An intravenous pyelogram is generally less sensitive and may be normal in patients with segmental infarctions. The optimal therapy for renal infarction caused by clot emboli is uncertain, but medical therapy is generally preferred. Although surgery can restore vascular patency, it is associated with a higher mortality and with no better recovery of renal function than that seen with anticoagulation alone. The latter modality can lead to substantial improvement even in patients who pre-sent with bilateral emboli and advanced renal failure. The one setting in which early surgery remains the treatment of choice is in patients with traumatic renal artery thrombosis, particularly if the surgery is performed within the first 24 hours.
Early therapy is clearly desirable to maximally salvage functional renal parenchyma.
Unfortunately, the diagnosis is often delayed because the significance of the characteristic findings described above is not recognized. In one study of 17 patients, for example, the time to diagnosis was usually 3 to 6 days, with only five patients being diagnosed on the first day. Intravenous heparin followed by warfarin has been the standard anticoagulant regimen used in this setting. Although not usually part of the initial regimen, surgical revascularization can be considered in patients with severe renal failure in whom there is no functional recovery within 4 to 6 weeks. Late embolectomy has led to improvement in renal function in selected patients, indicating that ischemic atrophy can still be reversed.