6. This 38-year-old renal transplant recipient had primary function over the first 4 days. He developed sudden pain and anuria. A duplex scan showed renal vein thrombosis and patent iliac veins. He had an exploration of the transplanted kidney. The following are the intra-operative findings as shown in this picture:
- Describe the picture shown above
- What is the best option?
The Above picture shows edmatous, swollen and congested transplant kidney with rupture of the graft kidney….
The best option available at this point of time is Graft nephrectomy to avoid further complications like DIC and Sepsis
Allograft renal vein thrombosis can occur after few days after surgery, but it is rare months after the transplant
Few factors implicated are
There have been reports of thrombectomy, catheter directed thrombolysis but all are with very poor results
This is rupture of the graft due to renal vein thrombosis . The patient is for nephrectomy.
Ruptured graft kidney
management;nephrectomy
bleeding and rupture graft kidney. Graft nephrectomy.
Hyperemic, swollen, ruptured, grafted kidney
Graft nephrectomy
1.Swollen,ruptured transplanted renal graft due to renal vein thrombosis.
2.Treated by graft nephrectomy.
Swollen transplanted kidney due to thrombosis of renal veins and it is treated by graft nephrectomy
non-viable, swollen shiny ruptured graft
graft nephrectomy
Due to renal vein thrombosis, the image depicts graft engorgement and non-viability. It is a surgical emergency, and graft outcomes are poor if it is not recognized and treated within the first few hours.
According to the image, the graft appears to be non-viable and requires nephrectomy.
Describe the picture shown above
Ø Ruptured, Swollen, cyanosed transplanted kidney graft due to acute renal vein thrombosis
What is the best option?
Ø Graft nephrectomy
Describe the picture shown above
Swollen ruptured renal graft
What is the best option?
Graft nephrectomy
The picture shows swelling, congested graft with ruptured capsule indicating the diagnosis of RVT.
RVT carry poor prognosis to both the graft and the recipient.Nephrectomy is the best option for management.
The picture show swollen graft with partially ruptured capsule due to renal vein thrombosis,it Cary very bad prognosis so nephrectomy should be done
Picture showing swollen,congested graft with rupture if the parenchymal suggsting severe renal vein thrombosis.
Post-transplant renal vein thrombosis is rare occurring in 0.3% to 4.2% of kidney transplant recipients.
The outcome is usually poor because of the lack of collateral circulation with the venous flow originating from the renal vein .
This can not only lead to the loss of the graft itself but may also result in a high mortality rate due to graft rupture and embolic complications .
Successful revascularization with thrombolytic therapy, thrombus-aspiration, or direct surgical thrombectomy have been reported with poor results
Power Doppler is more sensitive than color Doppler for detection of blood flow with increased confidence in the diagnosis of renal vein thrombosis
For this case with sever RVT with ruptured parenchyma Graft nephrectomy is the best option
Mark Lerman, Matthew Mulloy.Post transplant renal vein thrombosis, with successful thrombectomy and review of the literature.Int J Surg Case Rep. 2019; 61: 291–293
This picture shows a congested and ruptured transplanted kidney.
Immediate surgical intervention and graft nephrectomy.
the renal graft is swollen, congested and ruptured.
it seems to be a nephrectomy
This graft is swollen and ruptured.
Option is graft nephrectomy.
The picture is revealing a devastating allograft rupture, which is mostly related allograft renal vein thrombosis.
Other causes of allograft rupture are acute rejection which might precipitate renal vein thrombosis as well. Acute tubular necrosis is another factor reported to cause allograft rupture.
Causes of allograft renal vein thrombosis:
Technical issues related surgical implantation, such as size discrepancy, or contra-lateral right allograft transplantation and pediatric patient.
At this stage, its unfortunately too late to salvage this devastating rupture,
Nephrectomy is best to save life of the patient.
the picture showed a rupture graft and cyanosis due to renal vein thrombosis this complication is rare about 0.4 to 4% occur postrenal transplant and usually causes graft loss and ends with nephrectomy such as this case
The best option for this graft is nephrectomy
reference
UpToDate
he images shown is a transplanted kidney graft that is swollen or increased in size, cyanosed, and the graft is ruptured which is classic when there is a renal vein thrombosis. It is a very serious complication and there is a high possibility of graft loss.
The possible management is:early detection + throbectomy
Even though the above is done most times the diagnosis is late and there is a loss of graft function. The likely next step is nephrectomy.
references
update
The snap shows swollen, cyanosed, and ruptured kidney. Initially the best would be use of thrombolysis, thrombectomy, if no response the better option would be nephrectomy.
The provided picture shows a swollen, cyanosed, and ruptured kidney. Renal vein thrombosis is uncommon, occurring in 0.5–6% of renal transplants, associated with loss of the graft in most cases, and responsible for 30 % of the cases with early graft loss. Although it is rare, but catastrophic. In this case, graft nephrectomy is the best treatment option.
Renal graft rupture, secondary to renal vein thrombosis.
graft nephrectomy.
The pic shows a swollen ruptured graft as a consequence of RVT.
RVT can effect 0.1 to 4.2% of grafts
Risk factors are both donor and recipient related
Early diagnosis can salvage however most of the remaining me it’s difficult to save such kidneys.
This patient requires graft Nephrectomy
Swollen, congested, ruptured graft.
Life-threatening condition require graft nephrectomy.
Describe the picture shown above
This picture depicts a swollen, edematous, cyanosed and engorged graft with rupture.
This is a surgical emergency and threatening complication of kidney transplant
What is the best option?
The best option in such case is “Life over graft”
The graft may rupture and lead to disastrous outcome
So, the best option is immediate surgical exploration and graft nephrectomy.
This picture shows swelling and cyanosed and ruptured kidney graft.
Renal vein thrombosis post kidney transplant is a rare but serious and threatening graft condition.
Renal vein thrombosis is accounted 0.3–4.2% of kidney transplants.
The main cause is anatomical abnormalities or technical problem.
To avoid renal vein thrombosis need good hydration and anticoagulant post surgery.
Patient need urgent surgical exploration and graft nephrectomy. The early detection helps immediate surgical thrombectomy and it may re-implanting the allograft.
Reference:
MarkLermanaPersonEnvelopeMatthewMulloyaChristieGoodenaSalmanKhanaAliKhalilaLincolnPatelbXin JZhouc
Post transplant renal vein thrombosis, with successful thrombectomy and review of the literature: International Journal of Surgery Case Reports:
Volume 61, 2019, Pages 291-293
Problem list :
Sudden pain and anuria on fifth day post kidney transplantation, that was functioning well at the beginning.
Duplex scan showed renal vein thrombosis with patent iliac veins, so the patient sent immediately to operating room.
Describe the picture shown above
Swollen, cyanosed graft with graft parenchymal rupture – severe renal vein thrombosis.
Renal vein thrombosis is a rare complication post kidney transplantation with incidence of 0.4-4%., but it is a serious one leading mostly to a graft loss and nephrectomy.
Preventive measures are:
Ensure good hydration, early start of anticoagulants, early mobilization, thorough vascular evaluation of the recipient before the transplantation, careful selection of the donor’s kidney as the is high risk with Rt kidney donation due to anatomical issues, intraoperative anastomosis by skilled surgeon to decrease the risk of kinking.
What is the best option?
The best option in this case is a graft nephrectomy, given the severe RVT with ruptured graft.
Other options are:
– Use of local thrombolytic therapy- percutaneous approach.
– Surgical thrombectomy.
but both would not be beneficial in such a case.
References:
[1] El Zorkany K, Bridson JM, Sharma A, Halawa A. Transplant Renal Vein Thrombosis. Exp Clin Transplant. 2017 Apr;15(2):123-129. doi: 10.6002/ect.2016.0060. PMID: 28338457.
[2] Ponticelli C, Moia M, Montagnino G. Renal allograft thrombosis. Nephrol Dial Transplant. 2009 May;24(5):1388-93. doi: 10.1093/ndt/gfp003. Epub 2009 Jan 31. PMID: 19182239.
The image shown is a transplanted kidney graft that is swollen or increased in size, cyanosed, and the graft is ruptured which is classic when there is a renal vein thrombosis. It is a very serious complication and there is a high possibility of graft loss.
The possible management is:
1) Early detection
2) The use of thrombolytic
3) Surgically thrombectomy
Even though the above is done most times the diagnosis is late and there is a loss of graft function. The likely next step is nephrectomy.
The other measures that can be taken to ensure prevention:
1) Thrombosis prophylaxis
2) Control the risk factors like ensuring weight loss, the use of specific immunosuppression like calcineurin inhibitors, allowing when possible early mobilization, avoiding dehydration, surgical techniques, atherosclerosis, high dose steroids, long cold ischemia time, and delayed graft function recovery.
References:
Ponticelli, C., Moia, M., Montagnino, G., Nephrology Dialysis Transplantation (2009). Renal allograft thrombosis. Volume 24, Issue 5, May 2009, Pages 1388–1393, https://doi.org/10.1093/ndt/gfp003
Describe the picture shown above
The picture showed ruptured kidney graft, which is engorged and bluish as a consequence of TRVT.
· Incidence: Transplant renal vein thrombosis usually occurs early after surgery with a reported prevalence of 0.1% to 4.2%. It is a devastating event when occurring early post transplant, may be catastrophic that ultimately leads to graft loss in almost all cases with or even death1,2.TRVT accounts for up to one-third of early allograft losses3. prior to development of collateral venous outflow
· There are many predisposing factors related to donor, recipient, surgery, and immunosuppression, with mechanical factors being considered the most common causes of transplant renal vein thrombosis.
· The clinical manifestations of acute renal vein thrombosis are nonspecific and are not dissimilar to the features of urine leak, urinary obstruction, or severe acute rejection.
· The diagnosis of transplant renal vein thrombosis depends on a high index of clinical suspicion and duplex ultrasonographic scans. Although venography remains the criterion standard, this procedure is invasive and nephrotoxic, due to use of ionizing contrast agents and also due to exposure to ionizing radiation.
· Management:
a) Repeated duplex sonography may therefore be a valuable tool to monitor patients at risk for RVT in the first 2 weeks post-transplant, particularly in the presence of delayed graft function3.
b) There are 2 therapies that have been described in the literature for salvaging a renal allograft with transplant renal vein thrombosis: thrombolytic therapy and surgical thrombectomy.
· Urgent angiographic administration of tissue plasminogen activator and suction thrombectomy4.
· Heparin and clopidogrel post procedure4.
· Prompt diagnosis and immediate surgical thrombectomy after ex-planting allograft with subsequent re-implanting the allograft was successful in a case report2.
What is the best option?
· The best option for the index case is graft nephrectomy.
· To search for the cause of this coagulopathy to treat the patient and to prevent recurrence.
Reference
1. El Zorkany K, Bridson JM, Sharma A, Halawa A. Transplant Renal Vein Thrombosis. Exp Clin Transplant. 2017 Apr;15(2):123-129. doi: 10.6002/ect.2016.0060. PMID: 28338457.
2. Lerman M, Mulloy M, Gooden C, Khan S, Khalil A, Patel L, Zhou XJ. Post transplant renal vein thrombosis, with successful thrombectomy and review of the literature. Int J Surg Case Rep. 2019;61:291-293. doi: 10.1016/j.ijscr.2019.07.066. Epub 2019 Jul 31. PMID: 31401437; PMCID: PMC6699557.
3. Markus Aschwanden, Christoph Thalhammer, Stefan Schaub, Thomas Wolff, Jürg Steiger, Kurt A. Jaeger, Renal vein thrombosis after renal transplantation – early diagnosis by duplex sonography prevented fatal outcome, Nephrology Dialysis Transplantation, Volume 21, Issue 3, March 2006, Pages 825–826, https://doi.org/10.1093/ndt/gfi193
4. Thiessen L, MacDonell S, Wall C, Jacob P, Shoker A, Moser MAJ. Transplant renal vein thrombosis in a recipient with aberrant venous anatomy. CEN Case Rep. 2018 Nov;7(2):264-267. doi: 10.1007/s13730-018-0340-3. Epub 2018 May 22. PMID: 29790081; PMCID: PMC6181885.
-The picture shows graft rupture secondary to Transplant renal vein thrombosis can lead to extensive haemorrhage , and shock ,which could be life threatening
-In this case the prognosis is bad as the patient is in need of graft nephrectomy
If it was detected earlier surgical thrombectomy or thrombolytic therapy could have been given although prophylactic therapy is always the best to avoid this unfavourable prognosis
References
El Zorkany K, Bridson J M., Sharma A ,Halawa A.Transplant renal vein thrombosis Experimental and Clinical Transplantation (2017) 2: 123-129
its a case of the ruptured graft after RVT
Its caused by surgical and nonsurgical risk factors like thrombophilia
thrombectomy but usually failed and most the cases need graft nephrectomy
Renal graft rupture, is probably secondary to renal vein thrombosis.
There is a need for an immediate surgical procedure for graft nephrectomy. Early diagnosis may have heroic treatments such as graft revascularization and damage control, but the prognosis tends to be grim.
The best at this time is graft nephrectomy.
This is graft rupture ,due to TRVT.
acute allograft rejection:
but other causes such as renal vein thrombosis.
acute tubular necrosis .
renal biopsy.
lymphatic obstruction.
ureteric obstruction.
trauma.
nephrostomy tubes .
and renal cell cancer development.
Transplant nephrectomy .
Describe the picture shown above
This is rupture graft due to acute renal vein thrombosis
The typical clinical presentation is usually rapid onset of oliguria or anuria, hematuria with worsening graft function, and a painful swollen graft, which may progress to rupture, hemorrhage, and shock
Conventional grayscale ultrasonography with color and spectral Doppler is used immediately posttransplant for early detection of complications and evaluation of the renal allograft; It is noninvasive and may avoids use of ionizing radiation and iodinated contrast media
Causes of transplant renal vein thrombosis
1. donor risk factors:
· use of a donor’s right kidney
· Multiple graft vessels
· prolonged ischemia time
· vascular injuries
· Older age of donors
2. Recipient-related risk factors:
· extremes of age
· peritoneal dialysis
· Perioperative hemodynamic status
3. technical issues: kinking of the graft vein, a long vein, wide disparities in vessel size, and injury to the vascular endothelium
4. mechanical causes:
· a kink in the renal vein
· compression by hematomas or lymphoceles
· anastomotic stenosis
· extension of an underlying deep venous thrombosis
· compression of the renal vein by the renal artery
5. immunosuppression causes:
· cyclosporine, OKT3 antibody
· high doses of pulsed methyl prednisolone
· anti – thymocyte/antilymphocyte globulin
What is the best option?
Nephrectomy
http://www.ectrx.org/forms/ectrxcontentshow.php?year=2017&volume=15&issue=2&supplement=0&makale_no=0&spage_number=123&content_type=FULL%20TEXT#:~:text=Transplant%20Renal%20Vein,Ahmed%20Halawa2%2C4
Thank you
_The image above shows life threatening and ugly scenario of acute graft rupture following renal vein thrombosis.
_The only available management option is graft nephrectomy, as reconstruction is associted with massive sensitization and poor graft outcome.
_ Patient resuscitation and available matched fresh blood to save life is essential.
_ In addition, investigation to detect cause of RVT is crucial to be in consideration in next transplant.
_Exclusion of any hypercoaguable state as antiphospholipid syndrome, any inherited or acuired thrombophilia as protein C, S and anti thrombin III defficiency.
_Early and regular surveillance US and Doppler of the graft is crucial to early detect and manage such vascular complication to salvage the graft and avoid reaching such devasting complication.
_Early detection of RVT can be managed by thrombectomy, thrombolytic therapy that may salavge the graft.
Thank you
This picture shows congested, edematous, dark coloured graft kidney with a linear rupture. It’s one of the complication of acute onset RVT.
It is also some times associated with acute rejection and ATN.
This situation is defined as renal allograft rupture (RAR).
Initially majority of RAR were associated with acute rejection and not with RVT but with use of CNI RVT has become major cause of RAR, though overall incidence has reduced.
Management:
It primarily included stabilisation of patient as it’s a catastrophic event causing haemorrhage, hypotension, shock in patient. With respect to graft, in majority of cases it lands up in doing nephrectomy because even if rupture is repaired and it’s tried to salvage the graft, it ends up in major graft dysfunction.
REF
Kidney rupture due to a renal metastasis from an adenocarcinoma of the colon (Wolff et al 1994) and metastasis-induced perforated appendicitis (Ende et al 1995) have been reported.
From: Handbook of Pain Management, 2003
Thankyou
·Describe the picture shown above
The picture shows a ruptured kidney allograft caused by RVT & explaining the sudden onset of pain & anuria in this scenario.
/////////////////////////////
·What is the best option?
RVT, although not common, often leads to graft loss.
Causes of post-kidney transplant RVT include:
1. Compression from hematoma or lympocele
2. Kinking or angulation of the vein
3. Strictures of the anastomoses
4. Hypercoagulopathies & DVT
Management
Early clinical diagnosis is needed to salvage the graft.
Color flow Doppler will show swollen graft with a crescent of clot along the convex margin of the graft; the patient should immediately be rushed to the theatre in such situation.
Treatment
Urgent thrombectomy is the treatment of choice once the diagnosis of RVT is established.
Graft salvage, however, may not be possible (as the case in this current scenario), in which case the graft nephrectomy is inevitable.
References
Alexandros Giakoustidis, Nikolas Antoniadis and Dimitrios Giakoustidis Vascular Complications in Kidney Transplantation. October 28th, 2010 Published: September 6th, 2011 DOI:10.5772/18672
It is ruptured.
Renal vein thrombosis typically occurs in the early postoperative period and may result from kinking of the renal vein, stenosis of the venous anastomoses, hypotension, hypercoagulable state, and acute rejection.
With intraoperative venous thrombosis, the allograft appears swollen and cyanotic, and a clot may be palpable in the renal vein.
Delayed renal vein thrombosis is usually diagnosed by Doppler ultrasonography
because a clot may be visualized in the vein with decreased blood flow to the allograft.
Although thrombolytic therapy may be helpful, when possible emergent thrombectomy with revision of the anastomosis should be attempted. Unfortunately, these grafts are usually lost because of the prolonged ischemia time and require allograft nephrectomy.
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
Did you notice the ruptured graft.
Describe the picture shown above
The above figure shows classical picture of transplant renal vein thrombosis ( swollen, cyanosed and ruptured allograft) which is fatal and have devastating complications.
What is the best option?
With the above picture, the patient needs allograft nephrectomy as thrombolytic therapy thrombus-aspiration and surgical thrombectomy seems more of theoretical options and practically results poor. So better is prevention which can be done by avoiding all risk factors like multiple vascular anastomoses, prolonged ischemia time, Iatrogenic vascular injuries , techniques during operation and maintaining adequate hydration status ,and avoiding long term steroids use and doing detailed workup of thrombophilia and APLA before transplant.
References:
1-El Zorkany K, Bridson JM, Sharma A, Halawa A. Transplant Renal Vein Thrombosis. Exp Clin Transplant. 2017 Apr;15(2):123-129. doi: 10.6002/ect.2016.0060. PMID: 28338457.
2-Duckett T., Bretan P.N., Cockran S.T., Rajfer J., Rosenthal J.T. Non-invasive radiological diagnosis of renal vein thrombosis and renal transplantation. J. Urol. 1991;146:403–406.
Thankyou well done
The transplanted kidney is swelling and has ruptured. This is a late finding. The first 2-3 days may mask the pain because of analgesics given, and usually, there is late discovery. Therefore conservative treatment and thrombectomy are not successful, nephrectomy is mandatory in most cases.
——-
3 weeks ago, we had a similar case, the patient was 48 years old, Had a BMI of 40, but he refused dialysis. our team failed to persuade him to go with Hd, refused the fistula etc. The trasnplanted kidney was taken from his sister. He has excellent urine with deceleration till the third day. Heis now on HD with a temporary catheter. He was on colpedogrel because of ischemic heart disease which was restarted after trasnplantation.
Thankyou for joining with your similar case.
*The above image showed : RT longitudinal incision at right iliac fossa protruded from it rupture , edematous allograft kidney with scattered cyanosed areas due to renal vein thrombosis of transplanted graft (TRVT).
*Thrombolytic therapy , surgical thrombectomy could be tried but ,the best option is allograft nephrectomy because allograft cannot be salvage being always too late diagnosis.
*Prevention of RVT is most important because of bad outcomes and late presentation , 1. Being aware of all risk factors as; hypercoagulable state assessed by thrombophilia profile , obesity , multiple or long veins, some immunosuppression as use of CNI.
2.fine accurate surgery with maintain volume status and post-transplant close follow up, Low dose aspirin may be of little benefit.
References:
1. El Zorkany K, Sharma A, Halawa A.,etal; Transplant Renal Vein Thrombosis. Exp Clin Transplant. 2017 Apr;15(2):123-129.
2.Wilson CH, Wyrley-Birch H, et al. :Donor risk factors for renal graft thrombosis. Transplant Proc. 2007;39(1):138–139.
Thankyou Dina the condition here is graft rupture due to TRVT so there is no place for thrombolytic therapy.
Describe the picture shown above
The allograft kidney looks oedematose, ruptured and areas of cyanosis seen. This is the complication of renal vein thrombosis
What is the best option?
Renal vein thrombosis always presents late and unlikely can be salvaged.
The allograft kidney nephrectomy should be done.
Renal vein thrombosis may also result in a high mortality rate due to graft rupture and embolic complications
The patient should be screened for precipitating cause for the renal vein thrombosis and hematologic studies
Reference
Mark Lerman, Matthew Mulloy, Christie Gooden, Salman Khan, Ali Khalil, Lincoln Patel, Xin J Zhou,
Post transplant renal vein thrombosis, with successful thrombectomy and review of the literature,
International Journal of Surgery Case Reports,
Volume 61,
2019,
Pages 291-293,
ISSN 2210-2612,
https://doi.org/10.1016/j.ijscr.2019.07.066.
(https://www.sciencedirect.com/science/article/pii/S2210261219304481)
Thankyou well done
The image shows a ruptured, swollen, cyanosed allograft seen as a complication of of transplant renal vein thrombosis (TRVT).
The best option in this scenario is graft nephrectomy as the graft is not salvageable.
For the management of TRVT, there are other theoretical options like thrombolysis (for TRVT in late transplant period) and Surgical thrombectomy. In subacute or chronic TRVT, combined percutaneous mechanical thrombectomy and localized catheter-directed thrombolysis has been used. But the results of these are abysmally poor.
Prevention: Due to poor outcomes of TRVT, prevention is important. Meticulous surgery with taking care of all risk factors is the key for preventing TRVT. Maintaining adequate intravascular volume status, ipsilateral transplant in deceased donors and close monitoring post-transplant is important. Low dose aspirin and low molecular weight heparin use is beneficial.
References:
1) El Zorkany K, Bridson JM, Sharma A, Halawa A. Transplant Renal Vein Thrombosis. Exp Clin Transplant. 2017 Apr;15(2):123-129. doi: 10.6002/ect.2016.0060. PMID: 28338457.
Thank you
Describe the picture shown above :
Swollen , congested , Cyanosed with a rupture on the kidney
With an incidence rate of 0.1%-3.4%, transplant renal vein thrombosis (TRVT) is a catastrophic vascular event that typically results in allograft loss and nephrectomy.
Risk Factors :
Technique during operation :
vein kinking,
lengthy veins,
multiple veins, and endothelial damage
Recipient factors
increase thrombophilia ( APL syndrome , Protein C and S Deficiency , Homozygous Factor V mutation or MTHFR mutation )
obesity (BMI >30 kg/m2)
Older age
Immunosuppression
use of MMF and CNI
What is the best option?
Successful management of salvaging the allograft is often difficult, resulting in allograft loss>> Allograft Nephrectomy in most cases
However :
thrombolytic therapy thrombus-aspiration and surgical thrombectomy may be tried
References
Sanni A, Wilson CH, Wyrley-Birch H, et al. Donor risk factors for renal graft thrombosis. Transplant Proc. 2007;39(1):138–139.
Aktas S, Boyvat F, Sevmis S, Moray G, Karakayali H, Haberal M. Analysis of vascular complications after renal transplantation. Transplant Proc. 2011;43(2):557–561.
Eufrásio P, Parada B, Moreira P, et al. Surgical complications in 2000 renal transplants. Transplant Proc. 2011;43(1):142–144.
Thank you, well done
The picture showed: cyanotic, swollen, rupture allograft secondary to RVT.
-RVT post kidney transplant is a rare but graft threatening event.
– It is reported in 0.3–4.2% of kidney transplants.
– The outcome is usually poor because of the lack of collateral circulation with the venous flow originating from the renal vein.
-This can not only lead to the loss of the graft itself but may also result in a high mortality rate due to graft rupture and embolic complications.
-Early diagnosis and urgent treatment are necessary but often unsuccessful.
-The best treatment option in this case is graft nephrectomy to save patient life.
– Revascularization with thrombolytic therapy, thrombus-aspiration, or direct surgical thrombectomy have been rarely show success.
References:
Bakir N, Sluiter WJ, Ploeg RJ, et al. Primary renal graft thrombosis. Nephrol Dial Transplant 1996; 11:140.
Lerman M, Mulloy M, Gooden C, Khan S, Khalil A, Patel L, Zhou XJ. Post transplant renal vein thrombosis, with successful thrombectomy and review of the literature. Int J Surg Case Rep. 2019;61:291-293. doi: 10.1016/j.ijscr.2019.07.066. Epub 2019 Jul 31. PMID: 31401437; PMCID: PMC6699557.
Dear Dr Hadeel,
I like your summary and analysis.However, I have never seen success of thrombectomy or thrombolytic therapy in a patient with RVT. By the time, RVT is diagnosed, it is too late.
Ajay
Swollen, cyanosed and ruptured graft
Graft nephrectomy is the only option as the graft is not viable.
Hi Dr Heba,
I like your lucid decision-making. I wish you could have written more details of your approach with relevant references.
Ajay
The picture shows rupture graft cpsule , following renal vein thrombosis.
It occur hours to days post operative, although late occurance could be happen.
Best option;
Does all ruptures allograft removed;
Finally;
Ruptured allograft, can be preserved if;
Refferences;
Fathi T, Samhan M, Gawish A, Donia F, Al-Mousawi M. Renal allograft venous thrombosis is salvageable. Transplant Proc 2007;39:1120-1.
.Aschwanden M, Thalhammer C, Schaub S, Wolff T, Steiger J, Jaeger KA. Renal vein thrombosis after renal transplantation-early diagnosis by duplex sonography prevented fatal outcome. Nephrol Dial Transplant 2006;21:825-6.
Irish A. Renal allograft thrombosis: can thrombophilia explain the inexplicable?, Nephrol Dial Transplant, 1999, vol. 14 (pg. 2297-2303)Google ScholarCrossrefPubMedWorldCat
2Smith JM, Stablein D, Singh A, et al. Decreased risk of renal allograft thrombosis associated with interleukin-2 receptor antagonists: a report of the NAPRTCS, Am J Transplant, 2006, vol. 6 (pg. 585-588)
. Starzl TE. Experience in Renal Transplantation. Philadelphia: WB Saunders Co; 1964.
2. Weil R, III, Schröter GPJ, West JC, et al. A 14-year experience with kidney transplantation. World J Surg. 1977;1:145–156.
3. Murray JE, Wilson RE, Tilney NL, et al. Five years’ experience in renal transplantation with immunosuppressive drugs: Survival, function, complications and the role of lymphocyte depletion by thoracic duct fistula. Ann Surg. 1968;168:416–435.
Dear Dr Kamal,
I like your summary and analysis.However, I have never seen success of thrombectomy or thrombolytic therapy in a patient with RVT. By the time, RVT is diagnosed, it is too late.
Ajay
Describe the picture shown above:
The graft kidney is grossly swollen and dark with areas of hemorrhage and infarction with graft rupture due to increased intra-renal pressures as there is no outflow
What is the best option?
The best option is nephrectomy as the graft is not salvageable
Renal vein thrombosis post kidney transplant is a rare but graft threatening event. It has a reported incidence of 0.3%-4.2% of kidney transplants. Early diagnosis and urgent intervention is often necessary but almost always unsuccessful and requires graft nephrectomy
International Journal of Surgery Case Reports 61 (2019) 291-293
I like your summary and analysis.
Ajay
Describe the picture shown above :
What is the best option?
Well done
Describe the picture shown above
Gross appearance of graft swelling (infraction) and impending rupture this is a thrombosed graft DDX including accelerated vascular rejection, vascular thrombosis (renal vein thrombosis vs arterial thrombosis, TRVT is one of rare and catastrophic complication early post-transplantation and prevention is the best option.
What is the best option?
The best option is the prevention of such catastrophic complications by addressing those at risk and the need for meticulous surveillance post-operative by doppler US and daily graft function and use of anticoagulation.
in this -indexed case, it is too late to salvage this graft, he should go for a graft nephrectomy and sends for a histopathology study to address the underlying cause.
Risk factors for TRVT (1)
1. Donor-related or recipient-related risks
2. technical risk with short renal vein and risk of compression by a longer artery or longer vein and risk of kink,
3. multiple vascular anastomoses,
4. long ischemia time, IRI
5. PD as dialysis modality
6. pediatric transplant with the size difference
7. Hypovolemia and hypercoagulable state
8. Primary diseases like APL, Membranous nephropathy
9. Iatrogenic vascular injuries
Immunosuppressive medication and risk of thrombosis ( CNI, steroid ATG )
references
1. Transplant Renal Vein Thrombosis Khaled El Zorkany,1,2 Julie-Michelle Bridson,2 Ajay Sharma,2,3 Ahmed Halawa2,4
Well done