Renal allograft rupture: surgical treatment by renal corsetage with lyophilized human dura

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.

Surgical repair of spontaneous renal allograft rupture: a new procedure

BACKGROUND

The purpose of the present paper is to introduce a new surgical procedure using the external oblique aponeurosis (EOA) for repair of spontaneous renal allograft rupture.

METHODS

Thirty-eight cases with spontaneous renal allograft rupture were encountered in 1000 consecutive kidney transplants between April 1991 and August 2000. Thirty-three cases underwent surgical exploration with two grafts undergoing nephrectomy, while a further 31 were repaired using the new surgical procedure. The external oblique aponeurosis (EOA) from the incision was trimmed into 1 cm x 1 cm square pieces. A 2/0 Dexon suture was placed through each piece of the EOA, then through the parenchyma of the kidney perpendicular to the rupture. Each suture was then placed through another piece of EOA and tied.

RESULTS

Two repaired grafts were removed on day 7 and day 10, one due to graft re-rupture and another with ischaemia secondary to irreversible acute rejection. The graft function of 29 cases had recovered completely at 30 days following surgical repair with one graft improving rapidly. Thirteen grafts were diagnosed as undergoing mild to moderate acute rejection, whereas a further 20 cases were considered to have acute tubular necrosis on histopathology. The allograft survival rate at 1 year and 5 years post grafting was 86% and 64%, respectively. No patients died from postoperative complications following repair using this procedure.

CONCLUSIONS

Spontaneous renal allograft rupture is a relatively common post-transplant complication secondary to either acute tubular necrosis or acute rejection. This new surgical procedure is proposed as a reliable and practical method of repair following graft rupture. Preservation of graft function and viability following rupture appears achievable both in the medium and long-term.

Is the transplant-preserving management of renal allograft rupture justified?

OBJECTIVE

To evaluate the transplant-preserving management of renal allograft rupture.

PATIENTS AND METHODS

From April 1982 to January 1994 a total of 238 renal transplantations were performed on 227 patients. Eight cases (3.5%) of renal allograft rupture occurred. Transplant nephrectomy was necessary in one patient. Seven patients were surgically treated with collagen foam, fibrin glue and vicryl mesh.

RESULTS

In all seven cases treated conservatively, renal salvage and satisfactory graft function was achieved. After a mean follow-up of 52.9 months (range 2-94) the mean creatinine level was 15.6 mg/L (range 11-21). Of these seven patients with renal allograft rupture one returned to haemodialysis 22 months after transplantation and had several episodes of rejection. Almost 4.5 years after renal allograft rupture, the creatinine value in six of the seven patients was only slightly higher than the mean creatinine values of all donor kidney recipients (14.4 +/- 5.5 mg/L).

CONCLUSION

There should be an attempt to salvage the transplant after allograft rupture in all cases. Using these transplant-preserving techniques, renal function could be achieved for all patients with allograft rupture.

Spontaneous rupture of renal allograft

Spontaneous rupture of a renal allograft was encountered in 3 male patients among 75 consecutive renal transplants over a three-year period. In 1 patient, the transplant was from a living related donor, while the other two were cadaveric kidneys from pediatric donors. In 2 patients, allograft rupture followed steroid-resistant rejection, while in the third with cadaveric kidney transplant, the rupture was associated with renal vein thrombosis. Two patients presented with classic symptoms of renal allograft rupture: sudden onset of severe pain and swelling over the allograft and hypotension, while in the third the rupture was found during exploration of the allograft with clinical diagnosis of renal artery thrombosis. Transplant nephrectomy was done in 2 patients, while successful surgical repair was performed in the third patient with living related transplant.

Spontaneous rupture of human renal allografts

Preservation of renal allografts following spontaneous rupture is a surgical challenge. Salvage was attempted in 3 patients. Despite successful repair in all 3, transplant nephrectomy was ultimately required in 2 patients because of irreversible rejection. The third patient is doing well forty-eight weeks after transplantation.

Conservative treatment of renal allograft rupture with polyglactin 910 mesh and gelatin resorcin formaldehyde glue

Renal-sparing treatment of spontaneous renal allograft rupture remains a surgical challenge, since profuse hemorrhage may result from these friable kidneys during surgical repair. A technique is proposed to achieve control of local bleeding with a synthetic glue (gelatin, resorcin and formaldehyde) and external compression with a polyglactin 910 absorbable mesh. We report 4 cases of spontaneous allograft rupture associated with rejection and bleeding was controlled in all 4. Three grafts were preserved with more than 1 year of followup. The other graft had to be removed for uncontrolled vascular rejection despite satisfactory control of renal fractures. Renal wrapping with external compression is proposed to improve results of conservative management of renal allograft rupture.

The sapphire crystal infrared photocoagulator and polyglactin (Vicryl) mesh: two new alternatives to the suturing of radial nephrotomies

The sapphire crystal infrared photocoagulator and polyglactin (Vicryl) mesh, two new methods for closure of radial nephrotomies, were assessed in 16 dogs. Six radial nephrotomies were carried out in each dog; in 10 the nephrotomies were sealed by the infrared photocoagulator and in six they were left open, but the kidney was covered with a polyglactin mesh. Functional and morphological studies were performed using creatinine clearance, microfil casting, corrosion cast angiography and histology. There was no significant loss of function or loss of renal tissue. Both methods were shown to be safe and effective in the closure of radial nephrotomies.