Baylor University Medical Center Proceedings July 2017 - 327

Persistent hematuria caused by renal cell carcinoma after
aortic valve replacement and warfarin therapy
Sumera Bukhari, MD, Afolarin Amodu, MD, MPH, Michael Akinyemi, MD, and Sara Wallach, MD

Hematuria is a common finding in renal cell carcinoma, and persistent
hematuria, even in those receiving anticoagulation, warrants workup. We
present a case of a patient with persistent hematuria who was found to
have a renal mass that was not evident on renal ultrasound and computed tomography of the abdomen and pelvis but was seen on magnetic
resonance imaging.

ematuria is a common ﬁnding in urinary tract disease
and may be self-limiting or persistent. The etiology can
include infection, stones, immunological injury, or the
presence of a renal mass. Even in anticoagulated patients,
hematuria should be investigated, as anticoagulation per se is
rarely a cause of hematuria (1). We present a case of renal cell carcinoma (RCC) in a patient on anticoagulation who had persistent
gross hematuria. A renal mass was identiﬁed on magnetic resonance imaging (MRI) but was missed on earlier renal ultrasound
and computed tomography (CT) of the abdomen and pelvis.
CASE PRESENTATION
A 67-year-old man with a past medical history of diabetes
mellitus, hypertension, and nephrolithiasis after lithotripsy presented to the emergency department with a complaint of chest
pain and was admitted for acute coronary syndrome. Cardiac
catheterization showed severe multivessel coronary artery disease
and severe aortic stenosis. The patient subsequently underwent
coronary artery bypass surgery and mechanical aortic valve replacement. He was anticoagulated with warfarin and bridged with
heparin drip (target international normalized ratio of 2.5 to 3.5).
The next day, the patient developed gross hematuria and ﬂank
pain. Urinalysis showed a red blood cell count of >5 cells/highpower ﬁeld and a white blood cell count of 0 to 2 cells/high-power
ﬁeld, with no bacteria, red blood cell casts, or white blood cell
casts. A renal ultrasound revealed mild right renal hydronephrosis.
CT scan of the abdomen and pelvis (Figure 1) showed nonobstructing stones in the lower pole of the right kidney with fullness
of the right renal pelvis. Cystoscopic removal of the right kidney
stone was done with placement of a temporary stent. There was
no evidence of a bladder lesion. Mild hematuria present after
the procedure was considered iatrogenic. However, hematuria
persisted with worsening of right ﬂank pain, which warranted

Proc (Bayl Univ Med Cent) 2017;30(3):327-329

Figure 1. CT scan of the abdomen and pelvis showing a renal stone in the
lower pole of the right kidney with mild hydronephrosis and fullness of the right
renal pelvis.

further workup. MRI of the abdomen and pelvis showed a 2.9
× 2.5 × 3.8 cm mass with enhancement within the right renal
pelvis predominantly involving the lower portion, which was
concerning for underlying malignancy or hematoma (Figure 2).
The mass was not clearly visualized in imaging CT or ultrasound
imaging. A urine cytology study showed no malignant cells. Tissue samples were obtained through ureterocystoscopy, and biopsy
showed inﬂammatory cells (necrotic tissue), with no malignant
cells. Because a concern for possible malignancy remained, an
image-guided biopsy of the mass was attempted, although it
was technically challenging due to the location and surrounding necrotic tissue at the site of the mass. The biopsy result was
again negative for malignancy, showing only inﬂammatory cells.
From the Departments of Internal Medicine (Bukhari, Amodu, Wallach) and
Radiology (Akinyemi), Seton Hall University-St. Francis Medical Center, Trenton,
New Jersey.
Corresponding author: Sumera Bukhari, MD, Department of Internal Medicine,
Seton Hall University-St. Francis Medical Center, 601 Hamilton Avenue, Trenton,
NJ 08629 (e-mail: doc.smbk@gmail.com).
327

Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings July 2017