Spontaneous rupture of renal allograft

Spontaneous renal allograft rupture complicated by urinary leakage: case report and review of the literature

BACKGROUND

For more than forty years, graftectomy has been the standard treatment of spontaneous renal transplant rupture. However, recent evidences suggest that graft salvage strategies can be safely pursued, even in difficult cases.

CASE PRESENTATION

We report on a thirty-nine-year-old woman who received a deceased donor kidney transplant and experienced spontaneous allograft rupture due to acute rejection. The rupture was further complicated by urinary leakage. The kidney and the ureter were successfully repaired. Eight years after transplantation, graft function is still excellent.

CONCLUSION

Due to the lack of transplantable organs and the long time usually spent on the waiting list, graftectomy should be only considered in case of refractory haemodynamic instability or compromised graft viability.

Treatment of emergency surgical complications of kidney transplantations

Surgical complications subsequent to the kidney transplantation are not infrequent and they are characterized by the high percentage of graft loss (596-18% in standard surgical procedures and up to 37% in atypically performed transplantations). The study included 311 transplanted patients (206 (66.2%) living donors and 105 (33.8%) cadaver donors). Surgical complications developing during the immediate posttransplantation period as well as during the late period (after a year and a half) were classified as: I urinary complications; II vascular complications; III other complications. In majority of the cases urinary complications (urinary fistulas, ureteral obstructions, vesico-ureteral reflux) as well as other complications (cholecystopancreatitis and lymphocele) did not necessitate urgent treatment, unlike most of the vascular complications. All the vascular complications (29/311) developed during the immediate postoperative period, except for occurrence of arterial stenoses which ensued later on, while the development of symptoms was rapid. Severity of both symptoms and clinical picture necessitated urgent surgical re-intervention in order to preserve the graft and patient?s life. Vascular complications were classified as: true vascular complications, hemorrhages and kidney ruptures in order to distinguish technical and other factors contributing to development of the complications. Onset of the true vascular complications related to the graft and recipient blood vessel changes was evidenced in 20 patients (69%/29 patients) while the incidence of hemorrhages and ruptures was considerably lower (14%/29 patients and 17%/29 patients). As for the true vascular complications, vascular stem thrombosis subsequent to cadaveric transplantations was the most frequent, and transplantectomy was performed in all the cases in absence of any lethal outcomes. Two cases with iliac artery rupture resulted in graft loss subsequent to urgen exploration. In all cases with hemorrhages the applied therapy resulted in positive responses, except in one case in which massive gastrointestinal hemorrhage led to lethal outcome. The response to the urgent surgical treatment of spontaneous kidney graft ruptures was positive in 60% of the cases, while in the remaining 40% transplantectomy was necessitated due to the extensiveness of the lesion in order to preserve patient?s life. .

[Vascular complications after kidney transplantation]

INTRODUCTION

Despite high graft and recipient survival figures worldwide today, a variety of technical complications can threaten the transplant in the postoperative period. Vascular complications are commonly related to technical problems in establishing vascular continuity or to damage that occurs during donor nephrectomy or preservation [13].

AIM

The aim of the presenting study is to evaluate counts and rates of vascular complications after renal transplantation and to compare the outcome by donor type.

MATERIAL AND METHODS

A total of 463 kidneys (319 from living related donor--LD and 144 from cadaveric donor--CD) were transplanted during the period between June 1975 and December 1998 at the Urology & Nephrology Institute of Clinical Centre of Serbia in Belgrade. Average recipients' age was 33.7 years (15-54) in LD group and 39.8 (19-62) in CD group. Retrospectively, we analyzed medical records of all recipients. Statistical analysis is estimated using Hi-squared test and Fischer's test of exact probability.

RESULTS

Major vascular complications including vascular anastomosis thrombosis, internal iliac artery stenosis, internal iliac artery rupture, obliterant vasculitis and external iliac vein rupture were analyzed. In 25 recipients (5.4%) some of major vascular complications were detected. Among these cases, 22 of them were from CD group vs. three from LD group. Relative rate of these complications was higher in CD group vs. LD group (p < 0.0001). Among these complications dominant one was vascular anastomosis thrombosis which occurred in 18 recipients (17 from CD vs. one from LD). Of these recipients 16 from CD lost the graft, while the rest of two (one from each group) had lethal outcome.

DISCUSSION

Thrombosis of renal allograft vascular anastomosis site is the most severe complication following renal transplantation. In the literature, renal allograft thrombosis is reported with different incidence rates, from 0.5-4% [14, 15, 16]. Data from the present study demonstrate that the rate of this complication in LD group was low, only 0.3%, but significantly higher in CD group--11.8%. Many factors should be considered in order to understand for such significant difference among these groups. First of all, cadaveric transplant activity in our country is very low. In our series, median waiting period for renal transplantation was 2.8 years in LD group vs. 4.8 years in CD group (p < 0.01). Also, vascular damages because of long term hemodialysis are contributing factors. Mean age of CD recipients was 7.4 years bigger vs. LD recipients. Primary cadaveric graft damage by accident and further manipulations during cadaveric donor nephrectomy, preservation and perfusion are additional factors compromising the quality of cadaveric renal transplant outcome. Also, preoperative evaluation of cadaveric grafts is not as exact as in cases of LD grafts (excretory urography, arteriography, etc). In the available transplant literature it is almost impossible to find data about vascular complications by different donor types. Mostly, authors offer experiences related to all transplants and most of them agree that in the present time better results are obtained using living donors [17].

Renal allograft rupture is associated with rejection or acute tubular necrosis, but not with renal vein thrombosis

BACKGROUND

Whereas rejection was reported to be the most common cause of renal allograft rupture (RAR) in the pre-cyclosporin era, renal vein thrombosis (RVT) is purported to be the main cause of RAR in patients taking cyclosporin. The extremely low incidence of RVT in our series (0.11%) prompted us to analyse our collective with regard to RAR.

METHOD

Between 1974 and 1999, 1811 renal transplants were performed. Patients with RAR, defined as a tear of the renal capsule and parenchyma, were identified and possible underlying factors studied.

RESULTS

RAR was diagnosed in nine male and five female recipients (0.8%) with a median age of 36 years. Immunosuppression consisted of azathioprine and prednisolone in seven patients and of cyclosporin-based therapy in the seven others. At exploration five grafts were removed immediately: three because of irreversible rejection, one because of deep wound infection, and one with a twisted renal vein. Six of the nine salvaged kidneys have been functioning after a mean observation time of 45 months. In the pre-cyclosporin era RAR was associated with acute rejection in five out of seven cases as compared with only three of the seven on cyclosporin treatment. Core biopsies might have been the cause in three cases.

CONCLUSION

RAR is a rare complication after renal transplantation. Acute rejection still represents the most frequent cause of RAR in the cyclosporin era.

Spontaneous renal allograft rupture attributed to acute tubular necrosis

A renal allograft recipient receiving triple immunosuppressive therapy developed spontaneous allograft rupture 5 days after her second cadaveric renal transplantation. Renal biopsy showed interstitial edema with severe acute tubular necrosis (ATN). There was no evidence of acute rejection or renal vein thrombosis. The ruptured renal graft was salvaged by an aggressive fluid resuscitation therapy and surgical hemostasis. The renal function was satisfactory on discharge. We conclude that renal allograft rupture can be the result of interstitial edema solely attributed to ATN in the absence of graft rejection. The ruptured graft kidney is potentially salvageable for those patients whose hemodynamic status can be stabilized by appropriate supportive therapy.