5. Eight hours after living-related renal transplant in a 46-year-old man, urine output is slowing tailing to 20 ml per hour from 90 ml per hour until 6 hours. 500 ml IV fluid challenge consisting of normal saline does not improve urine output. He continues to have tachycardia of 110 per minute. The blood pressure is 108 systolic. The surgical drain is not draining anything for 3 hours, initially having drained 350 ml in 6 hours. US scan shows a small collection of about 30 ml around renal allograft. His haemoglobin is 78 gm/L, from a pre-operative level of 112, having already been transfused 2 units for an intra-op loss of 600 ml.
- How would you manage this case?
- Substantiate your answer
Dear All
Which modality is more sensitive or specific in detecting bleeding, USS, CT or MRI?
surgical site bleeding leads to graft loss if uncontrolled both by compromising blood flow of the transplanted kidney and prerenal because of hypoperfusion. as my colleagues stated, we need to correct hypovolemia and decompress the bleeding.
Back to the answer regarding modality:
ultrasound with doppler is the first choice and quickest and safest way.
CT with contrast is the gold standard but carries the risk of contrast nephropathy.
MR is time-consuming and lacks portability, and may carry risk of nephrogenic sclerosis
——–
summary of pros and cons are summarised in the attached table taken from (David E, Del Gaudio G, Drudi FM, Dolcetti V, Pacini P, Granata A, Pretagostini R, Garofalo M, Basile A, Bellini MI, D’Andrea V, Scaglione M, Barr R, Cantisani V. Contrast-Enhanced Ultrasound Compared with MRI and CT in the Evaluation of Post-Renal Transplant Complications. Tomography. 2022 Jun)
Well done for your choice.
The gold standard imaging for detecting post-operative bleeding is CT (1,2). The advantages include localizing the site of bleeding, as well as size of hematoma (3). A CT scan is very sensitive for detecting blood (4). Ultrasound is not able to pick small collections and misjudge their size, especially if present deep in pelvis or in obese patients (3,5). MRI, although has results similar to CT, is time-consuming.
References:
1) Gomez E, Horton K, Fishman EK, Johnson PT. CT of acute abdominopelvic hemorrhage: protocols, pearls, and pitfalls. Abdom Radiol (NY). 2022 Jan;47(1):475-484. doi: 10.1007/s00261-021-03336-w. Epub 2021 Nov 3. PMID: 34731281.
2) Tasu JP, Vesselle G, Herpe G, Ferrie JC, Chan P, Boucebci S, Velasco S. Postoperative abdominal bleeding. Diagn Interv Imaging. 2015 Jul-Aug;96(7-8):823-31. doi: 10.1016/j.diii.2015.03.013. Epub 2015 Jun 12. PMID: 26078019.
3) Lubner M, Menias C, Rucker C, Bhalla S, Peterson CM, Wang L, Gratz B. Blood in the belly: CT findings of hemoperitoneum. Radiographics. 2007 Jan-Feb;27(1):109-25. doi: 10.1148/rg.271065042. PMID: 17235002.
4) Sjekavica I, Novosel L, Rupčić M, Smiljanić R, Muršić M, Duspara V, Lušić M, Perkov D, Hrabak-Paar M, Zidanić M, Skender M. RADIOLOGICAL IMAGING IN RENAL TRANSPLANTATION. Acta Clin Croat. 2018 Dec;57(4):694-712. doi: 10.20471/acc.2018.57.04.12. PMID: 31168207; PMCID: PMC6544089.
5) David E, Del Gaudio G, Drudi FM, Dolcetti V, Pacini P, Granata A, Pretagostini R, Garofalo M, Basile A, Bellini MI, D’Andrea V, Scaglione M, Barr R, Cantisani V. Contrast Enhanced Ultrasound Compared with MRI and CT in the Evaluation of Post-Renal Transplant Complications. Tomography. 2022 Jun 28;8(4):1704-1715. doi: 10.3390/tomography8040143. PMID: 35894008; PMCID: PMC9326620.
Well done
_ we usually start with bed side US as it is mostly available , however it is less sensitive for detection of bleeding and may underestimate the heamatoma size or undetect retroperitoneal collection.
_ CTA is the most sensitive in determining size of collection and site of bleeding.
CT is better to detect collection site and amount but consistency of fluid collection may not be definitely evaluated
Although hematomas tend to dense on CT with variable T1 signal on MR, the consistency of the fluid collection cannot reliably be determined on imaging and generally requires imaging-guided fluid aspiration for laboratory analysis
Handbook of Kidney Transplantation Edited by Gabriel M. Danovitch, MD
Multidetector computed tomography (MDCT) is the first-line imaging test for the
diagnosis of abdominal bleeding, postoperative or otherwise.
MDCT is the most readily available and the least invasive test, which also provides
detailed vascular mapping.
The role of other types of imaging is limited.(1).
References:
1-J.-P.Tasu et al. Postoperative abdominal bleeding. Diagnostic and Interventional
Imaging. Volume 96, Issues 7–8, July–August 2015, Pages 823-831.
The patient has hemodynamically unstable with oliguria and drop of HB this is means that patient has bleeding
Management:
Resuscitation and blood transfusion with filtered RBCs
Rapid diagnosis with ultrasound but CTA is the gold standard not only can diagnosis hematoma but also the site of bleeding
Rapid surgical intervention
CT and MRI are excellent imaging methods to access post-operative renal transplant complications course; but both have drawbacks rendering them not convenient for all patients as gadolinium-based contrast can rarely cause nephrogenic systemic fibrosis, and iodine-based contrast can lead to contrast-induced nephropathy and CT also exposes the patients to ionizing radiation. Therefore contrast-enhanced ultrasound (CEUS) is presently considered an effective first-line imaging method for post-operative early and long-term follow-up in renal transplant recipients as it can detect vascular complications either micro or macro and lower the need for biopsies and provide adequate guidance for drainage procedures.
Reference
David, E.; Del Gaudio, G.; Drudi, F.M.; Dolcetti, V.; Pacini, P.; Granata, A.; Pretagostini, R.; Garofalo, M.; Basile, A.; Bellini, M.I.; D’Andrea, V.; Scaglione, M.; Barr, R.; Cantisani, V. Contrast Enhanced Ultrasound Compared with MRI and CT in the Evaluation of Post-Renal Transplant Complications. Tomography 2022, 8, 1704-1715.
The ultrasound may show active bleeding and expanding hematoma but small or minimal blood flow may not be able to detect. The CT is the best imaging investigation to show very small bleeds and hematoma at the exact site of the bleed. in light of MRI is also a good method but more expensive and may take longer to do
CT abdomen with contrast is gold standard for diagnosis a minimal collection of bleeding or fluid.
Postoperative hemorrhage was associated with a higher risk of graft loss or death.
Reference: Laureen D Hachem et al.
Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes: Transpl Int. 2017 May.
For post-operative bleeding or perigraft hematoma
USG with doppler is best, quick and bedside modality for diagnosis
Acute hematoma can appear heterogeneously hyperechoic
NCCT: acute hematomas are hyperattenuating collections (>30 HU)
NCCT should be done in case of doubt of ultrasound findings.
MRI: intrinsic increased signal intensity on precontrast T1-weighted images for acute hematoma
But, MRI is costly and time -consuming
Sugi MD, Joshi G, Maddu KK, Dahiya N, Menias CO. Imaging of renal transplant complications throughout the life of the allograft: comprehensive multimodality review. Radiographics. 2019 Sep;39(5):1327-55.
CT scan is more sensitive than the US for detecting bleeding; MRI is equal to CT but is costly.
Ct scan is the gold standard imaging. MRI has the same sensitivity , but is time-consuming. Us is not very sensitive or specific.
This patient refers to a case of renal transplant patient with a sudden drop in urine output with tachycardia and hypotension along with significant drop in hemoglobin – pointing towards hypovolemic shock…
Patient needs immediate blood transfusion to stabilize the bleeding…After stabilization of the vital signs it depends on the clinical condition of the patient whether to shift to the theatre for urgent re- exploration or imaging…electrolyte imbalance needs to be corrected and antiplatelets need to stopped
USG is not a sensitive modality for imaging…CT imaging with contrast will localize the bleed and it will delinate the hematoma for surgical evacuation. .The risk of contrast induced nephropathy is there with contrast
The incidence of bleeding after transplant is variable and studies have reported incidence from 4.9% to 10%. It usually occurs from unligated vessels in the graft hilum.
Those patients who have drop in hemoglobin and worsening hemodynamics will need urgent graft nephrectomy…
Am sorry ..urgent re exploration..not nephrectomy
This patient developed bleeding post renal transplantation that lead to symptoms of anemia and low urine output. Although the US was done but CT scan is more accurate in defining the site and size of bleeding .
Resuscitation with blood and i.v fluids
Stop the anticoagulant therapy if given
for surgical intervention if the the patient deteriorating or the bleeding increased
Post operative bleeding (tachycardia ,hypotension ,Hb drop despite blood transfusion)
For :
1-Resusscitation
2- US is the 1st line for investigations to diagnose and follow up US also is mandatory
,CT with contrast carry risk of CIN
3- surgical control of bleeding
This is a case of either surgical site bleed or anastomosis site leak.
Management.
1) Urgent bedside ultrasound.
2) If ultrasound finding not conclusive, proceed with CT scan. However, need to counsel patient regarding risk of CIN.
2) Transfer to ICU acute care unit.
3)Refer surgeon if bleed confirmed.
A case of postoperative surgical site hemorrhage after kidney transplantation
bleeding occur from vascular anastomoses , vessels in the renal hilum which dilate following reperfusion or injury of peritoneal tissues.
The patient had tachycardia, acute anemia.
urine output is decreased and the drain stopped drainage.
and presence of fluid collection.
Diagnosis : by aspiration of bloody fluid.
Ultrasound is the first imaging modality to assess the presence of collections, but it cannot differentiate between types of collection,
CT is more sensitive.
Hachem LD, Ghanekar A, Selzner M, Famure O, Li Y, Kim SJ. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transpl Int. 2017 May;30(5):474-483.
The patient has either surgical bed site bleeding or anastomosis leak, in view of tachycardia, low systolic blood pressure, failure of resuscitative fluid infusion and fall in hemoglobin level.
US is the initial investigation to look for hematoma but CECT will delineate bleeding and heamatoma better.
In such a situation, rather than proceeding for any further imaging, i would like to re-explore the patient and control surgical site bleeding
Ø This is a critical patient
Ø Second stage of shock: indicating he is losing not less than 750-1500ml of blood and since there is no apparent bleeding so its internal which is more serious.
Ø Ultrasound with Doppler is readily available but less sensitive while CT scan is much more sensitive and specific.
Ø Resuscitate with blood transfusion and fluid
Ø Call surgical team for assessment and surgical intervention if needed.
Handbook of Kidney Transplantation Sixth Edition Gabriel M. Danovitch
How would you manage this case?
A 46 year male who had live related renal transplant ,developed decrease urine output with blood pressure of 108 systolic and pulse of 110/min –Drain suddenly becomes empty and Ultrasound showing small collection of 30 ml around renal graft and hemoglobin dropped to 7.8gm/l.All these findings are consistent with vascular anastomotic leak leading to hypovolemia and ultimately kidney hypoperfusion and AKI. Bedside ultrasound though less sensitive can detect blood leak if done by experts but still the gold standard is CT abdomen which is easily available and non-invasive and can detect small bleeds as well. The main strategy of treatment is to stabilize the patient with blood transfusion and IV fluids and then referral to surgeon for surgical re-exploration.
REFERENCES:
Gabriel M. Danovitch. Handbook of Kidney Transplantation. Sixth edition, 2017
How would you manage this case?
8h post LRRT surgery, low UOP, low BP, high HR, no responding to IV fluids, dropped HB from 112-à 78.——à> all points to hypovolemia and my first DD is bleeding.
USS: small collection 30 ml around the graft. Ultrasound is the easiest portable way for imaging, however is not sensitive and operator dependent, and bleeding may be retro-peritoneal which will be missed by this scan. The gold standard is CT- angiogram to localize the site of bleeding and the extension. The main risk of CT is contrast induced nephropathy.
Drain: is not draining doesn’t mean that there is no bleeding, because the drain could be blocked by clots or the bleeding is some where else away from the drain.
This patient needs urgent CT-A and surgical team review if any intervention is needed.
If there is no bleeding or surgical cause, we will need to think about other differential diagnosis after ruling out acute surgical issues.
Other DD: TMA, acute rejection, and TRVT.
The constellation of decreasing UOP, tachycardia, hypotension and dropping Hb are indicated the diagnosis of hypovolemia due to ongoing blood loss from the surgical site.
The ultrasound modality is the fastest and easiest way in the immediate postoperative period to diagnose bleeding or collections, but it’s not sensitive to small bleeds . CT angiogram is the gold standard modality to localize the site of bleeding accurately.
Once diagnosis is made immediate action done by stabilizing the patient hemodynamically by fluid resuscitation and blood transfusion , if the condition not improve, surgical consultation for exploration are mandatory.
Decrease urine output ,drop in Hb and active drain all together point toward internal bleeding so we need to know the graft perfusion with Doppler ultrasound and to flow the collection around the graft if it increased urgent exploration should be done
How would you manage this case?
Patient developed tachycardia and hemoglobin drop with low systolic BP not responding to iv fluid ,and decrease of urine out put picture suggestive of hypovolemia most probably due to bleeding at vascular anastomosis.
This serious complication affects the graft due to hypotension and hypoperfusion.
Us with Doppler is fast bed side investigation to detect blood leak although it has low sensitivity than CT.
CT is the investigation of choice to detect even small or deep pelvic leak With caution in using contrast in case of AKI .
-Management with fluid and blood transfusion until the patient is hemodynamically stable.
-small hematoma may resolve spontaneously
-large hematoma or sever bleeding not responding to treatment with blood transfusion will require urgent Surgical exploration and correction of anastomotic leake .
He is unstable from bleeding because of his dropping Hb, tachycardia, low BP, oliguria in spite of small hematoma detected by US. Stabilize him with balanced crystalloid fluids. Reserve and infuse packed RBCs if needed. Holding anticoagulants if are used. If it is possible, confirm the diagnosis with CT-scan because US is not enough sensitive to detect active bleeding. Finally, urgent surgical exploration would be considered.
the patient looks to have bleeding and impending hemorrhagic shock.
the best image to diagnose bleeding is a CT scan abdomen, although it carries the risk of contrast kidney damage (CIN).
US is a quick modality to determine collection but may miss small ones. does not carry the risk of CIN.
MRI is time-consuming.
he needs resuscitation with blood and careful monitoring of the vital sign and urine output.
This is a case of perinephric hematoma following internal bleeding which clinically correlated with
-Decreased urine output
-Tachycardia of 110/ min
-Systolic BP 108
-Fall of Hb
-USG : small collection of about 30 ml around renal allograft
Management:
-Urgent CT to confirm diagnosis
-Supportive management
-Surgical correction
46 years old male 8 hours post kidney transplant he is not passed urine for 3 hours and has signs of intrabdominal bleeding, US graft detected small collection.
the risk of bleeding postrenal transplant is high
first resituated give crystalloid fluid till the blood transfusion takes place, send for CBC ,coagulation profile,PT, PTT, INR, hemolytic workup, full chemistry.
localized the site of bleeding so he need CT although the risk of contrast nephropathy angiography but MRI is time-consuming
surgical intervention may be needed in some situations such as:
dropping Hb in spite of multiple transfusions.
rapid decline in renal function.
evidence of graft hypo perfusion.
or haemodynamic instability
hematoma if it is small it resolved ponderously
risk factors for bleeding in kidney transplant recipients are anticoagulant,antiplatelet, thymoglobulin and plasmapheresis
References
1.Inci MF, Ozkan F, See TC, Tatli S. Renal transplant complications: Diagnostic and therapeutic role of radiology. Can Assoc Radiol J 2014;65:242-52.
2.Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005;25:1335-56.
The US showed a small area of the collection but it does not detect the site of bleeding so a CT scan is needed and more informative but the MRI is informative but is time consuming and carry risk of NSF
This patient showed a picture of hypoperfusion with low BP and tachycardia adding to the drop in Hb all these denote towards
Us is the first tool to start with, as it can detect the collection
Us may mislead in the first 6 hr as fresh blood could not be visualized by us .
US IS THE MORE USED RADIOLOgical image in the early postoperative period adding to the easy and non-expensive but it could not detect the bleeding
CT scan is the better modality for detecting the bleeding and the size of hematoma
referrence
uptodate
The possibility of hemorrhage should be considered as the patient has tachycardia and hypotension despite resuscitation, hemoglobin drop despite blood transfusion, the drain may be occluded by blood clot and the decreased UOP is due to hypovolemia and may be compression of the graft by hematoma.
Ultrasonography may not be accurate in the assessment of retroperitoneal hematoma, CT abdomen with contrast is more accurate.
Surgical exploration should be considered as the patient is still shocked despite resuscitation.
Humar A, Matas AJ. Surgical complications after kidney transplantation. InSeminars in dialysis 2005 Nov (Vol. 18, No. 6, pp. 505-510). Malden, USA: Blackwell Science Inc.
Ultrasound would be the preferred and first non-invasive modality diagnosis, if any bleeding would suggest further CTA and need of intervention.
The combination of a falling UOP, tachycardia, hypotension, and a falling Hb level indicates continuous blood loss.
The abdominal ultrasound reveals a modest collection around the kidney; therefore, a more precise approach, such as a CT scan, is required to rule out retroperitoneal hemorrhage.
When ultrasonography is insufficient for characterizing the degree of anatomic problems, CT and MRI can be useful adjuncts.
This is an example of hypovolemic AKI resulting from blood loss with subsequent diminished renal perfusion and acute kidney injury. In this situation, the patient should undergo thorough laboratory investigations, including a hemolytic workup and coagulation studies. Initial step of medical treatment aims to maintain hemodynamic stability and adequate tissue oxygenation, by fluid resusitation and blood transfusion.
The provided imaging modality is the preliminary step; however, other confirmatory imaging studies should follow. After confirmation by CT scan, call the surgical team immediately to discuss the necessity for re-opening and to stop the bleeding.
This patient suffers from a large bleed, leading to a perinephric hematoma. The majority of hematomas in the immediate post-transplantation period are small and do not require intervention. Localised swelling may be evident around the allograft, and a haemorrhagic drain might be visible. Occasionally, hematomas may gradually expand throughout the retroperitoneal space, compressing the allograft, ureter, and vascular supply, resulting in allograft dysfunction.
Immediately following surgery, the patient may experience signs of shock (tachycardia, hypotension) with a drop in haemoglobin levels. A Doppler USS may detect an echoic collection even though a haematoma may be missed by a USS. CT with an angiogram phase is more valuable but does carry a risk of contrast nephropathy. The immediate surgical evacuation of hematomas in an unstable recipient with suspected bleeding is mandatory to improve allograft function and prevent concurrent infections.
References:
1- Horrow MM. Sonographic Detection of Perirenal Transplant Hematomas. American Journal of Roentgenology. 2016 Apr;206(4):W58- W58.
2- Kirbas I, Tutar NU, Emiroglu FK, Coskun M, Haberal M. Multidetector computed tomography angiography in detection of active bleeding in renal and liver transplant recipients. Transplant Proc. 2007 May;39(4):1111-5.
3- Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, et al. Ureteral obstruction following renal transplantation: causes, diagnosis and management. The British Journal of Radiology. 2014 Dec;87(1044):20140169.
4- Buttigieg J, Agius-Anastasi A, Sharma A, Halawa A. Early urological complications after kidney transplantation: An overview. World J Transplant. 2018 Sep 10;8(5):142-149.
5- Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. The British Journal of Radiology. 2014 Dec;87(1044):20140169.
payient need urgent Ct scan to determine the site and amount of bleeding and at the same time to keep the patient well hydrated to avoid thrmbosis and later might need exploration to stop the bleeding and re position of drain.
Tachycardia
SBP of 108
drop of HB
Drop of urine output
This all suggests ongoing bleeding, He needs urgent CT angiogram to localize the bleeding and possible surgical exploration is needed
Diagnosis :
Mostly Post operative internal bleeding with perinephric hematoma :
Clincally decreased urine output , tachycardia of 110/ min and systolic BP 108
fall of Hb > 20gm/L (HB78 gm)
US : small collection of about 30 ml around renal allograft
Management:
Stabilization of the patient ( Prepare 3 units of packed RBCs)
supportive ( IV fluids – corrections of electrolytes imbalance)
Hold (anticoagulants , antiplatelets )
urgent CT:
(as some ultrasounds did not definitively indicate whether a large collection was in fact a hematoma or not )
CT scan can confirm the identity of these collections
urgent call of surgical team for discussion of the need for re-opening and control the source of bleeding
Prognosis :
The bleeding around the graft site early after transplantation may have increased incidence of of long-term graft loss or death:
As it may result in early graft dysfunction from:
Mechanical compression or complications such as hypotension, anemia, need for blood transfusions, or sepsis from infected hematomas
References :
Marietta M, Facchini L, Pedrazzi P, Busani S, Torelli G. Pathophysiology of bleeding in surgery. Transplant Proc 2006; 38: 812.
Mathis AS, Dave N, Shah NK, Friedman GS. Bleeding and thrombosis in high-risk renal transplantation candidates using heparin. Ann Pharmacother 2004; 38: 537.
Pawlicki J, Cierpka L, Krol R, Ziaja J. Risk factors for early hemorrhagic and thrombotic complications after kidney transplantation. Transplant Proc 2011; 43: 3013.
A collection of decreasing UOP, tachycardia, hypotension, and dropping Hb level points to ongoing blood loss.
The abdominal US shows a small collection around the kidney, a more accurate method is needed to exclude retroperitoneal haemorrhage, such as a CT scan.
CT and MRI can be helpful adjuncts in defining the extent of anatomic complications when suboptimally evaluated using ultrasonography (eg, when the transplant is shadowed by bowel gas)
Once bleeding is confirmed, urgent surgical exploration is needed.
Reference:
Fried JG, Morgan MA. Renal Imaging: Core Curriculum 2019. AJKD Vol 73 | Iss 4 | April 2019.
This patient may suffer from perinephric hematoma lead to drop of hemoglobin and circulatory instability, however it’s common complications post operative in kidney transplant and if not diagnosis early may lead to early graft loss.
The main causes is anti coagulant medication and induction therapy of thyroglobulin and plasma exchange. It’s diagnosis by ultrasound and Ct abdomen and MRI abdomen.
Treatment if small self limited and large by aspiration or surgical exploration.
Reference:
Iman alshamsi, hefsa alshamsi, Salamah Al.Falahi, Ajay sharma, Ahmed Halawa: Perinephric transplant fluid collection approach and management. saudi journal of kidney disease and transplant submitted, 25-sep2018.
Problem list :
Decreased urine out put to less than 20 cc/hr , not improving after 500 ml IV normal saline challenge.
Hypotenstion and tachycardia
Drain 350 cc in the first 3 hours but later on nothing drained.
US – 30 cc collection around the allograft.
The pere-operative Hgb was 11.2 and recived 2 units PRBC’s intraoperative for estimated 600 cc blood loss, Hgb now is 7.8 g/dl.
How would you manage this case?
Patient with significant blood drop and hemodynamic instability ( hypotension and tachycardia), with acute kidney injury ( decreased urine ouput < 20 cc/hr).
This is a case of hypovolemic AKI – due to blood loss or decreased renal perfusion. Given no volume over load signs excludes cardiorenal syndrome, this is most likely due to post-operative bleeding.
Will ask for coagulation profile test, PT,PTT,INR , bleeding time, full CBC- platelets count.- if low will send a blood film.
First, will call the surgeon to be involved in the management, will give more aggressive fluid management, insert, assure large vascular access ( central line or two large bore cannulas), O2 supplementation and assure normal oxygenation, will send him for an urgent pelvic CT with contrast (angio), to specify the site of bleeding, if his condition is stabilized, if not I’ll insist the surgeon to take him to the operation room as soon as possible.
Postoperative surgical-site hemorrhage was defined as a drop in hemoglobin ≥20 g/l over a 24-hour period within 3 days of transplantation, followed by an ultrasound indicating a significant hematoma/collection. Incidence of 4-5% and almost 90% occur within the first day of surgery[1].
Substantiate your answer:
Ultrasound is 15% sensitive in detecting post transplant hematoma and active bleeding this increase by two folds when using contrast enhanced ultrasound reaching 33% , however the imaging of choice in such cases is CTA, the contrast induced kidney injury is of concern in such cases, MRA is another modality with high sensitivity, the nephrogenic systemic fibrosis gadolinium induced in chronic kidney disease is of concern in such patients[2,3]
References :
[1] Hachem LD, Ghanekar A, Selzner M, Famure O, Li Y, Kim SJ. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transpl Int. 2017 May;30(5):474-483. doi: 10.1111/tri.12926. Epub 2017 Mar 2. PMID: 28120465.
[2] Grzelak P, Kurnatowska I, Nowicki M, Strzelczyk J, Durczyński A, Podgórski M, Stefańczyk L. The diagnostic value of contrast-enhanced ultrasonography in the assessment of perirenal hematomas in the early post-operative period after kidney transplantation. Clin Transplant. 2013 Nov-Dec;27(6):E619-24. doi: 10.1111/ctr.12257. Epub 2013 Oct 7. PMID: 24118471.
[3] Handbook of Kidney Transplantation Sixth Edition by Gabriel M.Danovitch.
The patient is 8 hours post-op with worsening vitals in terms of decreased urine output and blood levels decreasing and low blood pressure. The patient likely has post-op complications likely post-surgical bleeding or hemorrhage. The USS shows a collection of about 30mls. Despite blood transfusion, the hemoglobin has been decreasing. Also, the surgical drain stopped draining.
With all the above information, the patient has bleeding from the surgical region causing a hematoma with the activation of platelets blocking the drain. With this in mind with decreased Hb and blood pressure, there is a decrease in renal blood flow to the kidney decreasing GFR and worsening kidney function and that may lead to graft loss. Tachycardia is due to acute blood loss which the heart has to adapt to a mechanism to ensure proper oxygenation to the vital organs.
The patient will need an urgent surgical referral.
CT scan of the surgical region
Serial blood test to evaluate blood loss
Will need fluid replacement solution saline.
There are factors that can inform surgeons and other doctors for urgent exploration:
1) Decrease of Hb in serial CBC
2) Rapid decline in kidney functions
3) Expanding hematoma
4) Unable to maintain BP stable or normal.
5) There is evidence that there is a decrease in graft perfusion.
So from all the above, I think the patient needs re-exploration urgently to prevent graft loss due to low pressure, low Hb, etc.
References:
Hachem, D. L., et al, Transplant international (2017). Postoperative surgical site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. May;30(5):474-483
How would you manage this case?
The most likely diagnosis is perinephric hematoma( dropping Hb and BP beside tachycardia and sonographic collection of fluid around the graft).
Diagnosis:
· Serial measurement of haematocrit may show a falling haematocrit level.
· Ultrasonography, CT scan, or MRI may be used to identify haematoma, necessitating an emergency re-exploration. CTA is more sensitive but carries a high risk of CIN.
Management:
· Surgical exploration is usually not required because bleeding usually stops spontaneously.
· Surgical re-exploration may be required in case of:
a) Repeated transfusion of pure red blood cells.
b) Haemodynamic instability.
c) Compression of the kidney by haematoma.
– The patient seems to have perinephric site of bleeding lead to hematoma formation as evidenced by US as well as decreasing Hb level not catching up with blood transfusion along with tachycardia and hypotension
– Also the patient began suffering decreased urinary output .
– The patient needs adequate resuscitation with urgent investigation as
US including colour Doppler module which is the most suitable imaging modality to investigate the status of renal grafts in the first 24 hours after transplantation or CT with contrast as second-line imaging tool for questionable US findings, as it provides an overall assessment of vascular complications.
Magnetic Resonance Imaging has the benefit of avoiding iodinized radiation while it’s risk is the gadolinium nephrogenic systemic sclerosis
Contrast enhanced US is an option that permits the assessment of both macro- and micro-vascularity, as well as perirenal fluid and all the parenchymal abnormalities related to rejection, vascular complications.
-Surgical assessment is urgently needed
Reference
David, E.; Del Gaudio, G.; Drudi, F.M.; Dolcetti, V.; Pacini, P.; Granata, A.; Pretagostini, R.; Garofalo, M.; Basile, A.; Bellini, M.I.; D’Andrea, V.; Scaglione, M.; Barr, R.; Cantisani, V. Contrast Enhanced Ultrasound Compared with MRI and CT in the Evaluation of Post-Renal Transplant Complications. Tomography 2022, 8, 1704-1715.
this is a case of suspected bleeding post-operative based on clinical data as the patient’s BP started to be on the lower side despite good resuscitation, tachycardia, graft dysfunction, and hemoglobin drop
U/S is not a sensitive tool to role out or to prove diagnosis and the patient needs urgent CT
the size of the hematoma and clinical data plan of management should be discussed with the transplant surgeon which usually favors open surgery and exploration especially if the patient hemodynamic is unstable and the size of the hematoma was largely seen by CT
References
1. Kusyk T, Verran D, Stewart G, et al. Increased risk of hemorrhagic complications in renal allograft recipients receiving systemic heparin early post-transplantation. Transplant Proc 2005; 37:1026.
There are clinical and laboratory signs suggestive of hemorrhage, probably related to the surgical procedure. The surgical team along with Vascular must be activated while the investigation and first care are carried out:
– Vigorous hydration and replacement with packed red blood cells
– Doppler ultrasound for a quick and bedside assessment, but contrast-enhanced computed tomography is ideal for a quick and more thorough assessment.
Review operation notes, type of surgery, location of wound, drain
Urgent senior surgical review.
hydrated patient.
Urgent blood transfusion, RBC, platelets, and FFP.
CT with contrast to localize the cause.
If bleeding is suspected the patient transferred to Cath lab for angiography and
placement of arterial stent graft.
Drug-eluting stent placement in common iliac and external iliac artery is recommended ,
if bleeding not controlled with conservative treatment.
Handbook of Kidney Transplantation Edited by Gabriel M. Danovitch, MD
_ The current case presented with oliguria, hemodynamic instability in the firm of persistent tachycardia and low systolic blood pressure (not responding to fluid resuscitation) and drop of HB in spite of packed RBC replacement of intraoperative blood loss, all are suggestive of surgical site bleeding.
_ The managemnt policy:
_ urgent call of transplant and vascular surgeon for the need of surgical exploration, as a growing heamatoma and ongoing blood loss can compress the graft and leads to graft and life loss
_Urgent call for matched and filtered packed RBC to resuscitate our patient as angoing bleeding and HB drop can lead to grfat hypoperfusion, graft loss or even death
_ Evaluation of hematoma by bedside US is most easy and fast imaging modality, however it can miss or underestimate the hamatoma size, so CT angio is best sensitive method to determine size and site of bleeding.
_ Rapid intervention in such surgical emergency is the main predictor of graft and patient outcome
The patient has reduced urine output, tachycardia, lower BP/MAP and decreasing Hb suggestive of bleeding. This happens few hours after transplantation which suggestive of surgical site haemorrhage.
The bleeding can occur from vascular anastomoses, vessels in the renal hills which dilate following reperfusion, or retroperitoneal tissues surrounding the graft which traumatised during exposure of the illiac fossa and mobilisation.
The patient has haemodynamic instability which requires surgical revision.
I would probably do a CT to determine the site of bleeding which is gold standard for the detection of bleeding and haematoma.
The incidence of bleeding after kidney transplant is around 0.2-14%
The falling HCT, hypotension and tachycardia points toward haemorrhage and requirement of blood transfusion or increasing haematoma compressing the allograft and haemodynamic instability will require surgical revision.
Reference
Hachem LD, Ghanekar A, Selzner M, Famure O, Li Y, Kim SJ. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transpl Int. 2017 May;30(5):474-483. doi: 10.1111/tri.12926. Epub 2017 Mar 2. PMID: 28120465.
The clinical presentation of this case favours post operative surgical site bleeding . But there are few indications which are against this and hence mandate detailed evaluation rather than just keeping focus on post op bleed.
Hence, along with evaluation of surgical site bleed, I will also consider work up for DVT/PE which can mimic above clinical presentation
·How would you manage this case?
·Substantiate your answer
This is a scenario of postoperative surgical site hemorrhage (SSH) after kidney transplant surgery. SSH usually occurs early postoperative within the 1st few days following surgery.
Possible bleeding sites include:
1. Vascular anastomoses
2. Vessels in the renal hilum
3. Retroperitoneal tissues surrounding the graft (trauma during exposing the iliac fossa & mobilization of iliac vessels)
Postoperative SSH can be defined by:
A drop in Hb =/>2.0 g/dl over a 24-hour within 3 days after TX & subsequent USS showing a hematoma or collection considered as large or with a volume > 33.2 cm3(=diameter of 4 cm in all directions).
Other predictors of SSH include:
Low urine output
Abdominal pain
MAP <70 mm Hg
Management:
SSH management includes operative (surgical intervention +/- transfusion) or conservative (+/-transfusion).
R. Shaw et al reported: “We found better outcomes of graft and patient survival with shorter lengths of stay when we utilized non-operative management of postoperative hemorrhage in kidney transplant patients. Our findings suggest a role for conservative non-operative management in select patients. Ultimately, it is the surgeon’s choice of how best to manage the care of kidney transplant patients with postoperative hemorrhage.”
References
1. Victoria Socha. Managing Postoperative Hemorrhage after Kidney Transplant Surgery. Nephrology Times September 10, 20202. Laureen D. Hachem, Anand Ghanekar, Markus Selzner, Olusegun Famure, Yanhong Li, Sang Joseph Kim. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transplant International, 2017;30:474-483
References
1. Victoria Socha. Managing Postoperative Hemorrhage after Kidney Transplant Surgery. Nephrology Times September 10, 2020
2. Laureen D. Hachem, Anand Ghanekar, Markus Selzner, Olusegun Famure, Yanhong Li, Sang Joseph Kim. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transplant International, 2017;30:474-483
True surgeon is to decide but you mentioned all the indications above including the HB drastic drop with hypotension resistant to fluid challenge.
How would you manage this case
-Close observation of vital signs and serial hematocrits , hb, coagulation
-Ultrasound can help to confirm and monitor a peri-allograft hematoma.
If more than 4 units of blood are required within 48 hours, operative evacuation of the hematoma will usually accelerate graft function and patient comfort.
Hematomas are the most common peritransplant fluid collections in the immediate postoperative period,related to the surgery itself, allograft pseudoaneurysm rupture, or as a complication of biopsy performed to evaluate for transplant rejection. Hematomas may be subcapsular or extra-renal in location and are usually self-limited and resolve spontaneously. Occasionally, a hematoma may be large enough to cause allograft collecting system obstruction.
The imaging appearance of a hematoma depends on the age of blood products, appearing echogenic on US and hyperdense on CT in the acute phase and progressively decreasing in echogenicity on US and density on CT as hemolysis occurs. The signal characteristics of blood products on MR are more complicated, depending on the evolving concentrations of hemoglobin, deoxyhemoglobin, and methemoglobin. They may evolve from T1 hyperintense to T1 hypointense.
SIXTH EDITION
Handbook of
Kidney
Transplantation
Edited by
Gabriel M. Danovitch, MD
Medical Director, Kidney and Pancreas Transplant Program
Ronald Reagan Medical Center at UCLA
John J. Kuiper Chair of Nephrology and Renal Transplantation
Distinguished Professor of Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California
Case pertains to a fresh transplant with sudden onset fall in urine output with tachycardia and hypotension, in presence of fall in hemoglobin despite 2 units of blood transfusion, pointing towards surgical site hemorrhage.
The patient needs urgent re-exploration as the clinical condition of the patient is worsening.
The patient will need a CT scan with contrast for localizing the site of bleed as well as the quantification of the bleed as ultrasound is not a sensitive modality for detecting hematoma.
Other supportive measures which need to be taken care of include the fluid and electrolyte balance, reassessment of medications including antiplatelets and anticoagulants, need for dialysis in presence of dyselectrolytemia or metabolic acidosis.
A transplant recipient in the immediate post-transplant period may present with complications including vascular causes, urological causes, fluid collections, or wound related issues (1).
The incidence of bleeding post-transplant is 4.9% (2). It usually occurs from unligated vessels in the graft hilum, or from small retroperitoneal vessels of the recipient.
A falling hematocrit, hypotension, tachycardia and lower quadrant or flank pain should point towards bleeding. Most of the times, it is self-limiting, but in presence of hemodynamic instability, ongoing requirement of blood transfusions, or renal graft compression by the hematoma on imaging warrant surgical re-exploration (3).
References:
1) Buttigieg J, Agius-Anastasi A, Sharma A, Halawa A. Early urological complications after kidney transplantation: An overview. World J Transplant. 2018 Sep 10;8(5):142-149. doi: 10.5500/wjt.v8.i5.142. PMID: 30211022; PMCID: PMC6134271.
2) Hachem LD, Ghanekar A, Selzner M, Famure O, Li Y, Kim SJ. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transpl Int. 2017 May;30(5):474-483. doi: 10.1111/tri.12926. Epub 2017 Mar 2. PMID: 28120465.
3) Humar A, Matas AJ. Surgical complications after kidney transplantation. Semin Dial. 2005 Nov-Dec;18(6):505-10. doi: 10.1111/j.1525-139X.2005.00097.x. PMID: 16398714.
*By history Patient gained bleeding intraoperative then, post-transplanted surgery he gained hypotension, tachycardia , oliguric ( uop 20cc/hr ) with no response to IVF and there is a significant hemoglobin drop which mostly; due to big hematoma, documented with Us.( A case of post-operative surgical site hemorrhage (SSH) that can lead to graft compression, hypovolemic shock, graft loss and even death. SSH mostly occur in first few days post transplantation .It could occur due to leak of vascular anastomosis or trauma to retroperitoneal structure or hilum bleeding or injury to iliac vessels.
*The incidence of post renal transplantation bleeding up to 14% .
*Management:
1.Control Hemodynamics.
2.CTA must be done to allocate site of active bleeder and hematoma.
3.Urgent surgical intervention for possible re-exploration when documented active bleeding or even big hematoma to be evacuated that compress renal graft and may eventually leads to graft loss and even.
*Risk factors of post-transplant SSH : long dialysis time , donor type , chronic anticoagulation/ anti-platelets usage before and after surgery, complicated vascular anastomoses as double renal arteries.
*References:
1. Buggs J, Shaw R, Montz F, etal;: Operative Versus Nonoperative Management of Hemorrhage in the Postoperative Kidney Transplant Patient. Am Surg. 2020 Jun;86(6):685-689.
2.Hachem LD, Ghanekar A, Selzner M,etal; Postoperative surgical-site hemorrhage after kidney transplantation: Incidence, risk factors, and outcomes. Transpl Int. 2017;30(5):474-483.
3.Ozkan F., See T., etal; Renal Transplant Complications: Diagnostic and Therapeutic Role of Radiology. Canadian Association of Radiol. Jour., 2014;65: 242-252.
The patient mostly has surgical site hemorrhage, hemodynamic instability not responding to bolus fluids, decreased UOP, Hb drop, the drain is not draining mostly due to a blood clot blocking it.
The patient should be resuscitated with packed RBCs transfusion and IV fluids, CT abdomen with contrast should be performed to detect site of bleeding and to detect the size of hematoma.
The transplant surgeons should be informed to decide the need for exploration and evacuation of the hematoma and/or repair of the bleeding vessel.
Humar A, Matas AJ. Surgical complications after kidney transplantation. InSeminars in dialysis 2005 Nov (Vol. 18, No. 6, pp. 505-510). Malden, USA: Blackwell Science Inc.
Thank you, Heba
The patient has signs of intravascular depletion, secondary to surgical site hemorrhage evident by:
– Tachycardia, low BP.
– Reduced urine output.
– No improvement after volume resuscitation.
– Significant drop in hemoglobin.
– Collection seen in US.
Postoperative surgical site hemorrhage is defined as:
-Drop in Hg >20g/L over 24 hr period within 3 days of transplantation.
-Followed by US indicating a significant hematoma/ collection.
Bleeding may occur from vascular anastomoses, vessels in the renal hilum which dilate following reperfusion, or retroperitoneal tissues surrounding the graft which were traumatized during exposure of the iliac fossa and mobilization of the iliac vessels.
It may lead to compression of kidney transplant , systemic sequelae of hemorrhagic shock and graft loss.
Previous studies have reported rates of 0.2-14% of postoperative hemorrhage in kidney transplantation.
R. Shaw et al. found the following signs are predictive of postoperative hemorrhage by 92.5%:
-Low urine output (P=.044)
-Drop in hemoglobin (P<.000)
-Abdominal pain (P=.005)
-MAP <70 mm Hg (P=.034).
Management:
– Hematoma may expand in the retroperitoneal space and US is may miss retroperitoneal collection
– CT scan to confirm and identify the collection.
– Careful monitoring of vital signs and fluid balance.
– Drain and folly’s catheter flushing as it may be blocked.
– Hold anticoagulation if patient is commenced on it.
– If patient continued to be anuric, dialysis is indicated.
– Conservative management can be in consider if hematoma is small and patient is hemodynamically stable.
– In our case the patient will require surgical exploration, So the surgical team involvement for the surgical option is highly indicated.
References:
Hachem LD, Ghanekar A, Selzner M, Famure O, Li Y, Kim SJ. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transpl Int. 2017 May;30(5):474-483.
Managing Postoperative Hemorrhage after Kidney Transplant Surgery, Victoria Socha is editor of the Nephrology section of DocWire News, 2020.
Hi Dr Hadeel,
Rather than stating that surgical involvement is indicated, I would say that surgeons would proactively see such a patient themselves and would not leave hospital when such a patient needs exploration.
Thanks prof. Sharma. Totally agree
References:
Rather than surgical consultation being seeked for, I would say that surgeons would proactively see such a patient themselves and would not leave hospital when such a patient needs exploration.
How would you manage this case?
This is a patient who is developing graft dysfunction due to the drop in urine output that is not responding to a fluid challenge. He is also getting tachycardic and hypotensive with a drop in hemoglobin despite having been transfused 2 units intraoperatively. An USS has shown a small collection of around 30 mls around the graft
The surgical drain has stopped draining having drained 350 mls – almost 60 mls per hour. This could suggest that the drain is blocked and may need to be flushed
The patient may be bleeding at the surgical site or at the anastomotic site and thats why the Hb has dropped and the patient is becoming hemodynamically unstable
The small collection could be a lymphocyte, urinoma or hematoma.
With the drop in hemoglobin and tachycardia, the patient is most likely bleeding with blood accumulating in the abdomen
The patient will require a CT scan and urgent surgical exploration while being given more blood.
The medications pre-op should also be assessed to ensure that the patient was not on any anticoagulants or anti-platelets
Post operative hemorrhage has been associated with a higher incidence of graft loss and death (HR 1.62 CI:1.01,2.60)
Living donor transplant and a higher BMI were associated with a lower incidence of post=operative hemorrhage in the study by Hachem L et al
Transpl Int. 2017 May;30(5):474-483. doi: 10.1111/tri.12926. Epub 2017 Mar 2.
Postoperative surgical-site hemorrhage was defined as a drop in hemoglobin ≥20 g/l over a 24-hour period within 3 days of transplantation, followed by an ultrasound indicating a significant hematoma/collection.
Postoperative hemorrhage was associated with a higher risk of graft loss or death
Management
Note
Various imaging modalities have been used to diagnose Page kidney.
Ultrasound
cheap, easy to perform and non-invasive
; but highly operator dependent, it can miss small sub capsular hematomas.
Doppler evaluation
may give valuable clues toward the diagnosis
it signals a rapid and high increase in renal resistive index.
CT of the abdomen
is the preferred modality because it is a non-invasive, readily accessible test, which can detect even very small hematomas
(MRI)
may be helpful in assessing the age of the hematomas and patency of renal blood vessels.
Note
The decision to undergo surgery was based on multiple factor
As in this case where the Hb is decreased notably- the presence of tachycardia
Therefore surgical intervention is needed
The treatment of choice for our patient is surgical re-exploration
REFERENCES
https://pubmed.ncbi.nlm.nih.gov/28120465/
https://www.sciencedirect.com/science/article/pii/S2451959617300070#:~:text=The%20treatment%20of%20choice%20for,resistive%20index%20on%20Doppler%20ultrasound.
Well done.
But offcouse this is not a Page kidney as the US reported 30 cc only.
How would you manage this case? Substantiate your answer :
Well done
Needless to mention the location of the lost blood needs a CT before the exploration.
This is the case of SSH ( surgical site hemorrhage post surgery.
Almost occur shortly post surgery, hours to dys.
Defined as;
Risk factors;
Recipient factor;
Donor factors;
Surgical factors;
Pre-operative factors;
Anticoagulation.
Outcome;
Management;
Refferences;
Kaufman JA, Lee MJ. Vascular and interventional radiology, the requisites. Mosby Inc. (2004) ISBN:0815143699.
Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomesLaureen D Hachem 1, Anand Ghanekar 1 2, Markus Selzner 1 2, Olusegun Famure 1 3, Yanhong Li 1, Sang Joseph Kim 1
Well done
This is immediate post-surgical hemodynamic instability, hypotension tachycardia oliguria, with a history of intra-operative blood transfusion no response to IVF boluses and there is a significant drop of HB by > 3 gm with the initial high output drain then stopped could be due to big hematoma and clotted, this is likely indicate ongoing hypovolemic shock with the possibility of the intra and post-operative ongoing bleeding, we should ask about any vascular complication during surgery and consider urgent CT angio to localize the site of active bleeding or the hematoma. the need for surgical intervention vs conservative management with optimizing the hemodynamics and blood transfusion will be decided by the transplant surgical team and possible re-exploration only in case of active ongoing bleeding with a big collection that compresses the graft and hemodynamic instability need surgical evacuation and may associate with a high risk of graft loss and even death depending on associated recipient comorbidities.
Substantiate your answer
Few studies report the risk of postoperative bleeding after kidney transplant however the prevalence stated up to 14% and in one recent study from Canada, the incidence was even lower 4.9%. The majority of such surgical site hemorrhage (SSH) occurs in the first 24-48 hours after surgery 89% (2). Early postoperative bleeding could be due to vascular anastomosis bleed or hilar bed dilation after reperfusion or deeply seated bleed retroperitoneal due to iliac vessels injuries during dissection, so oliguria, abdominal pain with a drop of HB > 20gm /L, hypovolemic shock and US collection> 4cm, perioperative blood transfusion all considered alarming sings for ongoing bleeding.
Risk factors of post-transplant -SSH
1. The dialysis duration the longer time on dialysis associated with a higher risk of SSH
2. Donor type ( DD vs LD), ECD
3. long CIT due to the loss of vascular integrity
4. pre and post-operative anticoagulation antiplatelet use,
5. multiple or complex vascular anastomoses
6. low BMI of the recipient(2).
References
1. Buggs J, Shaw R, Montz F, Meruva V, Rogers E, Kumar A, Bowers V. Operative Versus Nonoperative Management of Hemorrhage in the Postoperative Kidney Transplant Patient. Am Surg. 2020 Jun;86(6):685-689.
2.Hachem LD, Ghanekar A, Selzner M, Famure O, Li Y, Kim SJ. Postoperative surgical-site hemorrhage after kidney transplantation: incidence, risk factors, and outcomes. Transpl Int. 2017 May;30(5):474-483.
Well done Thankyou