Case presentation
Patient A is a 32-year-old woman, who was admitted to undergo an elective living-donor kidney transplant. Medical history includes end-stage renal disease due to focal segmental glomerulosclerosis (confirmed by histology) treated with conservative management, 8-year history of chronic hypertension and pre-eclampsia.
Family history includes a brother who underwent a living-donor kidney transplant as a treatment for end-stage renal disease secondary to membranous nephropathy.
Preoperative medical assessment was unremarkable. Vital signs were within normal limits, except for a blood pressure of 152/89 mmHg. Laboratory results showed a baseline serum creatinine levels of 877 μmol/L.
The surgery was performed without per-operative complications, and the patient was transferred to the intensive care unit for observation.
Within 24 hours of admission, the patient presented an acute oliguria, nonresponsive to fluid resuscitation. Physical examination showed a soft and nontender abdomen. Vital signs were normal. Serial laboratory results showed a progressive increase in serum creatinine levels, after reaching a nadir of 284 μmol/L. Acute renal rejection was suspected.
A Color-Doppler sonography of transplant kidney performed urgently revealed a renal graft of normal size, measuring 10.8cm, located in the right iliac fossa, with normal echostructure and without hydronephrosis. Subcapsular renal hematoma of 22 mm thickness, extending on a length of 9 cm, with an estimated volume between 50 – 76 ml (Figure 1), responsible of a compression on the major part of the renal parenchyma, was noted. CDUS showed a high resistive flow, without a diastolic component, with a resistive index (RI) of 1 (Figure 2). Diastolic reflux was noted. The graft vessels were patent, with no stenosis or thrombosis detected. Due to these findings, ATN was suspected.
Following these results, the patient underwent an emergent surgical evacuation of the subcapsular renal hematoma. Subsequently and immediately, the diuresis was back to normal. A prompt repeat CDUS revealed complete resolution of the subcapsular hematoma (Figure 3) with a normal RI, between 0.56 and 0.6 (Figure 4). Serial laboratory results showed a continuous decline in serum creatinine levels until reaching normal levels of 80 μmol/L within two days only.
Thereafter, the patient had an uncomplicated in-hospital stay, and was discharged home one week later.
Patient B is a 40-year-old woman, who was admitted to undergo an elective living-donor kidney transplant. Medical history includes end-stage renal disease due to bilateral vesicoureteral reflux with recurrent urinary tract infections treated with bilateral ureteral reimplantation. Family history was negative.
Preoperative medical assessement was unremarkable. Vital signs were within normal limits. Laboratory results showed a baseline serum creatinine levels of 687 μmol/L.
The surgery was performed without per-operative complications, and the patient was transferred to the intensive care unit for observation.
Within 24 hours of admission, the patient presented an acute oliguria, nonresponsive to fluid resuscitation. Physical examination showed a soft and nontender abdomen. Vital signs were normal. Serial laboratory results showed a progressive increase in serum creatinine levels, after reaching a nadir of 273 μmol/L. Acute renal rejection was suspected.
A Color-Doppler sonography of transplant kidney performed urgently revealed a renal graft of normal size, measuring 10.7cm, located in the right iliac fossa, with normal echostructure and without hydronephrosis. Subcapsular renal hematoma of 20 mm thickness, extending on a length of 7.1 cm (Figure 1’), responsible of a compression on the major part of the renal parenchyma, was noted. CDUS showed a high resistive flow, without a diastolic component, with a resistive index (RI) of 1 (Figure 2’). Diastolic reflux was noted. The graft vessels were patent, with no stenosis or thrombosis detected. Due to these findings, ATN was suspected.
Following these results, the patient underwent an emergent surgical evacuation of the subcapsular renal hematoma. Subsequently and immediately, the diuresis was back to normal. A prompt repeat CDUS revealed complete resolution of the subcapsular hematoma (Figure 3’) with a normal RI, between 0.62 (Figure 4’). Serial laboratory results showed a continuous decline in serum creatinine levels until reaching normal levels of 64 μmol/L within two days only.
Thereafter, the patient had an uncomplicated in-hospital stay, and was discharged home one week later.