|Year : 2022 | Volume
| 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|
Dr. Asuri Krishna
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
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.,, Some other causes such as renal graft biopsy and lymphatic obstruction are also mentioned as possible causes., 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. 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.,, 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 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%.,, RAR is usually caused by 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., The most frequent cause of RAR is acute graft rejection. 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., 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. 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., Patients who are hemodynamically unstable even after proper and aggressive resuscitation, graft nephrectomy should be considered the only definitive treatment.,
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., 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.
| 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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]