Renal allograft fracture: clinicopathological study of 21 cases

Spontaneous Renal Allograft Rupture Caused by Acute Tubular Necrosis: A Case Report and Review of the Literature

Renal allograft rupture (RAR) is a rare but lethal complication of renal transplantation. It potentially threatens graft and patient survival. RAR is frequently associated with acute rejection, but other causes like renal vein thrombosis and acute tubular necrosis have also been observed. Most commonly a graft nephrectomy is required, but graft repair can also be attempted in selected cases to salvage the graft. Herein, we describe a rare case of spontaneous renal allograft rupture in the early posttransplant period due to acute tubular necrosis. A 42-year-old male, living donor renal allograft recipient, experienced RAR on the sixth posttransplant day. Surgical exploration showed two lacerations of 10 cm and 5 cm length at the upper and mid pole of the kidney. Histologically, the graft demonstrated acute tubular injury; no features of humoral or cellular rejection were identified. The successful management of this complication resulted in the salvage of the patient and the graft. This case demonstrates that early diagnosis and prompt treatment of a life-threatening RAR can salvage the graft.

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.

Salvaging of severely ruptured living-related renal allograft secondary to acute antibody mediated rejection

INTRODUCTION

Spontaneous renal allograft rupture (RAR) is a serious and potentially life-threatening complication of kidney transplantation. Debate on the management of RAR has focused on graft nephrectomy versus salvaging in cases where: the allograft rupture site is surgically manageable; the bleeding can be controlled; and/or leaving the renal allograft in situ does not compromise patient survival.

PRESENTATION OF CASE

A 45-year-old, living-related, female, kidney allograft recipient experienced RAR on the fourth day post transplantation. Surgical exploration showed 12 cm laceration along the convex border of the graft. Histologically the graft demonstrated mild acute kidney injury and linear deposition of C4d along the cortical peritubular capillaries; morphological features for violent humoral or cellular rejection were not identified. The graft was surgically salvaged with excellent clinical and biochemical improvement.

DISCUSSION

Observations arising from this case are: (1) RAR caused by rejection is still encountered in clinical practice despite effective immunosuppressive management; (2) the severity of the histopathological features of rejection does not necessarily correlate with the extent of graft rupture; and (3) salvaging the graft should be attempted whenever possible as current immunosuppression and advances in surgical techniques may have an impact on long-term graft function and survival, differing from those previously published.

CONCLUSION

With modern immunosuppression therapy and proven surgical procedures, the efficacy of salvaged renal grafts and graft survival rates may improve substantially.

[A fractured kidney, an unexpected sequela of a remote lumbar trauma]

A 40-year old man is evaluated for arterial hypertension of one's year duration, which responded well to salt restriction and mild antihypertensive medication. The standard investigation for possible secondary hypertension is negative. In view of a remote history of left renal trauma, it is decided to do an angiogram, which reveals the presence of a fractured left kidney. This unusual image is considered to be secondary to the combination of an arterial supply provided by two polar arteries and of scarring in the mid-portion of the renal parenchyma secondary to the remote trauma.

Multidetector computed tomography findings of spontaneous renal allograft ruptures

AIM

To describe the characteristics of spontaneous renal allograft rupture using multidetector computed tomography (MDCT).

METHOD

Five patients with spontaneous renal allograft rupture, as confirmed by pathologic examination, were referred to our institution between 1985 and 2008. The clinical records and preoperative MDCT findings of the patients were studied retrospectively.

RESULTS

Clinical and/or histological findings were consistent with acute rejection in all cases. Using MDCT, disruption of the capsular integrity and parenchymal rupture was seen in four patients. Four of the five patients showed decreased enhancement and swollen grafts. Perirenal (n=4), subcapsular (n=1), and intraparenchymal (n=1) haematomas were also seen. In the patient with an intraparenchymal haematoma there was no disruption of capsular integrity, but capsular irregularities were seen near the haematoma.

CONCLUSION

MDCT is a useful investigative tool for the evaluation of suspected spontaneous renal allograft rupture. As well as a swollen graft, disruption of the capsule, parenchyma, and/or haematoma should prompt the radiologist to consider this diagnosis.

Graft repair: the treatment of choice for renal allograft rupture

The incidence of renal allograft rupture among 237 live donor renal transplant patients was 6.3%. The most common association was with acute rejection. The graft salvage rate was 73% and the longest graft function was 10 years.

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 renal allograft rupture: a disappearing phenomenon in the cyclosporine era?

Spontaneous renal allograft rupture occurred in six patients in a series of 384 consecutive renal transplants performed between July 1983 and December 1990. All cases occurred in patients treated with Azathioprine and Prednisolone, and none occurred in patients immunosuppressed with Cyclosporine. Acute allograft rejection was the underlying cause of rupture. All patients underwent urgent operation and repair of the ruptured transplant. Four patients had good renal function 74-84 months after repair, while two returned to dialysis 3 and 65 months after repair because of irreversible rejection.

Spontaneous rupture of the renal allograft

Spontaneous renal allograft rupture, an unusual complication of renal transplantation, occurred in a 35-year-old woman 10 days after transplantation. Unusual localized pain and tenderness at allograft site, oliguria, and hypotension, a triad frequently seen in renal allograft rupture, were present. Management by transplant nephrectomy was inevitable because of the patient's downhill course. Histopathologic findings diagnostic of acute allograft rejection support current thinking that spontaneous rupture may be the final outcome, although unusual, of renal allograft rejection.

Mechanism, pathophysiology, diagnosis, and management of renal transplant rejection

In recent years, there has been a steady progress in basic research (immunogenetics and cellular immunology) that helped us in understanding the mechanisms underlying allograft rejection. Several laboratory tests were developed, and the results were shown to correlate with clinical rejection. However, most of these studies have not found a place in clinical practice because of their nonspecificity, lack of sensitivity, time lag, added expense, and inconvenience. The commonly employed diagnostic tests (i.e., renal transplant ultrasound and 131I hippuran scintigram) are helpful in differentiating rejection from other causes of graft malfunction. The specific renal parenchymal disease, such as acute or chronic rejection or de novo or recurrent glomerular disease, contributing to graft malfunction can only be diagnosed by renal histopathologic study. Because hyperacute and accelerated acute rejections are irreversible and necessitate graft nephrectomy, measures should be taken to prevent this problem. High-dose corticosteroids still remain the mainstay of therapy for acute cellular rejection. In the case of steroid-resistant rejections, treatment with ALG or OKT3 appears promising. As there is no effective therapy for chronic allograft rejection, usual measures of delaying the progression of chronic renal failure should be employed, and patients should be advised to return to maintenance dialysis before they develop uremic symptoms. If current experiments demonstrating selective immunosuppression with monoclonal antibodies are found successful in human trials, one can expect further improvement in the outcome of renal transplantation.

Spontaneous renal allograft rupture. Clinical and pathological patterns

Rupture of an allografted kidney occurred in five patients 5-17 days after transplantation. In one patient the microscopic pathological changes corresponded with the nodose polyarteritis pattern. In four patients interstitial rejection nephritis with severe haemorrhage and haematoma was found. It is suggested that the bleeding is due to peristatic hyperaemia and defects in the inner elastic membranes. In one case multifocal necrotizing arteriopathy was the main pathogenetic factor.

Status of renal transplantation. A clinical perspective

Although the survival of patients on chronic dialysis has improved in recent years, the quality and status of rehabilitation remains poor. Renal transplantation must be used to complement chronic dialysis in the management of these patients. Physicians should not be biased and commit their patients to one or the other form of long-term treatment.

Should the ruptured renal allograft be removed?

During a 16-month period when 93 renal transplants were performed, eight kidney graft ruptures were detected within 18 days of transplantation, without evidence of venous obstruction. Six grafts were removed at the time of an exploratory operation for rupture and only one showed signs of probable irreversible rejection when examined by microscopy. Two graft ruptures were repaired and one of these grafts has had good long-term function 22 months later. These observations suggest that if bleeding at the site of grafts has had good long-term function 22 months later. These observations suggest that if bleeding at the site of graft rupture can be securely controlled and if the conditions of the patient and of the graft are favorable except for the rupture, it may be possible to save more than one of eight grafts.