitting position, and became less marked in the supine position. However, it gradually became worse even in the supine position, and he attended the Emergency Outpatient Unit of our hospital at 0500 hours on June 14. His serum creatinine, total bilirubin, and CPK levels were increased to 2.1 mg/dl, 2.8 mg/dl (the reason for an increase in total bilirubin was unclear), and 329 U/L, respectively, and the patient was referred to our department. On June 14, CT 24, 48, and 96 h after the administration of contrast medium showed patchy lesions (Fig. 38)... 

In this case, ALPE was complicated by nocturnal hemoglobinuria. At the age of 20 years, the patient developed nocturnal hemoglobinuria. He had been treated in the Department of Hematology and Immunology in our hospital. On June 18, 2000, he participated in a practice baseball game from 0900 hours until 1500. At 1700 hours, right abdominal and loin pain occurred. On June 19, his serum creatinine level was 3.4mg/dl (before onset, 0.7mg/dl). On June 22, CT 24h after the administration of contrast medium showed patchy lesions (Fig. 43). On June 26, his serum creatinine level had returned to 1.2mg/dl. 

The findings for the patients on their first visit to a clinician included loin pain, nausea/vomiting (96%), and slight fever (76%) (Fig. 48). Among our patients, 18 (85.7%) of 21 patients were positive for C-reactive protein (CRP), 8 (38.1%) of 21 patients had hypertension, and weight gain was noted in 13 (65.0%) of 20 patients, suggesting overhydration. 

Table 7 shows the sites and features of reported pain. Most patients complained of loin pain. However, some patients complained of abdominal pain. The grade of pain in our patients was severe in 10 of the 22 patients, making lying down, sleeping, and driving impossible. 

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