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Persistent clot anuria complicating renal transplant biopsy
PERSISTENT CLOT ANURIA COMPLICATING RENAL TRANSPLANT BIOPSY SUHAYL S. KALASH,
M.D.
WAEL F. MUAKKASSA, EDWARD
M.D.
W. CAMPBELL,
JR., M.D.
JOHN D. YOUNG, JR., M.D. FUAD J, DAGHER,
M.D.
From the Department of Surgery, Division of Urology and Transplantation Section, University of Maryland Hospital, School of Medicine, Baltimore, Maryland
ABSTRACT-Serious morbidity from renal transplant biopsy is reported to be infrequent. However, 4 of 43 patients who had renal transplant biopsy between July, 1981, and March, 1984, experienced anuria from upper urinary tract obstruction by blood clots. Although these clots usually dissolve, 3 patients (7%) experienced persistent clot anuria and deterioration of renal function. Awareness of this complication is important. Retrograde pyelography and ureteral catheterization are preferred primarily for diagnosis and treatment. Percutaneous techniques are reserved for those cases in which the ureter cannot be catheterized cystoscopically.
Percutaneous needle biopsy of the kidney is commonly performed in transplant patients to differentiate rejection from other causes of impaired renal function. Several modifications of the technique of kidney biopsy have been advocated in an effort to decrease the complication rate, including radiographic,‘%2 fluoroscopic,3 and sonographic localization and guidance.4x5 Renal transplant biopsies are associated with microscopic and gross hematuria in most instances but rarely with serious sequelae.5’0 In contradistinction, the authors report on 4 patients in whom immediate and delayed bleeding following renal transplant biopsy and subsequent renal pelvic clot formation developed. Anuria persisted in 3 patients and resolved in 1. Diagnosis and management of these patients is presented. Case Reports Case 1 A twenty-five-year-old man underwent a living related renal transplant and had a rejection
UROLOGY
/
JUNE 1985
/
VOLUME XXV, NUMBER 6
episode six weeks after surgery. The diagnosis was confirmed by a kidney biopsy, Immediate gross hematuria and progressive decrease in urine output developed, culminating in anuria one day later. A sonogram revealed evidence of moderate hydronephrosis. Anuria persisted for thirty-six hours and serum creatinine rose to 3 mg/lOO ml. The ureter was easily intubated cystoscopically with a 5-F whistle-tip catheter, and a hydronephrotic drip with hemolyzed blood was obtained. A ureteropyelogram revealed an irregular filling defect at the ureteropelvic junction (UPJ) and dilation of the pyelocalyceal system (Fig. 1A). A repeat ureteropyelogram, after irrigation of the pyelocalyceal system and irrigation of blood clots, was normal (Fig. 1B). Urine output ensued immediately, Ureteral intubation was maintained for five days with a return of serum creatinine to normal. A repeat ureteropyelogram at this time was normal, and the catheter was removed.
591
FIGURE 1. (A) Retrograde pyelogram shows dilated pyelocalyceal system withfilling defect obstructing UP]. (B) Ureteropyelogram reveals delicate ureteropyelocalyceal system and resolution of UP] filling defect.
Case 2 This patient had immediate gross hematuria which resolved five days after kidney biopsy. She was discharged to be readmitted four days later with recurrent hematuria and hypotension. Serum creatinine was 2.2 mg/lOO ml. She became anuric one day later. A sonogram revealed hydronephrosis. Anuria persisted for two days, and serum creatinine rose to 3.9 mgl 100 ml. The ureter was easily intubated cystoscopically with a 5-F whistle-tip catheter, and hemolyzed blood was obtained under pressure.
FIGURE
2.
struction.
592
A ureteropyelogram revealed multiple filling defects obstructing the ureteropelvic junction (Fig. 2A). Repeat ureteropyelogram five days later revealed resolution of the filling defects and obstruction (Fig. 2B). Case 3 A forty-two-year-old man underwent a cadaver transplant which was complicated by acute tubular necrosis. The patient was discharged five weeks later with a creatinine of 3.4 mg/100 ml only to be readmitted with elevation
(A) Retrograde pyelogram shows dilation of pyelocalyceal system; arrowheads (B) Ureteropyelogram shows resolution of filling defects and obstruction.
UROLOGY
I
JUNE 1985
I
indicate UP] ob-
VOLUME
XXV, NUMBER
6
bulb ureteropyelogram showed evidence of filling defects in a dilated pyelocalyceal system (Fig. 4A). An attempt at cannulating the ureter failed. An antigrade pyelogram utilizing a no. 22 Chiba needle demonstrated multiple filling defects obstructing the renal pelvis (Fig. 4B). The Chiba needle was used as a guide to place a percutaneous nephrostomy. Irrigation of the system yielded 10 cc of old blood clot, and a ureteral diuresis ensued. Urine output was normal thereafter, and an antegrade pyelogram five days later revealed a blood clot at the UPJ without obstruction. The percutaneous tube was clamped, and the patient voided 3.5 L daily. An antegrade study (Fig. 4C) and serum creatinine were normal one week later, and the percutaneous nephrostomy tube was removed. Case 4
A twenty-one-year-old man underwent cadaver renal transplant and was maintained on cyclosporin. Serum creatinine increased to 8 mg/lOO ml with questionable rejection. He underwent kidney biopsy and gross hematuria immediately developed which resolved in twentyfour hours. Antirejection treatment was initiated, and urinary output increased to 3 L per day while serum creatinine dropped to 6.5 mg/lOO ml. Four days after biopsy he was readmitted with anuria of twelve hours’ duration and a serum creatinine of 8.4 mg/lOO ml. On admission the patient voided 100 ml of grossly bloody urine, and his urine output increased to 1 L over the next twelve hours. The patient has subsequently done well. Comment Sonogram: arrows show separation pyelocalyceal echoes (hydronephrosis). FIGURE
3.
of
of serum creatinine to 5 mg/lOO ml and a questionable rejection episode which was documented by a kidney biopsy. This was complicated by gross hematuria and passage of blood clots which persisted five days after biopsy. The patient responded to antirejection treatment with a daily urinary output of 2.2 L and a drop in serum creatinine to 3.1 mg/lOO ml. A sharp decrease in urine output occurred which was followed by persistent anuria for forty hours. A sonogram revealed hydronephrosis (Fig. 3). A
UROLOGY
/ JUNE 1985
/ VOLUME
XXV, NUMBER 6
Kidney biopsies are frequently performed in the course of evaluating renal transplant patients with impaired renal function. Persistent anuria secondary to complete upper tract obstruction by blood clots after transplant renal biopsy has not been reported. Usually clots resolve spontaneously as evidenced by the transient anuria experienced by the fourth patient presented. However, persistent anuria occurred in 3 of 43 renal biopsies (7%) performed between July, 1981, and March, 1984. Decrease in urinary output associated with acute rejection may prevent clot dissolution. Early diagnosis of this complication is important. The excretory urogram is rarely useful in cases of complete obstruction or poor kidney function and isotope
593
FIGURES. (A) Bulb tip retrograde pyelogram reveals contrast material fills dilated pyelocalyceal system partially with multiplefilling defects. (B) Antegrade pyelograph reveals dilated pyelocalyceal system; arrows indicate UP] obstruction by filling defects. (C) Antegrade pyelogram shows resolution of filling defects and obstruction.
renography often does not help in distinguishing obstruction from other processes affecting the kidney. Ultrasound is a reliable noninvasive test for detecting hydronephrosis. Direct contrast study of the ureter by retrograde catheterization may confirm the diagnosis and localize the site of obstruction, although technically impossible in some patients; fine-needle antegrade pyelography provides an alternative in these situations. Several authors have demonstrated the safety of needle antigrade pyelography in renal transplants and recommend its use as a primary approach to study an obstructed ureter, citing the possible technical difficulty of retrograde catheterization and the inferior radiographic details.7’8 However, Goldstein, Cho, and Ols-
594
son0 reported that the mainstays of the diagnostic armamentarium in ureteral complication after renal transplantation were endoscopy and retrograde ureterography, the latter being successful in all attempted ureters. Others have recommended the use of retrograde pyelography and if unsuccessful needle antegrade pyelography. lo-l2 Retrograde pyelography and ureteral intubation were easily performed, and were diagnostic and therapeutic in the first 2 cases presented. Retrograde intubation of the ureter was not possible in the third case, while retrograde pyelography with a bulb tip catheter was diagnostic. The authors recommend retrograde pyelography and intubation of the ureter be attempted initially in patients with renal
UROLOGY
/ JUNE1985 / VOLUMEXXV,NUMBER6
transplants and ureteral obstruction. This opinion is fostered by our clinical experience including the first 3 cases presented. The management of clot anuria secondary to a kidney biopsy in transplant patients has been nonsurgical in the authors’ experience. If retrograde pyelography is successful in the diagnosis of obstruction secondary to clot, intubation of the renal pelvis is therapeutic, as demonstrated in the first 2 patients. However, if retrograde intubation of the renal pelvis is unsuccessful then percutaneous nephrostomy drainage is therapeutic, as demonstrated in Case 3. This procedure is well tolerated and highly successful in the immunosuppressed transplant patient.r3,14 Persistent clot anuria secondary to percutaneous kidney biopsy is not infrequent (7 %) and is a potential problem in renal transplants. The diagnosis of this entity is suggested by the clinical events and confirmed by sonography and retrograde pyelography. Antegrade pyelography is a safe alternative if the retrograde study is not successful. The management of clot anuria in immunosuppressed patients is nonsurgical. Initial attempt at retrograde catheterization is preferred by the authors. If this is unsuccessful, percutaneous nephrostomy drainage provides an alternative to open surgical drainage.
UROLl)GY
/
JUNE 1985
/
VOLUME
XXV, NUMBER
6
University of Maryland Hospital 22 S. Greene Street Baltimore, Maryland 21201 (DR. KALASH) References 1. Iversen P, and Brun C: Aspiration biopsy of the kidney, Am J Med 11: 324 (1951). 2. Muehreke G, Kark RM, and Pirani CL: Technique of percutaneous renal biopsy in the prone position, J Urol 95: 618 (1966). 3. Fernstrom I, and Lindblom L: Selective renal biopsy using roentgen television control, ibid 88: 709 (1962). 4. Hertz JHD, Lang E, and Klingerman El Ultrasonic localization for renal bionsv. RadioloPv 115: 167 (1975). 5. Spigos D, Capek U, and Jozasson 0: Percutaneous biopsy of renal transplants using ultra sonographic guidance, J Urol 117: 699 (1977). 6. Murphy GP: Percutaneous needle biopsy of human renal allotransplants, ibid 107: 193 (1972). 7. Turner AG, Howlett KA, Eban R, and Williams, GB: The role of antegrade pyelography in the transplant kidney, ibid 123: 812 (1980). 8. Lieberman RP, Crummy AB, Glass NR, and Belzer FO: Fine needle antegrade pyelography in the renal transplant, ibid 126: 155 (1981). 9. Goldstein I, Cho SI, and Olsson CA: Nephrostomy drainage for renal transplant complications, ibid 126: 159 (1981). 10. RCS: Editorial comment, ibid 126: 158 (1981). 11. Novick A: Editorial comment, ibid 123: 812 (1980). 12. Askari A, Novick A, Brawn W, and Steinmaller D: Late ureteral obstruction and hematuria from de novo angiosarcoma in a renal transplant patient, ibid 124: 717 (1980). 13. Barbaric AL, and Thomson KR: Percutaneous nephropyelostomy in the management of obstructed renal transplants, Diae Radio1 126: 639 (1978). 1;. Schiff M Jr, Rosenfield AT, and McGuire EJ: The use of percutaneous antegrade renal perfusion in kidney transplant recipients, J Urol 122: 246 (1979).
595
M.D.
WAEL F. MUAKKASSA, EDWARD
M.D.
W. CAMPBELL,
JR., M.D.
JOHN D. YOUNG, JR., M.D. FUAD J, DAGHER,
M.D.
From the Department of Surgery, Division of Urology and Transplantation Section, University of Maryland Hospital, School of Medicine, Baltimore, Maryland
ABSTRACT-Serious morbidity from renal transplant biopsy is reported to be infrequent. However, 4 of 43 patients who had renal transplant biopsy between July, 1981, and March, 1984, experienced anuria from upper urinary tract obstruction by blood clots. Although these clots usually dissolve, 3 patients (7%) experienced persistent clot anuria and deterioration of renal function. Awareness of this complication is important. Retrograde pyelography and ureteral catheterization are preferred primarily for diagnosis and treatment. Percutaneous techniques are reserved for those cases in which the ureter cannot be catheterized cystoscopically.
Percutaneous needle biopsy of the kidney is commonly performed in transplant patients to differentiate rejection from other causes of impaired renal function. Several modifications of the technique of kidney biopsy have been advocated in an effort to decrease the complication rate, including radiographic,‘%2 fluoroscopic,3 and sonographic localization and guidance.4x5 Renal transplant biopsies are associated with microscopic and gross hematuria in most instances but rarely with serious sequelae.5’0 In contradistinction, the authors report on 4 patients in whom immediate and delayed bleeding following renal transplant biopsy and subsequent renal pelvic clot formation developed. Anuria persisted in 3 patients and resolved in 1. Diagnosis and management of these patients is presented. Case Reports Case 1 A twenty-five-year-old man underwent a living related renal transplant and had a rejection
UROLOGY
/
JUNE 1985
/
VOLUME XXV, NUMBER 6
episode six weeks after surgery. The diagnosis was confirmed by a kidney biopsy, Immediate gross hematuria and progressive decrease in urine output developed, culminating in anuria one day later. A sonogram revealed evidence of moderate hydronephrosis. Anuria persisted for thirty-six hours and serum creatinine rose to 3 mg/lOO ml. The ureter was easily intubated cystoscopically with a 5-F whistle-tip catheter, and a hydronephrotic drip with hemolyzed blood was obtained. A ureteropyelogram revealed an irregular filling defect at the ureteropelvic junction (UPJ) and dilation of the pyelocalyceal system (Fig. 1A). A repeat ureteropyelogram, after irrigation of the pyelocalyceal system and irrigation of blood clots, was normal (Fig. 1B). Urine output ensued immediately, Ureteral intubation was maintained for five days with a return of serum creatinine to normal. A repeat ureteropyelogram at this time was normal, and the catheter was removed.
591
FIGURE 1. (A) Retrograde pyelogram shows dilated pyelocalyceal system withfilling defect obstructing UP]. (B) Ureteropyelogram reveals delicate ureteropyelocalyceal system and resolution of UP] filling defect.
Case 2 This patient had immediate gross hematuria which resolved five days after kidney biopsy. She was discharged to be readmitted four days later with recurrent hematuria and hypotension. Serum creatinine was 2.2 mg/lOO ml. She became anuric one day later. A sonogram revealed hydronephrosis. Anuria persisted for two days, and serum creatinine rose to 3.9 mgl 100 ml. The ureter was easily intubated cystoscopically with a 5-F whistle-tip catheter, and hemolyzed blood was obtained under pressure.
FIGURE
2.
struction.
592
A ureteropyelogram revealed multiple filling defects obstructing the ureteropelvic junction (Fig. 2A). Repeat ureteropyelogram five days later revealed resolution of the filling defects and obstruction (Fig. 2B). Case 3 A forty-two-year-old man underwent a cadaver transplant which was complicated by acute tubular necrosis. The patient was discharged five weeks later with a creatinine of 3.4 mg/100 ml only to be readmitted with elevation
(A) Retrograde pyelogram shows dilation of pyelocalyceal system; arrowheads (B) Ureteropyelogram shows resolution of filling defects and obstruction.
UROLOGY
I
JUNE 1985
I
indicate UP] ob-
VOLUME
XXV, NUMBER
6
bulb ureteropyelogram showed evidence of filling defects in a dilated pyelocalyceal system (Fig. 4A). An attempt at cannulating the ureter failed. An antigrade pyelogram utilizing a no. 22 Chiba needle demonstrated multiple filling defects obstructing the renal pelvis (Fig. 4B). The Chiba needle was used as a guide to place a percutaneous nephrostomy. Irrigation of the system yielded 10 cc of old blood clot, and a ureteral diuresis ensued. Urine output was normal thereafter, and an antegrade pyelogram five days later revealed a blood clot at the UPJ without obstruction. The percutaneous tube was clamped, and the patient voided 3.5 L daily. An antegrade study (Fig. 4C) and serum creatinine were normal one week later, and the percutaneous nephrostomy tube was removed. Case 4
A twenty-one-year-old man underwent cadaver renal transplant and was maintained on cyclosporin. Serum creatinine increased to 8 mg/lOO ml with questionable rejection. He underwent kidney biopsy and gross hematuria immediately developed which resolved in twentyfour hours. Antirejection treatment was initiated, and urinary output increased to 3 L per day while serum creatinine dropped to 6.5 mg/lOO ml. Four days after biopsy he was readmitted with anuria of twelve hours’ duration and a serum creatinine of 8.4 mg/lOO ml. On admission the patient voided 100 ml of grossly bloody urine, and his urine output increased to 1 L over the next twelve hours. The patient has subsequently done well. Comment Sonogram: arrows show separation pyelocalyceal echoes (hydronephrosis). FIGURE
3.
of
of serum creatinine to 5 mg/lOO ml and a questionable rejection episode which was documented by a kidney biopsy. This was complicated by gross hematuria and passage of blood clots which persisted five days after biopsy. The patient responded to antirejection treatment with a daily urinary output of 2.2 L and a drop in serum creatinine to 3.1 mg/lOO ml. A sharp decrease in urine output occurred which was followed by persistent anuria for forty hours. A sonogram revealed hydronephrosis (Fig. 3). A
UROLOGY
/ JUNE 1985
/ VOLUME
XXV, NUMBER 6
Kidney biopsies are frequently performed in the course of evaluating renal transplant patients with impaired renal function. Persistent anuria secondary to complete upper tract obstruction by blood clots after transplant renal biopsy has not been reported. Usually clots resolve spontaneously as evidenced by the transient anuria experienced by the fourth patient presented. However, persistent anuria occurred in 3 of 43 renal biopsies (7%) performed between July, 1981, and March, 1984. Decrease in urinary output associated with acute rejection may prevent clot dissolution. Early diagnosis of this complication is important. The excretory urogram is rarely useful in cases of complete obstruction or poor kidney function and isotope
593
FIGURES. (A) Bulb tip retrograde pyelogram reveals contrast material fills dilated pyelocalyceal system partially with multiplefilling defects. (B) Antegrade pyelograph reveals dilated pyelocalyceal system; arrows indicate UP] obstruction by filling defects. (C) Antegrade pyelogram shows resolution of filling defects and obstruction.
renography often does not help in distinguishing obstruction from other processes affecting the kidney. Ultrasound is a reliable noninvasive test for detecting hydronephrosis. Direct contrast study of the ureter by retrograde catheterization may confirm the diagnosis and localize the site of obstruction, although technically impossible in some patients; fine-needle antegrade pyelography provides an alternative in these situations. Several authors have demonstrated the safety of needle antigrade pyelography in renal transplants and recommend its use as a primary approach to study an obstructed ureter, citing the possible technical difficulty of retrograde catheterization and the inferior radiographic details.7’8 However, Goldstein, Cho, and Ols-
594
son0 reported that the mainstays of the diagnostic armamentarium in ureteral complication after renal transplantation were endoscopy and retrograde ureterography, the latter being successful in all attempted ureters. Others have recommended the use of retrograde pyelography and if unsuccessful needle antegrade pyelography. lo-l2 Retrograde pyelography and ureteral intubation were easily performed, and were diagnostic and therapeutic in the first 2 cases presented. Retrograde intubation of the ureter was not possible in the third case, while retrograde pyelography with a bulb tip catheter was diagnostic. The authors recommend retrograde pyelography and intubation of the ureter be attempted initially in patients with renal
UROLOGY
/ JUNE1985 / VOLUMEXXV,NUMBER6
transplants and ureteral obstruction. This opinion is fostered by our clinical experience including the first 3 cases presented. The management of clot anuria secondary to a kidney biopsy in transplant patients has been nonsurgical in the authors’ experience. If retrograde pyelography is successful in the diagnosis of obstruction secondary to clot, intubation of the renal pelvis is therapeutic, as demonstrated in the first 2 patients. However, if retrograde intubation of the renal pelvis is unsuccessful then percutaneous nephrostomy drainage is therapeutic, as demonstrated in Case 3. This procedure is well tolerated and highly successful in the immunosuppressed transplant patient.r3,14 Persistent clot anuria secondary to percutaneous kidney biopsy is not infrequent (7 %) and is a potential problem in renal transplants. The diagnosis of this entity is suggested by the clinical events and confirmed by sonography and retrograde pyelography. Antegrade pyelography is a safe alternative if the retrograde study is not successful. The management of clot anuria in immunosuppressed patients is nonsurgical. Initial attempt at retrograde catheterization is preferred by the authors. If this is unsuccessful, percutaneous nephrostomy drainage provides an alternative to open surgical drainage.
UROLl)GY
/
JUNE 1985
/
VOLUME
XXV, NUMBER
6
University of Maryland Hospital 22 S. Greene Street Baltimore, Maryland 21201 (DR. KALASH) References 1. Iversen P, and Brun C: Aspiration biopsy of the kidney, Am J Med 11: 324 (1951). 2. Muehreke G, Kark RM, and Pirani CL: Technique of percutaneous renal biopsy in the prone position, J Urol 95: 618 (1966). 3. Fernstrom I, and Lindblom L: Selective renal biopsy using roentgen television control, ibid 88: 709 (1962). 4. Hertz JHD, Lang E, and Klingerman El Ultrasonic localization for renal bionsv. RadioloPv 115: 167 (1975). 5. Spigos D, Capek U, and Jozasson 0: Percutaneous biopsy of renal transplants using ultra sonographic guidance, J Urol 117: 699 (1977). 6. Murphy GP: Percutaneous needle biopsy of human renal allotransplants, ibid 107: 193 (1972). 7. Turner AG, Howlett KA, Eban R, and Williams, GB: The role of antegrade pyelography in the transplant kidney, ibid 123: 812 (1980). 8. Lieberman RP, Crummy AB, Glass NR, and Belzer FO: Fine needle antegrade pyelography in the renal transplant, ibid 126: 155 (1981). 9. Goldstein I, Cho SI, and Olsson CA: Nephrostomy drainage for renal transplant complications, ibid 126: 159 (1981). 10. RCS: Editorial comment, ibid 126: 158 (1981). 11. Novick A: Editorial comment, ibid 123: 812 (1980). 12. Askari A, Novick A, Brawn W, and Steinmaller D: Late ureteral obstruction and hematuria from de novo angiosarcoma in a renal transplant patient, ibid 124: 717 (1980). 13. Barbaric AL, and Thomson KR: Percutaneous nephropyelostomy in the management of obstructed renal transplants, Diae Radio1 126: 639 (1978). 1;. Schiff M Jr, Rosenfield AT, and McGuire EJ: The use of percutaneous antegrade renal perfusion in kidney transplant recipients, J Urol 122: 246 (1979).
595