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Late-onset renal vein thrombosis in renal allograft
Indian Journal of Transplantation 10 (2016) 40–42
Contents lists available at ScienceDirect
Indian Journal of Transplantation journal homepage: www.elsevier.com/locate/ijt
Case Report
Late-onset renal vein thrombosis in renal allograft Vaidehi K. Pandya *, Harsh C. Sutariya Department of Radio Diagnosis and Imaging, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) & Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 March 2016 Accepted 7 May 2016
Renal vein thrombosis (RVT), though very rare, is one of the serious and fatal vascular complications of renal transplantation, which may lead to graft loss. The causative factor may be unknown in majority of cases. However, a variety of causes have been identified. Here, we report a case of a 46-year-old postrenal transplant male patient, who presented with acute onset of right flank pain, tenderness, hematuria, and reduced urine output after 40 months of transplantation. Renal vein thrombosis distal to the level of hilum of transplanted renal vein was found on color Doppler study. The patient was treated with standard anticoagulant drug therapy and eventually he had to undergo graft nephrectomy. Unfortunately, on second postoperative day, the patient expired due to cardiac arrest. Radiology, in particular color Doppler study, plays an important role as a noninvasive investigation to diagnose RVT at the earliest and to guide prompt management. ß 2016
Keywords: Transplantation Allograft Renal vein thrombosis
1. Introduction Renal vein thrombosis is a rare complication that may prove fatal after renal transplantation, often encountering graft loss.1,2 Depending on the time of occurrence, it is briefly divided into early- and late-onset renal vein thrombosis. Early-onset RVT occurs within the first 2 weeks postoperatively with the reported incidence rate of 0.4–6%,3 whereas late-onset RVT, being more uncommon, occurs later than 2 weeks postoperatively with incidence rate of 0.5–4%.4 RVT typically presents as iliac fossa pain, tenderness over graft site, reduced urine output or anuria and hematuria, and sometimes fever.5
2. Case report Our patient was a 46-year-old hypertensive, hepatitis C positive male with single, right kidney diagnosed to have end-stage renal disease due to hypertensive nephropathy three years ago. He underwent cadaveric renal transplantation in Right Iliac Fossa (RIF) at our institute in 2011. The postoperative course was uneventful. With standard immunosuppression he maintained basic serum
* Corresponding author at: Department of Radio Diagnosis and Imaging, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) & Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat, India. Tel.: +91 79 22687046; fax: +91 79 22685454; mobile: +91 9825605025. E-mail address: [email protected] (V.K. Pandya). http://dx.doi.org/10.1016/j.ijt.2016.05.002 2212-0017/ß 2016
creatinine of 1.8 mg/dl on follow-up with normal color Doppler studies periodically. In December 2014, he presented with convulsions with no abnormality on CT Scan Brain. Serum creatinine was 5.2 mg/dl and he received maintenance hemodialysis 4–5 times and was managed conservatively. In April 2015, he presented with sudden onset of pain in RIF, tenderness, hematuria, and reduced urine output. On clinical examination, tenderness over graft site was present and BP was 140/80 mmHg. The rest of the findings were unremarkable. Urine output was 250 cc. On lab investigations, Hb was 7.0 mg/dl, total leukocyte count was 130 103 and serum creatinine was 7.87 mg/dl. On Doppler study, graft was swollen, showed hypoechoic parenchyma with preserved cortico-medullary differentiation and about 140 cc septated collection at lower pole and soft tissue density material within the renal vein at the level of hilum (Fig. 1). Transplanted renal vein at and distal to the level of anastomosis showed no evidence of color filling within it even on power Doppler study (Fig. 2). Transplanted renal artery at and distal to the level of hilum showed reversed diastolic flow on spectral wave tracing. These two findings were in favor of diagnosis of renal vein thrombosis. The patient was treated with standard anticoagulants and maintenance hemodialysis. Eventually, he had to undergo graft nephrectomy, which was uneventful. But unfortunately, we lost the patient due to cardiac arrest on the 2nd postoperative day. 3. Discussion RVT can prove to be a lethal condition post renal transplantation, which can lead to graft loss. Timely diagnosis and prompt
V.K. Pandya, H.C. Sutariya / Indian Journal of Transplantation 10 (2016) 40–42
41
Fig. 1. (a) Gray scale ultrasound image showing septated anechoic collection at lower pole of graft. (b) Swollen renal allograft showing soft tissue material within the renal vein at the level of hilum (+) with no evidence of color flow within it.
treatment can prevent graft loss and associated morbidities. There is increased incidence of venous thromboembolism in end-stage renal disease.6 Various risk factors are identified, which can be related to recipients, donor, operative technique, or immunosuppression. Young age, membranous nephropathy, history of peritoneal dialysis, and hypercoagulable state are recipients factors,7 while female sex and old age are considered as donor factors. Prolonged ischemia time, multiple graft vessels anastomosis,8 and technical errors by vascular clamping are considered in operative factors. Genetic factors can also be considered where deficiencies of antithrombin, and protein C and S, are seen in <1% patients.9 Kinking or compression of renal vein by lymphocele or other fluid collection
also can lead to RVT. Our patient had approximately 140 cc collection at lower pole of graft. On color Doppler study of renal allografts with RVT, reverse diastolic flow is seen, which is a sign of high vascular resistance, which indicates graft dysfunction correlating with increased risk of graft loss. Various conditions responsible for this change on color Doppler study are acute tubular necrosis, rejection, RVT, hematoma, and low cardiac output. RVT is more commonly seen in early posttransplant period. In later stage, RVT is rare, has poorer prognosis, and is associated with 80% graft loss.10 Early diagnosis of RVT is of paramount importance in treatment. Anticoagulant therapy is important in treatment. Percutaneous mechanical thrombectomy and localized catheter
Fig. 2. (a) Gray scale ultrasound image showing swollen renal allograft. (b) Power Doppler study showing normal color flow in external iliac vessels and no evidence of color flow in renal vein distal to the level of anastomosis.
42
V.K. Pandya, H.C. Sutariya / Indian Journal of Transplantation 10 (2016) 40–42
directed thrombolysis are also used to treat RVT and reverts the graft function.11 Radiology plays a pivotal role in such cases where early diagnosis can salvage the graft. 4. Conclusion RVT is rarer in later stages but carries poorer prognosis. Early diagnosis in such cases is an important step to prevent graft loss, which can be achieved by noninvasive color Doppler study and prompt treatment can be guided. Conflicts of interest The authors have none to declare. Financial support Nil. Acknowledgements The authors extend their heartily gratitude to Dr. Vivek Kute, Professor in Nephrology, IKDRC & ITS and Ms. Jyotsana Suthar for their valuable guidance.
References 1. Szabo C, Farago M, Horvath I, Lohinai Z, Kovach AG. Hemorrhagic hypotension impairs endothelium-dependent relaxations in the renal artery of the cat. Circ Shock. 1992;36(3):238–241. PMID: 1611708. 2. Pillot P, Bardonnaud N, Lillaz J, et al. Risk factors for surgical complications after renal transplantation and impact on patient and graft survival. Transplant Proc. 2012;44(9):2803–2808. PMID: 23146528 3. Ripert T, Menard J, Schoepen Y, Nguyen P, Rieu P, Staerman F. Preventing graft thrombosis after renal transplantation: a multicenter survey of clinical practice. Transplant Proc. 2009;41(10):4193–4196. PMID: 20005367 4. Hogan J, Rosenthal S, Yarlagadda S, et al. Late-onset renal vein thrombosis: a case report and review of the literature. Int J Surg Case Rep. 2015;6:73–76. 5. Ponticelli C, Moia M, Montagnino G. Renal allograft thrombosis. Nephrol Dial Transplant. 2009;24(May (5)):1388–1393. PMID: 19182239 6. Poli D, Zanazzi M, Antonucci E, et al. Renal transplant recipients are at high risk for both symptomatic and asymptomatic deep vein thrombosis. J Thromb Haemost. 2006;4(5):988–992. 7. Khan SA, Al-Huneini MN, Al-Mula Abed YW., Mohammed SM, Al-Riyami DA. Acute allograft renal vein thrombosis: a case report. Oman Med J. 2014;29(5). 8. Rigotti P, Flechner SM, Van Buren CT, Payne WT, Kahan BD. Increased incidence of renal allograft thrombosis under cyclosporine immunosuppression. Int Surg. 1986;71(January–March (1)):38–41. PMID: 3522469. 9. Tait RC, Walker ID, Reitsma PH, et al. Prevalence of protein C deficiency in the healthy population. Thromb Haemost. 1995;73(January (1)):87–93. PMID: 7740502. 10. Lockhart ME, Wells CG, Morgan DE, Fineberg NS, Robbin ML. Reversed diastolic flow in the renal transplant: perioperative implications versus transplants older than 1 month. AJR. 2008;190:650–655PMID: 18287435 11. Melamed ML, Kim HS, Jaar BG, et al. Combined percutaneous mechanical and chemical thrombectomy for renal vein thrombosis in kidney transplant recipients. Am J Transplant. 2005;5:621–626PMID: 15707419
Contents lists available at ScienceDirect
Indian Journal of Transplantation journal homepage: www.elsevier.com/locate/ijt
Case Report
Late-onset renal vein thrombosis in renal allograft Vaidehi K. Pandya *, Harsh C. Sutariya Department of Radio Diagnosis and Imaging, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) & Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 March 2016 Accepted 7 May 2016
Renal vein thrombosis (RVT), though very rare, is one of the serious and fatal vascular complications of renal transplantation, which may lead to graft loss. The causative factor may be unknown in majority of cases. However, a variety of causes have been identified. Here, we report a case of a 46-year-old postrenal transplant male patient, who presented with acute onset of right flank pain, tenderness, hematuria, and reduced urine output after 40 months of transplantation. Renal vein thrombosis distal to the level of hilum of transplanted renal vein was found on color Doppler study. The patient was treated with standard anticoagulant drug therapy and eventually he had to undergo graft nephrectomy. Unfortunately, on second postoperative day, the patient expired due to cardiac arrest. Radiology, in particular color Doppler study, plays an important role as a noninvasive investigation to diagnose RVT at the earliest and to guide prompt management. ß 2016
Keywords: Transplantation Allograft Renal vein thrombosis
1. Introduction Renal vein thrombosis is a rare complication that may prove fatal after renal transplantation, often encountering graft loss.1,2 Depending on the time of occurrence, it is briefly divided into early- and late-onset renal vein thrombosis. Early-onset RVT occurs within the first 2 weeks postoperatively with the reported incidence rate of 0.4–6%,3 whereas late-onset RVT, being more uncommon, occurs later than 2 weeks postoperatively with incidence rate of 0.5–4%.4 RVT typically presents as iliac fossa pain, tenderness over graft site, reduced urine output or anuria and hematuria, and sometimes fever.5
2. Case report Our patient was a 46-year-old hypertensive, hepatitis C positive male with single, right kidney diagnosed to have end-stage renal disease due to hypertensive nephropathy three years ago. He underwent cadaveric renal transplantation in Right Iliac Fossa (RIF) at our institute in 2011. The postoperative course was uneventful. With standard immunosuppression he maintained basic serum
* Corresponding author at: Department of Radio Diagnosis and Imaging, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases & Research Centre (IKDRC) & Dr. H.L. Trivedi Institute of Transplantation Sciences (ITS), Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat, India. Tel.: +91 79 22687046; fax: +91 79 22685454; mobile: +91 9825605025. E-mail address: [email protected] (V.K. Pandya). http://dx.doi.org/10.1016/j.ijt.2016.05.002 2212-0017/ß 2016
creatinine of 1.8 mg/dl on follow-up with normal color Doppler studies periodically. In December 2014, he presented with convulsions with no abnormality on CT Scan Brain. Serum creatinine was 5.2 mg/dl and he received maintenance hemodialysis 4–5 times and was managed conservatively. In April 2015, he presented with sudden onset of pain in RIF, tenderness, hematuria, and reduced urine output. On clinical examination, tenderness over graft site was present and BP was 140/80 mmHg. The rest of the findings were unremarkable. Urine output was 250 cc. On lab investigations, Hb was 7.0 mg/dl, total leukocyte count was 130 103 and serum creatinine was 7.87 mg/dl. On Doppler study, graft was swollen, showed hypoechoic parenchyma with preserved cortico-medullary differentiation and about 140 cc septated collection at lower pole and soft tissue density material within the renal vein at the level of hilum (Fig. 1). Transplanted renal vein at and distal to the level of anastomosis showed no evidence of color filling within it even on power Doppler study (Fig. 2). Transplanted renal artery at and distal to the level of hilum showed reversed diastolic flow on spectral wave tracing. These two findings were in favor of diagnosis of renal vein thrombosis. The patient was treated with standard anticoagulants and maintenance hemodialysis. Eventually, he had to undergo graft nephrectomy, which was uneventful. But unfortunately, we lost the patient due to cardiac arrest on the 2nd postoperative day. 3. Discussion RVT can prove to be a lethal condition post renal transplantation, which can lead to graft loss. Timely diagnosis and prompt
V.K. Pandya, H.C. Sutariya / Indian Journal of Transplantation 10 (2016) 40–42
41
Fig. 1. (a) Gray scale ultrasound image showing septated anechoic collection at lower pole of graft. (b) Swollen renal allograft showing soft tissue material within the renal vein at the level of hilum (+) with no evidence of color flow within it.
treatment can prevent graft loss and associated morbidities. There is increased incidence of venous thromboembolism in end-stage renal disease.6 Various risk factors are identified, which can be related to recipients, donor, operative technique, or immunosuppression. Young age, membranous nephropathy, history of peritoneal dialysis, and hypercoagulable state are recipients factors,7 while female sex and old age are considered as donor factors. Prolonged ischemia time, multiple graft vessels anastomosis,8 and technical errors by vascular clamping are considered in operative factors. Genetic factors can also be considered where deficiencies of antithrombin, and protein C and S, are seen in <1% patients.9 Kinking or compression of renal vein by lymphocele or other fluid collection
also can lead to RVT. Our patient had approximately 140 cc collection at lower pole of graft. On color Doppler study of renal allografts with RVT, reverse diastolic flow is seen, which is a sign of high vascular resistance, which indicates graft dysfunction correlating with increased risk of graft loss. Various conditions responsible for this change on color Doppler study are acute tubular necrosis, rejection, RVT, hematoma, and low cardiac output. RVT is more commonly seen in early posttransplant period. In later stage, RVT is rare, has poorer prognosis, and is associated with 80% graft loss.10 Early diagnosis of RVT is of paramount importance in treatment. Anticoagulant therapy is important in treatment. Percutaneous mechanical thrombectomy and localized catheter
Fig. 2. (a) Gray scale ultrasound image showing swollen renal allograft. (b) Power Doppler study showing normal color flow in external iliac vessels and no evidence of color flow in renal vein distal to the level of anastomosis.
42
V.K. Pandya, H.C. Sutariya / Indian Journal of Transplantation 10 (2016) 40–42
directed thrombolysis are also used to treat RVT and reverts the graft function.11 Radiology plays a pivotal role in such cases where early diagnosis can salvage the graft. 4. Conclusion RVT is rarer in later stages but carries poorer prognosis. Early diagnosis in such cases is an important step to prevent graft loss, which can be achieved by noninvasive color Doppler study and prompt treatment can be guided. Conflicts of interest The authors have none to declare. Financial support Nil. Acknowledgements The authors extend their heartily gratitude to Dr. Vivek Kute, Professor in Nephrology, IKDRC & ITS and Ms. Jyotsana Suthar for their valuable guidance.
References 1. Szabo C, Farago M, Horvath I, Lohinai Z, Kovach AG. Hemorrhagic hypotension impairs endothelium-dependent relaxations in the renal artery of the cat. Circ Shock. 1992;36(3):238–241. PMID: 1611708. 2. Pillot P, Bardonnaud N, Lillaz J, et al. Risk factors for surgical complications after renal transplantation and impact on patient and graft survival. Transplant Proc. 2012;44(9):2803–2808. PMID: 23146528 3. Ripert T, Menard J, Schoepen Y, Nguyen P, Rieu P, Staerman F. Preventing graft thrombosis after renal transplantation: a multicenter survey of clinical practice. Transplant Proc. 2009;41(10):4193–4196. PMID: 20005367 4. Hogan J, Rosenthal S, Yarlagadda S, et al. Late-onset renal vein thrombosis: a case report and review of the literature. Int J Surg Case Rep. 2015;6:73–76. 5. Ponticelli C, Moia M, Montagnino G. Renal allograft thrombosis. Nephrol Dial Transplant. 2009;24(May (5)):1388–1393. PMID: 19182239 6. Poli D, Zanazzi M, Antonucci E, et al. Renal transplant recipients are at high risk for both symptomatic and asymptomatic deep vein thrombosis. J Thromb Haemost. 2006;4(5):988–992. 7. Khan SA, Al-Huneini MN, Al-Mula Abed YW., Mohammed SM, Al-Riyami DA. Acute allograft renal vein thrombosis: a case report. Oman Med J. 2014;29(5). 8. Rigotti P, Flechner SM, Van Buren CT, Payne WT, Kahan BD. Increased incidence of renal allograft thrombosis under cyclosporine immunosuppression. Int Surg. 1986;71(January–March (1)):38–41. PMID: 3522469. 9. Tait RC, Walker ID, Reitsma PH, et al. Prevalence of protein C deficiency in the healthy population. Thromb Haemost. 1995;73(January (1)):87–93. PMID: 7740502. 10. Lockhart ME, Wells CG, Morgan DE, Fineberg NS, Robbin ML. Reversed diastolic flow in the renal transplant: perioperative implications versus transplants older than 1 month. AJR. 2008;190:650–655PMID: 18287435 11. Melamed ML, Kim HS, Jaar BG, et al. Combined percutaneous mechanical and chemical thrombectomy for renal vein thrombosis in kidney transplant recipients. Am J Transplant. 2005;5:621–626PMID: 15707419