|Year : 2019 | Volume
| Issue : 4 | Page : 289-291
Successful salvage of ruptured renal allograft resulting from renal vein thrombosis
Subrahmanian Sathiavageesan1, Vel Arvind Subramaniam2, Alagappan Chockalingam3, Naveen Sangamareddy4
1 Department of Nephrology, Trichy SRM Medical College Hospital and Research Centre; Department of Nephrology, Sundaram Hospital, Tiruchirappalli, Tamil Nadu, India
2 Department of Nephrology, Pineapple Dialysis Care,Trichy SRM Medical College Hospital and Research Centre, Tiruchirappalli, Tamil Nadu, India
3 Department of Urology, Apollo Hospital, Tiruchirappalli, Tamil Nadu, India
4 Department of Urology, Trichy SRM Medical College Hospital and Research Centre, Tiruchirappalli, Tamil Nadu, India
|Date of Submission||30-Jun-2019|
|Date of Acceptance||26-Nov-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Subrahmanian Sathiavageesan
Department of Nephrology, Trichy SRM Medical College Hospital and Research Centre, Tiruchirapalli - 621 105, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Allograft renal vein thrombosis is a rare vascular catastrophe which occurs usually in the first few weeks following renal transplantation. The occurrence of allograft rupture due to venous thrombosis compounds the situation and often it leads to allograft nephrectomy. We present a case of renal allograft rupture resulting from allograft renal vein thrombosis which was successfully salvaged. We describe the clinical presentation and Doppler imaging findings of allograft vein thrombosis and surgical therapy undertaken in the patient.
Keywords: Allograft rupture, graft thrombosis, graft vein thrombus
|How to cite this article:|
Sathiavageesan S, Subramaniam VA, Chockalingam A, Sangamareddy N. Successful salvage of ruptured renal allograft resulting from renal vein thrombosis. Indian J Transplant 2019;13:289-91
|How to cite this URL:|
Sathiavageesan S, Subramaniam VA, Chockalingam A, Sangamareddy N. Successful salvage of ruptured renal allograft resulting from renal vein thrombosis. Indian J Transplant [serial online] 2019 [cited 2020 Jan 24];13:289-91. Available from: http://www.ijtonline.in/text.asp?2019/13/4/289/274602
| Introduction|| |
Vascular complications related to renal transplantation usually occur during the first few days to weeks following transplantation and include allograft artery kinking and thrombosis, venous kinking and thrombosis, pseudoaneurysm etc. Vascular complications threaten graft survival as well as patient survival. We present one such acute vascular catastrophe following renal transplantation in which patient presented with renal allograft rupture due to venous thrombosis.
| Case Report|| |
A 23-year-old male developed end-stage renal disease due to unknown chronic interstitial nephritis. He remained on hemodialysis and had recurrent primary malfunction of arteriovenous (AV) fistulas. His father volunteered for renal donation. There was 2/6 human leukocyte antigen mismatch. There was no preformed donor-specific antibody; standard complement-dependent cytotoxicity cross-match was negative. He underwent successful renal transplantation. Donor kidney had single renal artery and vein. Anastomoses included graft artery to external iliac artery and vein to external iliac vein in the right iliac fossa.
The patient had good early graft function. No induction agent was given. He received tacrolimus (C0 = 9.2 ng/ml), mycophenolate mofetil, and prednisolone. His hourly urine output was good (around 150–200 ml/h by 6th posttransplant day). His serum creatinine declined to 1.5 mg/dl, and routine allograft Doppler done on the 3rd posttransplant day was normal.
On the 7th posttransplant day, urethral catheter was removed. About 4 h after the removal of urethral catheter, the patient passed a scanty amount of blood-stained urine. Subsequently, he developed intense pain at graft site and became anuric. Doppler ultrasonogram revealed allograft renal vein thrombosis. There was a paucity of flow signals in allograft renal vein and external iliac vein and there was reversal of diastolic flow in the main and segmental renal artery [Figure 1]. Abdominal pain worsened and the patient progressed to shock. A repeat ultrasonogram was done about 30 min after the first and it revealed perinephric fluid collection. He was resuscitated with red cell transfusion and crystalloids. Emergent exploration was done. Allograft had 4 cm cortical laceration [Figure 2] with active hemorrhage. There was no kinking or mechanical distortion of the graft vein or iliac vein.
|Figure 1: Allograft Doppler reveals a paucity of venous flow signals and reversal of diastolic flow due to renal vein thrombosis|
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Allograft nephrectomy was done; 1 cm acute thrombus from the allograft vein and 5 cm organized thrombus [Figure 3] from the external iliac vein were mechanically retrieved. The allograft was perfused with hypothermic histidine–tryptophan–ketoglutarate solution, and good venous efflux of perfusion fluid with uniform perfusion of allograft was noted. The time interval from the onset of first symptom (hematuria in this case) to the onset of cold perfusion was 4 h. The allograft was reanastomosed in the same anatomical location. The allograft became turgid and uniformly pink without any mottling or cyanosis. After restoration of venous outflow, there was spontaneous hemostasis at the site of cortical laceration. Thromboprophylaxis was initiated with unfractionated heparin and later switched over to oral anticoagulant. Daily serial ultrasound Doppler examination was performed for 1 week and it revealed good flow in the allograft renal vein, external iliac vein, and allograft artery [Figure 4]. The patient developed allograft dysfunction necessitating temporary dialysis and allograft biopsy was performed on the 10th day of second surgery which revealed severe acute tubular injury without any rejection. The patient regained normal allograft function in 4 weeks. The timeline of events is as follows:
|Figure 3: Venous thrombi extracted from the allograft renal vein and external iliac vein|
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|Figure 4: Restoration of normal arterial flow pattern in allograft after thrombectomy|
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- Time duration from renal transplantation to clinical presentation of renal allograft venous thrombosis and graft rupture: 7 days
- Time duration from the first clinical manifestation (i.e. scanty blood stained urine in this patient) to the onset of cold ischemia during surgical exploration: 4 h
- Duration of delayed graft function following surgical intervention: 4 weeks.
| Discussion and Review of Literature|| |
Acute vascular complications that could occur in the early posttransplant period include allograft arterial kinking, arterial thrombosis, pseudoaneurysm, venous kinking, and thrombosis. In a retrospective analysis of renal transplant recipients, Fathi et al. reported an incidence of 1% for allograft renal vein thrombosis. Previous case reports and series reveal variable graft outcome, with the greater majority of cases ending up with graft nephrectomy and graft loss., Renal allograft venous thrombosis usually presents in the first few weeks following transplantation with manifestations such as graft dysfunction, hematuria, and abdominal pain. There have been reports of successful salvage of renal allograft in cases of venous thrombosis with different therapeutic approaches such as surgical thrombectomy, pharmacological thrombolysis, and percutaneous endoluminal thromboaspiration. Renal allograft vein thrombosis can lead to graft rupture and our patient had renal allograft rupture due to venous thrombosis. The common causes of renal allograft rupture include vascular rejection, venous thrombosis, and acute tubular necrosis. Allograft rupture is a potentially fatal catastrophe due to attendant exsanguination and hemorrhagic shock.
Ruptured allografts are associated with variable graft outcomes with many studies reporting allograft loss, and some reporting salvage of grafts. In a single-center experience, Finley andRoberts reported frequent salvage of ruptured allografts (14 out of 22). Ruptured allografts have also been rescued using argon laser for achieving hemostasis.
Both allograft renal vein thrombosis and graft rupture are emergencies and prompt recognition and intervention are needed to save the patient and graft. Our patient had progressed to hypovolemic shock due to graft rupture. Decision-making in such scenario is complex and requires team effort. While there is a scope for endovascular intervention in allograft renal vein thrombosis, allograft rupture is an absolute surgical emergency and mandates immediate exploration of allograft in the operating room. Understandably, in a patient who is found to have a ruptured allograft with exsanguinating bleeding on table, there could be an inclination from the transplant team to sacrifice the allograft in an attempt to save the life of the patient. While saving the life of the patient takes precedence over saving the allograft, the graft need not always be abandoned and this case report highlights the fact that there is a scope for saving the patient as well as the graft in the context of graft rupture resulting from venous thrombosis. Although previous case reports had reported salvage of renal allografts in either scenario, to our knowledge, this is the first case report of salvage of an allograft with venous thrombosis and rupture. Notably, there was spontaneous hemostasis at the site of allograft rupture after restoration of venous outflow and no specific therapeutic intervention was needed.
Our patient had no kinking or mechanical compression of the allograft vein, but history of recurrent AV fistula thrombosis points out to probable existence of a procoagulant milieu. The patient required dialysis for about 2 weeks following the second surgical procedure and regained normal allograft function by 4 weeks. Allograft biopsy was done on the 10th postoperative day, and it revealed acute tubular injury without any evidence of rejection. Four different phases of graft injury could be hypothesized in this case. An initial phase of venous ischemia resulted from venous thrombosis. In the second phase, the patient had allograft rupture which alleviated venous ischemia but resulted in hypovolemic shock and allograft arterial hypoperfusion. This was followed by a third phase of cold ischemia and fourth phase of ischemia reperfusion injury. Although allograft rupture resulted in hypovolemic shock, it acted as a venous outflow channel and abbreviated the duration of critical venous ischemia.
| Conclusion|| |
Allograft rupture resulting from renal vein thrombosis is a rare but graft and life-threatening complication. We present this case to highlight the following facts:
- Ruptured allograft due to venous thrombosis can be salvaged with timely recognition and surgical intervention. The time from the onset of first symptom to the onset of cold ischemia was 4 h in this case. To the best of our knowledge, this is the first case report of successful salvage of allograft with venous thrombosis and rupture
- Restoration of venous outflow by itself could establish hemostasis at the site of allograft rupture and a specific surgical repair of rupture may not be needed always.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]