A 72-years-old male, was found to have elevated creatinine levels for more than 1 year and was admitted to the nephrology department after vomiting for 15 days. According to laboratory tests, creatinine was 1088µmol/L, urea was 36.77mmol/L, potassium was 5.31mmol/L and urine routine indicates white blood cells +++. The diagnosis of chronic renal insufficiency and urinary tract infection was made at day 1. The CT examination revealed calculi at the ends of both ureters and severe hydronephrosis of both ureters and kidneys, urine culture was positive for Enterococcus faecalis. Obstructive renal failure was the diagnosis. Hemodialysis was performed immediately, along with support treatment such as anti-infection (Cefoperazone and sulbactam sodium), blood transfusion and albumin supplementation. Local anesthesia was used for bilateral percutaneous nephrostomy at day 5. The preoperative blood routine tests showed: WBC 7.15 × 109/L, NEUT 5.18 × 109/L, NEUT% 72.4%, hemoglobin 85 g/L, and platelet 197 × 109/L (Fig. 1). The surgical process went smoothly, the patents postoperative condition was stable, and the urine and drainage fluid were clear. However, the patient began to develop fever on the day 7, with a maximum body temperature of 39.2 degrees, rapid respiration of 25 times per minute, and blood pressure of 80/60mmHg. The urine and the nephrostomy fluid were both dark red, and about approximately 200 ml of dark red hematuria was discharged from the right nephrostomy. Laboratory examination showed 54 g/L hemoglobin, WBC 16.76 × 109/L, NEUT14.55 × 109/L, neutrophil 86.8%, platelet 165 × 109/L, PT15.8s, INR1.25, ATPP34s, TT22s, FIB5.47 g/L, D dimer 13.1 mg/L, PCT1.52ng/ml (Fig. 1). The diagnosis implies sepsis accompanied by hemorrhage, and surgical factors cannot be exclude the cause of the hemorrhage. Unlike sepsis caused by ureteroscopy, which is mainly due to prolonged high-pressure perfusion, the patient in this case has renal insufficiency, combined with postoperative indwelling catheter and urine diversion. Anti-infection (Meropenem), fluid replacement, pressure boosting, oxygen inhalation, and red blood cell transfusion were all treatments given. During the same time (day 7), percutaneous selective renal angiography was performed, and it was found that a pseudoaneurysm in the right kidney was formed, which was accompanied by arterial embolism (Fig. 2). Even after embolization, the hemorrhage has not stopped after, and follow-up blood and coagulation tests show infection and coagulation disorders (Fig. 1). The cause of hemorrhage was considered SAC/SIC. In addition to continuing red blood cell transfusion, treatment also includes the meropenem for anti-infection, as well as platelet and cryoprecipitate transfusion and vitamin K. On the day 10, laboratory tests showed WBC 7.96 × 109/L, NEUT6.54 × 109/L, NEUT% 82.2%, PT11.7, INR1.02, TT15.2, APTT30.8, FIB6.35, D dimer 8.75 (Fig. 1). After the onset of fever, three consecutive urine cultures were positive for Enterococcus faecalis and Escherichia coli, thus increasing the anti-infection effect of linezolid and strengthening nutritional support treatment, the patient’s urine and drainage gradually clear up on the day 10. Half a month later, the patient’s condition stabilized and recovered well.

Changes in laboratory indicators during the disease process

Detection and embolization of pseudoaneurysm through DSA A and B show the discovery of a pseudoaneurysm through DSA, C shows embolization of the pseudoaneurysm, D- shows there are no leakage of contrast agent after embolization