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| CASE REPORT |
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| Year : 2022 | Volume
: 16
| Issue : 4 | Page : 441-443 |
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Successful management of hydronephrosis and anuric renal failure of transplant kidney, masquerading as extrarenal pelvis - A case report
Arunkumar Neelakandan, Nagarajan Palaniappan, Anil Tarigopula, Milly Mathew, Georgi Abraham
Institute of Renal Sciences, MGM Healthcare, Chennai, Tamil Nadu, India
| Date of Submission | 06-Nov-2021 |
| Date of Acceptance | 02-Feb-2022 |
| Date of Web Publication | 30-Dec-2022 |
Correspondence Address:
Dr. Georgi Abraham
MGM Healthcare, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijot.ijot_113_21
An unusual case of kidney allograft dysfunction following mechanical obstruction of the allograft at distal ureter, secondary to scarred vas deferens, testicular vessels, and lower abdominal muscles due to the previous right inguinal hernia mesh repair. This led to anuric renal allograft failure on the 2nd postoperative day, which was successfully managed with a multidisciplinary team.
Keywords: Anuric kidney failure, transplant kidney dysfunction, ureteric obstruction
How to cite this article:
Neelakandan A, Palaniappan N, Tarigopula A, Mathew M, Abraham G. Successful management of hydronephrosis and anuric renal failure of transplant kidney, masquerading as extrarenal pelvis - A case report. Indian J Transplant 2022;16:441-3 |
How to cite this URL:
Neelakandan A, Palaniappan N, Tarigopula A, Mathew M, Abraham G. Successful management of hydronephrosis and anuric renal failure of transplant kidney, masquerading as extrarenal pelvis - A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 8];16:441-3. Available from: https://www.ijtonline.in/text.asp?2022/16/4/441/364608 |
| Introduction | |  |
Anuric renal allograft dysfunction in the early posttransplant period, although infrequently seen, it calls for investigations including imaging, kidney biopsy, and immunological work up to elucidate the cause.[1]
Multidisciplinary team effort is necessary to address this, including nephrologist, transplant surgeon, radiologist, pathologist, and immunologist.[2]
Here, we describe an anuric graft dysfunction in a live-related male kidney transplant recipient in <24 h after engrafting due to a rare complication from a prior right inguinal hernia repair.
The causes, investigations, and management are discussed along with the patient outcomes.
| Case Report | | |
A 33-year-old male was diagnosed to have chronic kidney disease which was progressive reaching end stage, requiring hemodialysis for the past 3 years. He was previously operated for the right inguinal hernia with mesh repair in 2020. The blood group of the donor was “O” positive and the recipient was “A” negative. The recipient had no preformed antibodies. At the time of admission, he had a serum creatinine level of 8.46 mg/dL and urea was 45.3 mg/dL. He underwent a live-related renal transplantation on October 19, 2021. The donor was the sister-in-law of the patient. While investigating the donor, she was found to have an extrarenal pelvis. The donor's left kidney was harvested laparoscopically. The cold and warm ischemia times were 50 min and 45 min, respectively. The recipient was inducted with intravenous thymoglobulin 100 mg.
The donor's left kidney was transplanted into the right iliac fossa of the recipient. The single donor renal artery was anastomosed end to side to the external iliac artery and the single donor vein was anastomosed to the external iliac vein and neocystoureterostomy was done without anti-reflux procedure. Other medications were prednisolone 35 mg and mycophenolate mofetil 1 g twice a day.
The immediate postoperative period was uneventful with profound diuresis of 3390 ml of urine in <24 h after the transplantation. His creatinine had declined from 8.46 to 5.59 mg/dL in <24 h. The fluid replacement was with normal saline and plasma-lyte. Around 10.30 am on the 1st day, there was a profound fall in urine output and in a couple of hours' time, he became anuric. Ultrasound examination of the graft including renal Doppler study revealed normal flow velocities and resistivity indices (RIs) in the main renal, hilar, and the segmental arteries. Extrarenal pelvis was seen along with mild dilatation of the major calyces.[3] The proximal ureter was visualized, showed no significant dilatation [Figure 1]a and [Figure 1]b. No parenchymal abnormalities were seen.
As the patient remained anuric, the cause being unknown, the urinary catheter (18°F) was left in situ and imaging showed the absence of urine in the bladder and outside the bladder. The patient had no signs of an immunological abnormality such as fever, graft tenderness, or other systemic manifestations. The lymphocyte count remained 2%, 4%, 3.8%, and 5% on the first 4 days suggesting very significant lymphocyte depletion. An allograft biopsy was done on the 3rd day, which showed normal findings of the blood vessels, glomeruli, tubules, interstitium, and was negative for C4d staining [Figure 2].[4] | Figure 1: (a) Dilated pelvicalyceal system and extrarenal pelvis. (b) Renal Doppler showing increased resistivity index in the renal artery (Resistivity Index: 1)
Click here to view |
An immediate magnetic resonance (MR) urogram showed the presence of an extrarenal pelvis [Figure 3]a with moderate dilatation of the major calyces and no dilatation of the minor calyces. There was moderate dilatation of the proximal ureter with abrupt narrowing and cutoff distally, suggesting the possibility of kinking/stricture of the lower ureter. The renal parenchyma appeared edematous with minimal free fluid in the pelvis. | Figure 3: (a) Magnetic resonance urogram demonstrating the extrarenal pelvis and the distal ureter stricture. (b) Obstruction of transplant ureter, by scarred vas deferens and testicular vessels
Click here to view |
The patient was immediately re-explored on October 23, 2021, which showed mechanical obstruction of transplant kidney's mid ureter, secondary to scarred vas deferens, testicular vessels, and lower abdomen muscles following the previous right inguinal hernia mesh repair [Figure 3]b.
Mechanically compressed transplant mid ureter was ischemic and showed features of early stricture. Revision of neocystoureterostomy with DJ stenting was done.
Immediately following this the patient started diuressing with 11,680 ml on the 1st day, followed by 12,765 ml on the 2nd day, and 6250 ml on the 3rd day. The creatinine declined to 1.4 mg/dL with normal electrolytes and the patient was initiated on tacrolimus 4 mg and 3 mg am and pm with subsequent modification of the dosage as per the trough levels.
At the time of discharge on October 29, 2021, the kidney functions were, serum creatinine: 1.12 mg with normal electrolytes, blood pressure was 160/90 mm Hg and the immunosuppressives were tacrolimus 5 mg b.i.d., prednisolone 30 mg od, and sodium salt of mycophenolate 720 mg b.i.d., along with clonidine, diltiazem, metoprolol, and anti-infectives.
The patient was advised to leave the urinary catheter in situ for 2 weeks.
| Discussion | | |
Anuric kidney failure in the immediate posttransplant period calls for urgent investigations to rule out vascular thrombosis, hyperacute rejection, acute kidney injury (AKI), obstruction of the ureter by intraluminal or extraluminal causes, extravasation of urine, and bladder catheter dysfunction.[5] A multidisciplinary approach is urgently warranted to correct reversible causes as in our patient with distal ureter obstruction secondary to scarred vas deferens, testicular vessels, and lower abdominal muscles.
A Doppler study with an ultrasound showed patent blood vessels with normal blood flow and an obstruction masquerading as extrarenal pelvis present prior to transplantation. The rising RI from 0.7 to 1 could be due to hyperacute rejection, AKI, or obstruction. As the kidney biopsy did not show evidence of hyperacute rejection or AKI, we suspected ureteric obstruction which was evident on MR urogram. The prompt exploration and correction of the ureteric obstruction led to profound diuresis and recovery of allograft function. The ischemic lower ureter was repaired with a new re-implantation to the bladder and a DJ stent to facilitate smooth excretion of urine.
This rare cause of ureteric obstruction due to the previous surgery should be kept in mind and corrective action should be taken to prevent AKI, sepsis, and recovery of allograft function. Delay in diagnosis can lead to irreversible loss of allograft function and associated morbidity.
Declaration of patient consent
The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Hadiuzzaman KM, Islam SF, Faroque MO, Hossain RM, Munirunnessa M, Selim SI, et al. Etiology of early renal allograft dysfunction and comparison between dysfunction and function group: A single center study Mymensingh Med J 2017;26:748-55.  |
| 2. | Islam SF, Hadiuzzaman KM, Islam MN, Khanam A, Faroque MO, Ahmed AH. Role of protocol biopsy in early graft dysfunction in renal transplant recipient. Mymensingh Med J 2014;23:286-9. |
| 3. | Koratala A, Bhattacharya D. Extrarenal pelvis mimicking hydronephrosis: A case for caution. Clin Case Rep 2017;5:1720-21. |
| 4. | Goldberg RJ, Weng FL, Kandula P. Acute and chronic allograft dysfunction in kidney transplant recipients. Med Clin North Am 2016;100:487-503. |
| 5. | Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005;25:1335-56. |
[Figure 1], [Figure 2], [Figure 3]
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