Acute torsion of the renal transplant after combined kidney-pancreas transplant

Simultaneous Pancreas-Kidney Transplant Complicated by Kidney Allograft Torsion and Pseudoaneurysms of the Y-Allograft: A Case Report and Review of the Literature

Background. We report and review the literature of two rare complications of simultaneous pancreas-kidney transplantation (SPKT) occurring in one patient. Case Report. A 39-year-old man with dialysis-dependent kidney failure secondary to type 1 diabetes mellitus underwent successful SPKT in October 2018. Three months later, he presented with an acute kidney injury (AKI) and returned to dialysis. Kidney scintigraphy showed a central photopenic region, and angiograms showed absent flow in the kidney transplant artery without treatable thrombus and the incidental finding of two pseudoaneurysms of the pancreatic Y-graft. He remained dialysis-dependent for three weeks before spontaneous partial recovery of allograft function; repeat kidney scintigraphy showed significant improvement in perfusion. However, in April 2019 he was readmitted with a sudden deterioration in kidney allograft function again necessitating haemodialysis. Repeat imaging confirmed that the kidney allograft had shifted from the left iliac fossa to the midline. He underwent surgical exploration, during which torsion of the kidney allograft was confirmed and a nephropexy was performed. The kidney allograft was originally implanted in the left retroperitoneum via a midline transperitoneal approach, which likely predisposed it to torsion. The pseudoaneurysms of the pancreatic Y-graft were managed conservatively, and surveillance imaging demonstrated that they remained stable in size. The patient regained reasonable kidney allograft function (estimated glomerular filtration rate, eGFR, of 45 mL/min) and maintained normal pancreatic allograft function. Conclusion. Kidney allograft torsion should be considered post-SPKT in patients with AKI and absent arterial flow. Although most case reports describe surgical management of pseudoaneurysms post-SPKT, our case demonstrates successful conservative management.

Robotic Kidney Transplant: The Modern Era Technical Revolution

Since the mid 20th century, transplantation has been a fast-developing field of contemporary medicine. The technical aspects of transplant operations were developed in the 1950s, with little significant change for >50 y. Those techniques allowed completion of various organ transplants and successful patient outcomes, but they also carried the inherent disadvantages of open surgery, such as postoperative pain, wound complications and infections, and prolonged length of hospital stay. The introduction and adoption of minimally invasive surgical techniques in the early 1990s to various surgical specialties including general, gynecologic, and urologic surgery led to significant improvements in postoperative patient care and outcomes. Organ transplantation, with its precision demanding vascular anastomoses, initially had been considered infeasible to accomplish with conventional laparoscopic devices. The institution of robotic surgical technology in the late 1990s and its subsequent wide utilization in fields of surgery changed its accessibility and acceptance. With the steady camera, 3D views, and multidirectional wrist motions, surgical robotics opened new horizons for technically demanding surgeries such as transplantation to be completed in a minimally invasive fashion. Furthermore, the hope was this technique could find a niche to treat patients who otherwise are not deemed surgical candidates in many fields including transplantation. Here in, robotics in kidney transplantation and its ability to help provide equity through access to transplantation will be discussed.

Symptomatic Nephroptosis of the Transplant: First Report of Diagnostic Workup and Successful Minimal-Invasive Treatment

The symptomatic nephroptosis of a kidney transplant is a rare and potentially fatal complication and requires fast diagnosis and treatment. In this report, we describe a case in which intermittent symptomatic hydronephrosis and an increase of the creatinine levels were the leading symptoms of nephroptosis. Moreover, we describe the diagnostic procedures and the successful minimal-invasive treatment. To our knowledge, this is the first report of a symptomatic transplant nephroptosis with consecutive intermittent hydronephrosis and without complications of perfusion solved with a minimal-invasive approach.

Laparoscopic Fixation for Torsion of Transplanted Kidney: A Case Report

BACKGROUND

Kidney graft torsion and subsequent acute kidney injury is a rare yet potentially devastating complication of intraperitoneal kidney transplant. We report a case of this elusive diagnosis and describe kidney salvage by using laparoscopic fixation.

CASE REPORT

A 49-year-old male patient presented with multiple episodes of anuric acute kidney injury 16 months after an uneventful combined orthotopic liver and kidney transplantation. After a thorough investigation, a diagnosis of kidney torsion was made, and the patient was urgently operated. Upon surgery, a complete torsion of a viable kidney was found. Laparoscopic fixation was achieved by using an absorbable mesh "pocket." The patient has experienced no similar episodes in the subsequent year.

CONCLUSIONS

Nephrologists and surgeons should be aware of this rare complication. Prompt diagnosis and operative repair are crucial to save the graft. Prophylactic nephropexy should be considered in all intraperitoneal transplantations.

Transplant with a twist: A pitfall in sonographic diagnosis of renal transplant torsion

Torsion is an uncommon cause of impaired function in a renal transplant. We present a case of intraperitoneal transplant torsion secondary to adhesions to the left fallopian tube and ovary. Inability to confirm renal venous flow with Doppler misled to the erroneous sonographic diagnosis of renal vein thrombosis, although end diastolic flow was absent rather than reversed. The correct diagnosis was made with CT. The combination of abnormal orientation of the graft on ultrasonography, acutely impaired renal function, and abnormal Doppler study should have led to a diagnosis of transplant torsion. The case is also unusual in that the lead point was adnexal pathology. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:528-530, 2017.

Long-term Graft Survival After Kidney Allograft Torsion: Rapid Diagnosis and Surgical Management Key to Reversibility of Injury

INTRODUCTION

Kidney allograft torsion (KAT) is a rare complication of kidney transplantation (KT) that occurs when the transplanted kidney rotates around its vascular pedicle, which may result in a catastrophic compromise of the graft's blood supply, deterioration of kidney function, and eventually premature graft death.

CASE REPORT

We report the case of a patient who had an acute kidney injury (AKI) episode from KAT. Her diagnosis was ascertained expeditiously and she had prompt surgical management. Five years after the KAT event, her baseline creatinine (Cr) stabilized around 1.6 mg/dL and she has achieved >8-year graft survival.

DISCUSSION

This case illustrates the reversibility of injury that can occur after a KAT event with a commensurate return to baseline kidney function when KAT is promptly diagnosed and treated. A high index of suspicion of this uncommon but catastrophic complication of KT must be maintained to achieve desirable long-term outcomes. A diagnosis of KAT must be considered when routine etiologies of an acute deterioration of kidney allograft function have been excluded. Finally, prophylactic nephropexy must be strongly considered with intraperitoneal placement of a kidney allograft to avoid KAT.

Graft Kidney Torsion After Simultaneous Kidney-Pancreas Transplant: Report of 2 Cases and Literature Review

Torsion of an allograft kidney is an extremely rare and potentially reversible complication. Imaging diagnosis plays a crucial role because of the absence of specific clinical features. We report 2 cases in which kidney torsion after simultaneous kidney-pancreas transplant was diagnosed by ferumoxytol-enhanced magnetic resonance imaging/angiography and present a review of the relevant literature. Radiologists and clinicians should be aware of this entity because graft salvage depends on rapid diagnosis and surgical detorsion.

Robotic-assisted Kidney Transplantation: Our Experience and Literature Review

Kidney transplantation is the preferred treatment for patients with end-stage renal disease. While open surgery remains the gold standard, minimally invasive surgery has recently been introduced for the recipient undergoing kidney transplantation. Our team has employed the robotic surgical system to perform renal transplantation in obese recipients to minimize the risk of surgical site infections, with good results in terms of complications and graft and patient survival. However, others groups have performed kidney transplantation robotically in nonobese patients using different techniques. The da Vinci surgical system allows the performance of kidney transplantation under optimal operative conditions. Larger studies and long-term follow-up of recipients are required to determine the effectiveness of this approach. In this article, we describe our experience and review the development of the robotic-assisted kidney transplantation (RAKT).

Torsion of the retroperitoneal kidney: uncommon or underreported?

Vascular torsion in a renal allograft after placement in the retroperitoneum is rare and has only been reported twice in the literature. It is an extrinsically mediated process that occurs at the vascular pedicle resulting in graft compromise and potential loss. Rapid diagnosis and immediate surgical intervention may salvage allograft function. Herein, we present a unique case of a 42-year-old male that developed renal allograft torsion following a second kidney transplant placed in the retroperitoneum. Immediate detorsion did not resolve allograft dysfunction, and a biopsy revealed acute cellular mediated rejection. After antithymocyte globulin treatment, allograft function was salvaged. A review of the current literature shows that the incidence, morbidity, and long term allograft function of intraperitoneal and extraperitoneal torsion are different. As such, torsion of the retroperitoneal kidney demonstrates encouraging allograft salvage rates. Only the third case reported to date, this serves as a contribution to the growing body of literature in retroperitoneal renal torsion and reviews the risks, medication considerations, diagnostic tests, and treatment modalities in a unique disease process.

Sonography in the Diagnosis of Renal Transplant Torsion

Torsion following kidney transplant is a complication occurring when the kidney rotates around the vascular pedicle. It is a relatively rare occurrence but one that the sonographer should be aware of when a patient presents with severe abdominal pain and decreased urine output. In the best of circumstances, renal torsion can be repaired; in the worst cases, the kidney is lost. Prompt diagnosis of renal vein thrombosis, renal artery stenosis, and occlusion resulting from torsion permits graft detorsion and possible salvage of the kidney.