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Renal transplantation in inherited thrombophilias
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n 9 ( 2 0 1 5 ) 4 3 e4 5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ijt
Images in Transplantation
Renal transplantation in inherited thrombophilias Dhananjai Agrawal a, Kunal Gandhi b,*, Dharmendra Prasad b a b
Professor, Department of Nephrology, Sawai Man Singh Hospital, Jaipur, Rajasthan, India Resident, Department of Nephrology, Sawai Man Singh Hospital, Jaipur, Rajasthan, India
article info Article history: Received 2 April 2015 Accepted 21 April 2015 Available online 7 May 2015
We present a case of a 43 year old male with history of spontaneous deep vein thrombosis of right lower limb 8 years back. Further evaluation was suggestive of thrombosis of bilateral common iliac, internal iliac, femoral, renal veins extending up to the inferior venae cava. His serum creatinine level was 1.5 mg/dl at that time. Patient was managed conservatively with heparin followed by warfarin based on the INR values. Further workup for cause of hypercoagulability showed a protein C and S deficiency. Patients continued his
Fig. 1 e CT scan of the abdomen.
* Corresponding author. E-mail address: [email protected] (K. Gandhi). http://dx.doi.org/10.1016/j.ijt.2015.04.004 2212-0017/Copyright © 2015, Indian Society of Organ Transplantation. All rights reserved.
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i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n 9 ( 2 0 1 5 ) 4 3 e4 5
medications for one year after which he was lost to follow up. Presently, he was admitted with symptoms of nausea and generalized swelling. His serum creatinine was 12 mg/dl. Ultrasonography revealed bilateral small sized kidneys with multiple simple cortical cysts. After explaining the need of renal replacement therapy, the patient and his family are willing for live-related transplantation with brother a healthy donor. The CT scan is showed in Fig. 1.
1. What are the findings in the imaging study? 2. What are the options for venous anastomosis in this patient? 3. How to manage these patients with inherited thrombophilias post-renal transplantation (Answers to this quiz will be published in the next issue of Indian Journal of Transplantation.)
Answer to the Images in Transplantation Gandhi K, Prasad D, Agrawal D, Beniwal P, Malhotra V. Images in Transplantation. Indian J Transplant. 2014; 8(4):124.
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n 9 ( 2 0 1 5 ) 4 3 e4 5
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a) What are the imaging findings? X-ray shows a migrated Double J stent with a distal end displaced in the pelvis probably through a gap in the ureter leading to a urine leak. The finding is confirmed on the CT scan. b) What is the next step for diagnosis? Ascitic fluid creatinine equalling urine creatinine is indicative of the diagnosis. A renal scan with DTPA or MAG with diuretic renogram demonstrating extravasation is the most sensitive method to differentiate a urine leak from other fluid collections. c) How to manage this patient? Surgical correction with primary reconstruction or a new ureteral re-implantation should be performed at the earliest. d) What is the differential diagnosis in a patient with early allograft dysfunction? The differential diagnosis of early allograft dysfunction can be divided in to following heading. i. Pre-renal e Severe hypovolaemia/hypotension, Vascular complications such as Renal vessel thrombosis and Renal artery stenosis ii. Intra-renal e Ischaemic ATN, Hyperacute rejection, Accelerated acute or acute rejection, Acute cyclosporine/tacrolimus nephrotoxicity (±ATN), Thrombotic microangiopathy, Recurrence of primary glomerular disease (particularly FSGS) iii. Post-renal e Catheter obstruction, Urinary tract obstruction- Intrinsic (blood clots, poor reimplantation, ureteral slough), Extrinsic (ureteral kinking), Peri-nephric fluid collection (lymphocele, haematoma, urine leak)
Refers to DOI: http://dx.doi.org/10.1016/j.ijt.2015.01.002
Conflicts of interest All authors have none to declare.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ijt
Images in Transplantation
Renal transplantation in inherited thrombophilias Dhananjai Agrawal a, Kunal Gandhi b,*, Dharmendra Prasad b a b
Professor, Department of Nephrology, Sawai Man Singh Hospital, Jaipur, Rajasthan, India Resident, Department of Nephrology, Sawai Man Singh Hospital, Jaipur, Rajasthan, India
article info Article history: Received 2 April 2015 Accepted 21 April 2015 Available online 7 May 2015
We present a case of a 43 year old male with history of spontaneous deep vein thrombosis of right lower limb 8 years back. Further evaluation was suggestive of thrombosis of bilateral common iliac, internal iliac, femoral, renal veins extending up to the inferior venae cava. His serum creatinine level was 1.5 mg/dl at that time. Patient was managed conservatively with heparin followed by warfarin based on the INR values. Further workup for cause of hypercoagulability showed a protein C and S deficiency. Patients continued his
Fig. 1 e CT scan of the abdomen.
* Corresponding author. E-mail address: [email protected] (K. Gandhi). http://dx.doi.org/10.1016/j.ijt.2015.04.004 2212-0017/Copyright © 2015, Indian Society of Organ Transplantation. All rights reserved.
44
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n 9 ( 2 0 1 5 ) 4 3 e4 5
medications for one year after which he was lost to follow up. Presently, he was admitted with symptoms of nausea and generalized swelling. His serum creatinine was 12 mg/dl. Ultrasonography revealed bilateral small sized kidneys with multiple simple cortical cysts. After explaining the need of renal replacement therapy, the patient and his family are willing for live-related transplantation with brother a healthy donor. The CT scan is showed in Fig. 1.
1. What are the findings in the imaging study? 2. What are the options for venous anastomosis in this patient? 3. How to manage these patients with inherited thrombophilias post-renal transplantation (Answers to this quiz will be published in the next issue of Indian Journal of Transplantation.)
Answer to the Images in Transplantation Gandhi K, Prasad D, Agrawal D, Beniwal P, Malhotra V. Images in Transplantation. Indian J Transplant. 2014; 8(4):124.
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n 9 ( 2 0 1 5 ) 4 3 e4 5
45
a) What are the imaging findings? X-ray shows a migrated Double J stent with a distal end displaced in the pelvis probably through a gap in the ureter leading to a urine leak. The finding is confirmed on the CT scan. b) What is the next step for diagnosis? Ascitic fluid creatinine equalling urine creatinine is indicative of the diagnosis. A renal scan with DTPA or MAG with diuretic renogram demonstrating extravasation is the most sensitive method to differentiate a urine leak from other fluid collections. c) How to manage this patient? Surgical correction with primary reconstruction or a new ureteral re-implantation should be performed at the earliest. d) What is the differential diagnosis in a patient with early allograft dysfunction? The differential diagnosis of early allograft dysfunction can be divided in to following heading. i. Pre-renal e Severe hypovolaemia/hypotension, Vascular complications such as Renal vessel thrombosis and Renal artery stenosis ii. Intra-renal e Ischaemic ATN, Hyperacute rejection, Accelerated acute or acute rejection, Acute cyclosporine/tacrolimus nephrotoxicity (±ATN), Thrombotic microangiopathy, Recurrence of primary glomerular disease (particularly FSGS) iii. Post-renal e Catheter obstruction, Urinary tract obstruction- Intrinsic (blood clots, poor reimplantation, ureteral slough), Extrinsic (ureteral kinking), Peri-nephric fluid collection (lymphocele, haematoma, urine leak)
Refers to DOI: http://dx.doi.org/10.1016/j.ijt.2015.01.002
Conflicts of interest All authors have none to declare.