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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 145-146

Successful management of a rare complication after percutaneous transplanted kidney biopsy


1 Department of Nephrology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
2 Department of Radiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India

Date of Submission21-Dec-2018
Date of Acceptance01-Mar-2019
Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. Jitesh Jeswani
Department of Nephrology, Mahatma Gandhi Medical College and Hospital, Sirtapura, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_85_18

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  Abstract 


Renal hematoma is the most commonly reported complications after percutaneous renal biopsies, but fortunately, these are self-limited in most of the cases with no need for active intervention. Other complications such as arteriovenous fistula, colonic injury, infections, or pneumothorax are much less frequent life-threatening, and stated to occur in <0.1% of cases. We describe a case in which percutaneous renal biopsy is complicated by subcapsular hematoma due to tamponade following which the patient underwent surgical intervention. Although uncommon, sub capsular hematoma may be fatal and requires early intervention to save the graft kidney.

Keywords: Complications, renal biopsy, subcapsular hematoma


How to cite this article:
Godara S, Jeswani J, Gumber N. Successful management of a rare complication after percutaneous transplanted kidney biopsy. Indian J Transplant 2019;13:145-6

How to cite this URL:
Godara S, Jeswani J, Gumber N. Successful management of a rare complication after percutaneous transplanted kidney biopsy. Indian J Transplant [serial online] 2019 [cited 2019 Jul 19];13:145-6. Available from: http://www.ijtonline.in/text.asp?2019/13/2/145/261856




  Introduction Top


Percutaneous needle biopsy of the kidney is a common procedure. However, this procedure is not always free of complications.[1] The complication rate following this procedure has been reported to be 20%–30%. Complications include flank pain, hematuria, perirenal hematoma, arteriovenous fistula, laceration of the collecting system, and clot anuria, whereas a subcapsular hematoma of a renal allograft is a more serious complication following this procedure.[2]

We report a case of a subcapsular hematoma and hypertension after percutaneous biopsy of a transplanted kidney. The sonographic findings included reversal of diastolic flow in the interlobar arteries; this finding might be an important sign of ischemia resulting from renal compression.


  Case Report Top


A 45-year-old male post-renal allograft recipient from live-related donor with father as donor (histocompatible 3/6) was on triple immunosuppressants. His clinical course was uneventful until 4 months after transplantation, the serum creatinine increased from a postoperative value of 1.0 to 1.8 mg/dl.

A biopsy of the transplanted kidney was undertaken to elucidate the cause of acute graft dysfunction. His platelet counts and prothrombin time were within the normal limits. A real-time ultrasound was used to orientate the axis of the allograft and to define the upper pole, which was the preferred biopsy site with an 18G needle. On the day of renal biopsy, the patient developed pain at biopsy site followed by vomiting and decreased urine output.

An ultrasound showed a peripheral echogenic fluid collection in the transplanted biopsied kidney with indentation of renal parenchyma consistent with a subcapsular hematoma [Figure 1]a and a high resistance arterial waveform in the interlobar arteries with the reversed flow in diastole and increased resistive index (RI) of 1.48 [Figure 1]b. A helical computed tomography confirmed a large subcapsular hematoma compressing the allograft kidney [Figure 2].
Figure 1: (a) Ultrasound showed a peripheral echogenic fluid collection in the transplanted biopsied kidney. (b) A high resistance arterial waveform in the interlobar arteries with reversed flow in diastole

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Figure 2: A helical computed tomography confirmed a large subcapsular hematoma compressing the allograft kidney

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Hence, the patient was taken for immediate surgical intervention and evacuation of subcapsular hematoma which was causing compression on the renal allograft. The patients' urine output gradually improved over the next few hours with improvement in blood flow on color Doppler and RI decreased to 0.71. Serum creatinine gradually decreased to 1.7 mg/dl.

His graft renal biopsy showed severe acute tubular injury and areas of tubular atrophy and interstitial fibrosis.


  Discussion Top


Renal hematomas are the most commonly reported complications after percutaneous renal biopsies, but fortunately, these are self-limited in most of the cases with no need for active intervention.[3] Other complications such as arteriovenous fistula, colonic injury, infections, or pneumothorax are much less frequent life-threatening, and stated to occur in <0.1% of cases.[4] Renal artery pseudoaneurysm is another uncommon complication that could be fatal in case ruptured.[5] The prevalence has significantly reduced recently mainly due to the widespread use of ultrasound guidance and automated-gun biopsy devices.[6] These complications are less common in transplanted than in native kidneys biopsies.[7]

The occurrence of a perirenal hematoma in patients following percutaneous renal allograft biopsy is reported to be <5%,[2],[3],[4],[6],[7] however, there have not been any reports of a subcapsular hematoma in these patients. Uppot RN et al.[5] reported a case of anuria and hypertension secondary to a subcapsular hematoma following an ultrasound-guided needle biopsy of a renal allograft, where the anuria and hypertension were cured by surgical drainage.[5]

They concluded that the compressive effect of a subcapsular hematoma on the underlying renal parenchyma induced a significant decrease in the mean renal perfusion, with the subsequent development of anuria and hypertension.

Surgical drainage of the collected fluid is not advisable in most cases of hematomas of perirenal allografts because of both the self-limited nature of the hematoma and the risk of infection.[8]

On the other hand, a transplanted kidney forms a dense inelastic pseudocapsule as an immune response to the foreign organ,[5] and a subcapsular hematoma may result in severe irreversible compressive damage. Thus, we advocate early surgical treatment of subcapsular hematomas to prevent irreversible renal damage. Early drainage of the subcapsular hematoma in our patient resulted in the saving of the allograft.

Although uncommon in the present era, maybe a fatal complication, and early intervention is required to save the graft kidney.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hergesell O, Felten H, Andrassy K, Kühn K, Ritz E. Safety of ultrasound-guided percutaneous renal biopsy-retrospective analysis of 1090 consecutive cases. Nephrol Dial Transplant 1998;13:975-7.  Back to cited text no. 1
    
2.
Whittier WL, Korbet SM. Timing of complications in percutaneous renal biopsy. J Am Soc Nephrol 2004;15:142-7.  Back to cited text no. 2
    
3.
Figueroa TE, Frentz GD. Anuria secondary to percutaneous needle biopsy of a transplant kidney: A case report. J Urol 1988;140:355-6.  Back to cited text no. 3
    
4.
Jain V, Ganpule A, Vyas J, Muthu V, Sabnis RB, Rajapurkar MM, et al. Management of non-neoplastic renal hemorrhage by transarterial embolization. Urology 2009;74:522-6.  Back to cited text no. 4
    
5.
Uppot RN, Harisinghani MG, Gervais DA. Imaging-guided percutaneous renal biopsy: Rationale and approach. AJR Am J Roentgenol 2010;194:1443-9.  Back to cited text no. 5
    
6.
Bakri RS, Prime M, Haydar A, Glass J, Goldsmith DJ. Three 'pages' in a chapter of accidents. Nephrol Dial Transplant 2003;18:1917-9.  Back to cited text no. 6
    
7.
Abutaleb N, Obaideen A. Renal Tamponade Secondary to Subcapsular Hematoma. Saudi J Kidney Dis Transp 2005;29:39-41.  Back to cited text no. 7
    
8.
Oliveira GH, Garovic VD. 23-year-old man with hypertension and flank trauma. Mayo Clin Proc 2002;77:1229-32.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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