Postural renal transplant obstruction: a case report and review of the literature

Orthostatic Renal Transplant Compression Following Weight Gain Leading to Acute Kidney Injury

BACKGROUND

We present a first case of orthostatic renal graft compression and acute kidney injury following weight gain.

CASE REPORT

A 61-year-old male with a second cadaveric transplant presented with acute kidney injury - creatinine rise from 80 to 210 μmol/L (0.90 to 2.38 mg/dL). His medical history included diabetes, hypertension, ischemic heart disease, and obesity despite bariatric surgery. Renal biopsy was consistent with acute tubular necrosis. Serial renovascular duplex studies showed absence of diastolic flow and reduced renal perfusion despite a patent renal transplant artery and vein. Raising the fatty apron cephalad normalized renal blood flow with resistive indices throughout the kidney. Subsequent laparascopy ruled out adhesional obstruction and carbon dioxide angiogram confirmed normal transplant vessels, anastomotic sites, and intrarenal branches. He was treated with bedrest and an abdominal support belt with improvement of creatinine to 100 to 110 μmol/L (1.1-1.2 mg/dL).

CONCLUSIONS

Transplant physicians and surgeons need to be aware of positional renal graft compression from an enlarged bulky omentum and fatty apron. Diagnosis requires positional sonography.

Impact of ureteral length on urological complications and patient survival after kidney transplantation

BACKGROUND

Urologic complications are of the most important complications after kidney transplantation which increases mortality and morbidity significantly.

OBJECTIVES

We designed this study to evaluate the association between ureteral length and postoperative complications.

PATIENTS AND METHODS

We recorded the length of the transplanted ureter during the operation. Ureter-to-bladder anastomosis was performed using modified Lich-Gregoir method on the ureteral stent. Complications like urine leakage and increased creatinine were evaluated. We used both univariate and multivariate analyses and survival analysis according lengths of ureter. It means that the main variable is ureteral length and other variables are studied based on it.

RESULT

A total of 395 patients with the mean age of 37 years (range, 18 to 68 years) were enrolled in the study, twenty six graft lost during the follow-up period. The Mean age of recipients was 37 ± 13 years. Urinary stenosis was seen in 6 patients (1.5%) and urinary leakage in 4 (1%) patients. The complication rate was not significantly different between these groups (P = 0.67). We found that there were no significant difference among complication (P = 0.25), hospitalization (P = 0.31) and survival (P = 0.84) at 5.5 cm length cut off.

CONCLUSIONS

The length of transplanted ureter does not affect the postoperative urologic complications (including urinary fistula and ureter-to-bladder anastomosis stricture), and it seems that decreased rate of complication frequency during the recent years is due to technical improvement, surgeon's skillfulness and development in use of immunosuppressant's postoperatively.

When could the administration of furosemide be avoided?

PURPOSE

The purpose of this study was to evaluate whether some parameters of the basic renogram allow one to omit the administration of furosemide in cases of hydronephrosis.

MATERIALS AND METHODS

One hundred thirty-seven children (274 kidneys) referred for uni- or bilateral hydronephrosis were evaluated retrospectively. In all children additional furosemide challenges followed by postmicturition views were acquired because of unsatisfactory renal emptying. The patients were categorized into 2 groups according to the residual renal activity on the postmicturition view: those with good emptying (R-) of both kidneys, for which the administration of furosemide was considered of no influence, and those with partial or no emptying of at least 1 kidney (R+). The renogram parameters chosen for predicting R+ and R- were time to maximum (Tmax), output efficiency at 20 minutes (OE20), and normalized residual activity at 20 minutes (NORA20). For each parameter, the number of children was then calculated, for whom the administration of furosemide could have been omitted.

RESULTS

A total of 112 children were categorized as R- and 25 as R+. The cutoff values for 100% negative predictive value of Tmax, OE20, and NORA20 were 4.5 minutes, 66%, and 1.45 respectively. Application of these cutoff values for the parameters yields, in retrospect, 6 (4%), 29 (21%), and 22 (16%) children respectively for whom administration of furosemide could have been omitted.

CONCLUSION

On the basis of OE20 and NORA20, the administration of furosemide could have been omitted in a substantial number of patients, despite unsatisfactory renal emptying on the basic renogram.