Spontaneous renal allograft rupture of unknown etiology - A case report

Umar Maqbool; Asuri Krishna; VK Bansal; Om Prakash; Subodh Kumar

doi:10.4103/ijot.ijot_69_18

CASE REPORT

Year : 2022 | Volume : 16 | Issue : 4 | Page : 435-437

Spontaneous renal allograft rupture of unknown etiology - A case report

Umar Maqbool, Asuri Krishna, VK Bansal, Om Prakash, Subodh Kumar
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Date of Submission	24-Oct-2018
Date of Acceptance	30-Jun-2022
Date of Web Publication	30-Dec-2022

Correspondence Address:
Dr. Asuri Krishna
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_69_18

Abstract

Rupture of renal allograft is a rare but serious complication of transplantation. This is usually attributed to acute rejection, acute tubular necrosis, or renal vein thrombosis. Some other causes such as renal graft biopsy and lymphatic obstruction are also mentioned as possible causes. This usually occurs during the first 1–3 weeks following transplantation, but cases occurring as late as 72 months have been reported. A 23-year-old male with established chronic kidney disease stage 5, underwent live-related renal transplantation using a kidney from a 46-year-old donor (mother). The laparoscopic donor nephrectomy was uneventful. The patient had an uneventful intraoperative course with usual early postoperative recovery. The patient was having a good early postoperative course. On postoperative day (POD) 2, there was sudden decrease in urine output to 100 ml/h. Ultrasonography Doppler on the same day evening showed normal color flow in the renal artery and renal vein. At around 7 p.m., there was sudden increase in drain output with fresh blood as content (500 ml in 10 min) with tachycardia and hypotension. In view of increased drain output, the patient was taken to operating room and reexploration was done. At reexploration, the renal allograft was found to have two longitudinal ruptures of around 8 cm × 1 cm × 2 cm and 5 cm × 1 cm × 1 cm (length × width × depth) with active bleed. The initial attempt was made to achieve hemostasis and salvage the graft kidney, but due to uncontrolled bleed, explantation was performed. Histology showed features of acute tubular injury. However, there was no evidence of acute rejection, acute tubular necrosis, or vascular thrombosis. This case demonstrates that early diagnosis and prompt treatment of a life-threatening condition such as renal allograft rupture with explantation of the graft may be required in certain conditions as a life-saving procedure.

Keywords: Chronic kidney disease, complement-dependent cytotoxicity, flow cytometric cross-match, live-related renal allograft transplantation, renal allograft rupture

How to cite this article:
Maqbool U, Krishna A, Bansal V K, Prakash O, Kumar S. Spontaneous renal allograft rupture of unknown etiology - A case report. Indian J Transplant 2022;16:435-7

How to cite this URL:
Maqbool U, Krishna A, Bansal V K, Prakash O, Kumar S. Spontaneous renal allograft rupture of unknown etiology - A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 3];16:435-7. Available from: https://www.ijtonline.in/text.asp?2022/16/4/435/364624

Introduction

Rupture of the renal allograft is a rare and serious complication following renal allograft transplantation. This usually occurs following acute rejection, acute tubular necrosis, or renal vein thrombosis.^[1],[2],[3] Some other causes such as renal graft biopsy and lymphatic obstruction are also mentioned as possible causes.^[4],[5] This condition threatens the renal graft as well as the patient's life. This usually presents early during the first 1–3 weeks following transplantation, but cases occurring as late as 72 months have also been reported.^[6] The clinical presentation comprises tachycardia, hypotension, increased drain output, graft swelling, and pain, with a significant drop in hemoglobin. Treatment consists of immediate resuscitation and reexploration, often an urgent graft nephrectomy; however, graft salvage by repair has also been performed.^[7],[8],[9] We hereby report a rare case of spontaneous renal graft rupture without a diagnosed underlying cause.

Case Report

A 23-year-old young male with established chronic kidney disease stage 5 (CKD V) secondary to chronic glomerulonephritis was admitted for renal transplant in May 2018. The patient was diagnosed with CKD 2 years ago and was put on maintenance hemodialysis since December 2017. He underwent live-related renal allograft transplantation (LRRT) on May 2, 2018. He received a left kidney with single artery, vein, and ureter from his 46-year-old Mother with human leucocyte antigen mismatch of 2/6. It was an ABO-compatible transplant with negative complement-dependent cytotoxicity and flow cytometric crossmatch. Left donor nephrectomy was done laparoscopically, the warm ischemia time being 4 min. There was no injury to the renal vein or artery during donor nephrectomy. The laparoscopic donor nephrectomy was uneventful. The recipient had an uneventful intraoperative course with standard graft implantation in the right iliac fossa. Graft renal artery was anastomosed to the right external iliac artery and renal vein to the right external iliac vein, an end-to-side fashion with 6-0 prolene in a continuous manner. On declamping, the kidney was pink and turgid with brisk urine output. A modified Lich–Grégoir ureteroneocystostomy was made. One 18-Fr drain was placed in and the sheath closed back with loop nylon.

The patient was having a good postoperative course. Urine output was around 7 L per day with stable vital parameters. On POD 2, in the early morning hours, there was sudden decrease in urine output to around 100 ml/h. The patient remained hemodynamically stable. The CVP was around 8–10 cm of H₂O. 500 ml fluid challenge was given followed by a diuretic. However, there was no improvement in urine output. An ultrasound Doppler was subsequently done and showed normal color flow in the renal artery and renal vein. At around 7 p.m., there was sudden increase in drain output with fresh blood as content (500 ml in 10 min). The patient developed tachycardia with hypotension. In view of increased drain output and hemodynamic instability, the patient was urgently shifted to operating room and reexploration was done. At reexploration, the renal allograft was found to have two longitudinal ruptures of around 8 cm × 1 cm × 2 cm and 5 cm × 1 cm × 1 cm with active bleeding [Figure 1]. An attempt was made to achieve hemostasis and salvage the graft kidney using hemostatic sutures. However, this was to no avail and in view of uncontrolled bleed and worsening hemodynamics of the patient, explantation was performed [Figure 2]. The patient was managed in the surgical intensive care unit in immediate postoperative period and shifted to the ward on POD 1. The patient remained hemodynamically stable and was started orally on POD 1 and underwent hemodialysis on POD 2. Histopathology showed features of acute tubular injury. However, there was no evidence of acute rejection, acute tubular necrosis, or microvascular thrombosis. Renal vessels were unremarkable and no thrombus was identified. Immunostain for C4d was negative and no viral inclusions or evidence of glomerulitis was seen.

Figure 1: a) Graft in situ b) laceration in the graft

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Figure 2: a) Explanted graft showing the laceration b) explanted graft with the vessels

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Discussion

Renal allograft rupture (RAR) was first reported in 1968 by Murray et al. and is defined as a superficial or deep tear of the renal capsule or renal parenchyma. The prevalence of RAR ranges from 0.3% to 9% with a mean of 3.5%.^{[10],[11],[12]} RAR is usually caused by acute rejection, acute tubular necrosis, or renal vein thrombosis.^[1],[2],[3] Some other causes such as renal graft biopsy and lymphatic obstruction are also mentioned as possible causes.^[4],[5] The most frequent cause of RAR is acute graft rejection.^[13] As demonstrated in this case, a ruptured renal transplant usually presents as an acute event with increased drain output, hypotension, tachycardia, and swelling in the graft area. Treatment involves initial supportive management followed by surgical intervention with graft salvage or graft nephrectomy. Although graft salvage is possible, the preservation of renal allografts following spontaneous rupture is a surgical challenge and despite successful repair, transplant nephrectomy might still be required.^[5],[14] In our case, the decision to perform a nephrectomy was based on multiple factors which included hemodynamic instability of the patient despite aggressive resuscitation and inability to achieve satisfactory hemostasis. Susan et al.^[15] reported successful salvage in all four cases of early allograft rupture due to acute rejection concluding that transplant nephrectomy can be avoided except in the presence of uncontrollable hemorrhage. However, the outcome of salvaging attempts is shown to be rather poor in the literature. Even with successful salvage operations, often the patient ultimately requires a nephrectomy.^[5],[14] Patients who are hemodynamically unstable even after proper and aggressive resuscitation, graft nephrectomy should be considered the only definitive treatment.^[16],[17]

In the present case, histological examination from the renal graft demonstrated only mild interstitial edema and insignificant interstitial inflammation, along with features of acute kidney injury. Yet, the extent of graft rupture was severe and evident as a deep hemi fracture of the kidney. This is consistent with the observations of Dryburgh et al.,^[18] describing eight ruptured grafts, which were grossly tense/edematous, however, the histological examination did not suggest any cellular or humoral rejection. Histopathology, in this case, was inconclusive and showed no evidence of acute rejection, acute tubular necrosis, or microvascular thrombosis. Renal vessels were unremarkable and no thrombus was identified. Immunostain for C4d was negative. There were no viral inclusions or evidence of any glomerulitis. Murray et al. also reported in their case series of ruptured renal grafts that an apparent cause of RAR may not be found in all cases following LRRT.^[11]

Conclusion

This case demonstrates that early diagnosis and prompt treatment of a life-threatening condition such as RAR with explantation of the graft may be required in certain conditions as a lifesaving procedure. It may not be possible to save the ruptured graft kidney always. Although transplant nephrectomy is a definitive treatment, with advances in surgical techniques, attempts can be made to salvage the graft if hemostasis is achieved and the patient is hemodynamically stable. This is one of the few cases of graft kidney rupture without a histopathological diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Sanchez de la Nieta MD, Sánchez-Fructuoso AI, Alcázar R, Pérez-Contin MJ, Prats D, Grimalt J, et al. Higher graft salvage rate in renal allograft rupture associated with acute tubular necrosis. Transplant Proc 2004;36:3016-8.
2.	Szenohradszky P, Smehák G, Szederkényi E, Marofka F, Csajbók E, Morvay Z, et al. Renal allograft rupture: A clinicopathologic study of 37 nephrectomy cases in a series of 628 consecutive renal transplants. Transplant Proc 1999;31:2107-11.
3.	Ramos M, Martins L, Dias L, Henriques AC, Soares J, Queirós J, et al. Renal allograft rupture: A clinicopathologic review. Transplant Proc 2000;32:2597-8.
4.	Grochowiecki T, Szmidt J, Madej K, Frunze S, Gałazka Z, Nazarewski S, et al. Spontaneous kidney allograft rupture and cyclosporine immunosuppressive therapy. Transplant Proc 1996;28:3461-2.
5.	Lord RS, Effeney DJ, Hayes JM, Tracy GD. Renal allograft rupture: Cause, clinical features and management. Ann Surg 1973;177:268-73.
6.	Askandarani S, Aloudah N, Al Enazi H, Alsaad KO, Altamimi A. Late renal allograft rupture associated with cessation of immunosuppression following graft failure. Case Rep Transplant 2011;2011:512893.
7.	Chan YH, Wong KM, Lee KC, Li CS. Spontaneous renal allograft rupture attributed to acute tubular necrosis. Am J Kidney Dis 1999;34:355-8.
8.	Guleria S, Khazanchi RK, Dinda AK, Aggarwal S, Gupta S, Bhowmik D, et al. Spontaneous renal allograft rupture: Is graft nephrectomy an option? Transplant Proc 2003;35:339.
9.	Finley DS, Roberts JP. Frequent salvage of ruptured renal allografts: A large single center experience. Clin Transplant 2003;17:126-9.
10.	Shahrokh H, Rasouli H, Zargar MA, Karimi K, Zargar K. Spontaneous kidney allograft rupture. Transplant Proc 2005;37:3079-80.
11.	Murray JE, Wilson RE, Tilney NL, Merrill JP, Cooper WC, Birtch AG, et al. Five years' experience in renal transplantation with immunosuppressive drugs: Survival, function, complications, and the role of lymphocyte depletion by thoracic duct fistula. Ann Surg 1968;168:416-35.
12.	Azar GJ, Zarifian AA, Frentz GD, Tesi RJ, Etheredge EE. Renal allograft rupture: A clinical review. Clin Transplant 1996;10:635-8.
13.	Hochleitner BW, Kafka R, Spechtenhauser B, Bösmüller C, Steurer W, Königsrainer A, et al. Renal allograft rupture is associated with rejection or acute tubular necrosis, but not with renal vein thrombosis. Nephrology Dialysis Transplantation 2001;16:124-7.
14.	Rosario PG, Greenstein SM, Schechner RS, Tellis VA. Spontaneous rupture of human renal allografts. Urology 1993;41:21-3.
15.	Susan LP, Braun WE, Banowsky LH, Straffon RA, Valenzuela R. Ruptured human renal allograft. Pathogenesis and management. Urology 1978;11:53-7.
16.	Veroux M, Veroux P, Puliatti C, Fiamingo P, Macarone M, Cappello D. Renal allograft rupture caused by acute tubular necrosis. Chir Ital 2003;55:753-5.
17.	Heimbach D, Miersch WD, Buszello H, Schoeneich G, Klehr HU. Is the transplant-preserving management of renal allograft rupture justified? Br J Urol 1995;75:729-32.
18.	Dryburgh P, Porter KA, Krom RA, Uchida K, West JC, Weil R 3^rd, et al. Should the ruptured renal allograft be removed? Arch Surg 1979;114:850-2.