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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 2  |  Page : 248-252
Unusual Causes of Sudden Anuria in Renal Transplant Patients


1 Department of Nephrology, North West Armed Forces Hospital, Tabuk, Saudi Arabia
2 Department of Radiology, North West Armed Forces Hospital, Tabuk, Saudi Arabia
3 Department of Surgery, North West Armed Forces Hospital, Tabuk, Saudi Arabia

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   Abstract 

Sudden unexplained anuria in renal transplant patients could well be secondary to occult internal hemorrhage Erather than the usual vascular thrombotic or obstructive event, even in the completely stable patient. Urgent intervention in such bleeding states can save a patient's life and graft function. Graft survival is very exceptional in graft artery or vein thrombosis. Contrary to hemorrahagic events, life is usually not threatened by thrombotic events involving the renal graft vasculature. We present here three unfortunate cases that shared the problem of unexpected anuria due to a hemorrhagic event in apparently stable renal transplant patients.

Keywords: renal transplant, anuria, anastomosis, subcapsular, acute renal failure, hematoma, hemorrhage

How to cite this article:
Abutaleb N, Obaideen A, Zakaria M, El Jubab A, Hamza A, Younis S, Adem M. Unusual Causes of Sudden Anuria in Renal Transplant Patients. Saudi J Kidney Dis Transpl 2007;18:248-52

How to cite this URL:
Abutaleb N, Obaideen A, Zakaria M, El Jubab A, Hamza A, Younis S, Adem M. Unusual Causes of Sudden Anuria in Renal Transplant Patients. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2019 Nov 14];18:248-52. Available from: http://www.sjkdt.org/text.asp?2007/18/2/248/32318

   Introduction Top


We tackled three episodes of sudden anuria in three renal transplant patients within a short period during 2005. Though the outcome of these cases was most unfavorable, it would still be helpful to share such experiences with other colleagues caring for similar patients. None of these patient's mortality was encountered in our practice over the past 14 years. The cause of death in two of these patients was not directly related to the cause of anuria; two of the three patients presented here died because of septic shock secondary to ICU acquired multi-drug resistant (MDR) acine­tobacter infection.


   Case Report 1 Top


A 68 year-old man received a deceased renal transplant (DRTX), and was started on tacro­limus (0.15 mg/kg/day) based triple immuno­suppressive therapy because of delayed graft function (DGF). The patient was kept on prophylactic tinzaparin once daily at 4,500 units subcutaneously.

Two weeks post-DRTX, serum creatinine (S.Cr) plateaued at 150-180 µmol/L. At that time, an ultrasound (US) guided renal biopsy (Bx) was obtained (single core through one pass using an 18G Biopty needle and gun). No complications were observed. Mild acute rejection was revealed histopathologically, and methylprednisolone i.v. pulse therapy (250 mg x 3) was initiated.

Sub-therapeutic heparin was resumed three days later because of an episode of chest pain consistent with angina pectoris.

After two days, the patient complained of sudden onset graft pain. Urgent US exami­nation was carried out and repeated over five hours. Perinephric hematoma was detected on the initial examination. The patient received an immediate i.v. protamine sulfate dose to counteract the sc heparin effect. Anuria deve­loped simultaneously with the onset of pain. The repeated US revealed the presence of left ilio-femoral deep vein thrombosis (DVT) that was not present on the earlier exam, [Figure - 1]. The DVT extended up to the entry of the renal graft vein. Resistive index (RI) of the graft deteriorated from 0.87 to 1.0 over the five hour interval between the two US tests. Compu­terized tomography (CT) of the abdomen revealed extension of the hematoma to the pelvis. As sudden anuria was unexplained by the US findings, a renal scan was ordered, and revealed an acceptable renal graft perfusion and further ruled out the possibility of renal graft vascular occlusion. Inferior vena cava (IVC) filter insertion was ordered, but could not be performed. As the hematoma seemed stable by evening of that day, anticoagulation therapy was resumed with low dose heparin infusion (600 units/hour).

Eight hours later, however, the patient developed hypoxemia (oxygen saturation was 70%) and his blood pressure (BP) dropped to 69/32 mm Hg, which then became unde­tectable. The patient was immediately resusci­tated and intubated. The picture was consistent with hemorrhagic shock rather than massive pulmonary embolism. US supported this diagnosis and heparin was reversed with protamine sulfate. Coagulopathy was corrected to the normal range by aggressive replacement therapy. Surgical exploration was contem­plated. The next morning, the patient's abdomen became extremely tense; thigh muscles became tense and all peripheral pulses were lost. Bleeding from the arterial anasto­mosis of the renal graft was found on surgical exploration which was carried out about 48 hours after onset of the graft pain. The kidney was removed and the leak was sealed. No other bleeding focus was observed.

Postoperatively, the patient developed overt disseminated intravascular thrombosis (DIC) and rahabdomyolysis, besides ventilator related pneumonia secondary to MDR acinetobactor. Despite the antibiotics, imepenem and colistin, we failed to eradicate the bacteria from blood and the patient expired about one month after the hemorrhagic event from multiorgan failure.


   Case Report 2 Top


A 20 year-old woman who received a living unrelated renal transplant (LURD) abroad was new to our hospital. Her reports revealed that she had a past history of nephrectomy of Lt. dysplastic native kidney. The bladder trabeculations and hyper echoic large right native kidney on ultrasound imaging were consistent with probable adult recessive polycystic kidney disease (ARPKD). The patient also had also history of periportal fibrosis, and hypersplenism. She was admitted for evaluation of fever and lower abdomen pain.

On physical exam, the patient was not in distress, with BP 120/84, pulse 108/min, T 37.9. Her exam was remarkable only for splenomegaly (4 cm x 6 cm). The laboratory investigations revealed pancytopenia (WBC 3.0 x 10 3 , hemoglobin (Hgb) 67 g/L, platelet 38 x 10 3 /mm 3 ), and S.Cr 86 µmol/L. Her immunosuppressive therapy was modified by discontinuation of mycophenolate mofetil and switching cyclosporine to tacrolimus.

On the day of admission, the patient developed anuria. Examination revealed a palpable mass extending to just below the umbilicus. However, there was no urine output upon bladder catheterization. Suddenly, her blood pressure decreased from 119/82 to 77/50. Rapid fluid resuscitation was initiated; however, the patient progressed to cardiac arrest and did not respond to one hour of resuscitation that included four units of packed red blood cell transfusion. Her abdomen became very distended by the time of declaring her death. Though requested, no US examination or surgical intervention could be performed because of the rapid development of cardiac arrest.


   Case Report 3 Top


A 65 year-old man received a LURD renal transplant abroad. His post-transplant course was complicated by both diabetes mellitus (PTDM) and episodes of hemoptysis that were attributed to bronchiectasis as suggested by a CT scan of the chest.

Two months after transplantation, the patient was admitted with an asymptomatic rise of S. Cr. The patient declined renal biopsy initially, but accepted when S.Cr reached 300 µmol/L. One core was obtained with a single US guided pass, utilizing an 18G Biopty needle and gun. He became anuric after the biopsy for no obvious reasons. Repeat of US performed six hours later revealed a 1 cm "hematoma" with no evidence of obstruction. Renal scan confirmed the presence of perfusion with no evidence of urinary tract obstruction. The anuria recovered sponta­neously about 12 hours later, with urine output improving to a rate of >100 ml/hour followed by recurrence of oliguria 36 hours later. The renal biopsy revealed no specific pathology. F Further follow-up US, about five days post­biopsy, showed progression of the subcapsular hematoma to two cm [Figure - 2]A, which was confirmed by a CT scan.

Meanwhile, Cthe patient developed severe bilateral bronchopneumonia that progressed quickly to respiratory failure. Drainage of the subcapsular hematoma was postponed because of the worsened general condition of the patient. Septicemia with multi-drug resistant acinetobacter complicated the patient's condition and immunosuppressive therapy was withdrawn. Despite the use of i.v. colistin therapy to treat MDR acinetobactor septi­cemia, the condition progressed over a week later into a resistant shock that resulted in the expiration of the patient.


   Discussion Top


Sudden anuria in renal transplant patients is a classical emergency event that usually results from either a major vascular thrombotic event, or obstructive uropathy. We report here anastmosis blood leak and subcapsular hema­toma as two unusual causes of graft anuria. Early diagnosis and intervention in such conditions may not only save the patient's life, but may also save the graft itself.

In our patients, progressing to massive hemorrhage was slow and occult and was not suggested initially by the stable vital signs. However, anuria, though may be a late sign, should trigger complete and emergent work­up that includes ultrasound of any suspected swelling in the vicinity of the transplanted renal graft, besides renal scan of the graft in order to rule out thrombosis of the graft's vessels. Mukut Minz et al [1] have described similar early fatal hemorrhagic presentation associated with intense abdominal pain in the 8th post-operative day in a 52 year-old renal transplant patient. Immediate exploration was carried out after resuscitation, but the patient could not be salvaged. The graft artery showed a 1 x 1 cm perforation distal to the anasto­mosis. Post-mortem biopsy of the arterial wall showed transmural necrotizing inflam­mation with broad aseptate fungal hyphae characteristic of mucormycosis. Myriam Pastural et al [2] described similar hemorrhagic shock on the 18 th post-transplantation day due to a graft artery rupture secondary to Mycoplasma hominis infection. The timing of the anuria in our first and second cases was on the 18 th and the 11 th days post-transplantation, which suggested occult infection.

In the 3rd case, anuria was due mostly to subcapsular hematoma of 1.0 cm width and extension for 10 cm around the renal graft. A CT scan can be helpful for the proper evaluation of the hematoma volume. Anuria secondary to the subcapsular hematoma in patients with solitary kidneys, including renal transplant patients, was reported previously.[3],[4],[5] Murty et al [6] considered subcapsular hematomas of <2 cm as insignificant, which was clearly not the case with our patient. Only a few reports of subcapsular hematoma in renal transplant patients exist. Rea et al [5] observed that only one subcapsular hematoma­induced anuria in renal transplant patients was reported in the literature prior to their case. Thickening of the perinephric capsule secondary to earlier wound infection three years earlier to the biopsy might have precipitated the bleeding that resulted in the compression of the renal parenchyma and anuria. Such capsule thickening is obviously unexpected to be significant at this stage in our recently transplanted patient. Later yield in the renal capsule in our patient allowed early recovery of urine flow and improvement of R.I despite significant increases in hematoma size indicated above. Transient renal tamponading effect may explain the loss of the correlation between the hematoma size and its functional effects.

 
   References Top

1.Minzm M, sharma A, Kashoop R et al. Isolated renal allograft arterial mucor­mycosis: an extremely rare complication. Nephrol Dial Transplant 2003;18: 1034-35.  Back to cited text no. 1    
2.Pastural M, Audard V, Bralet MP, et al. Mycoplasma hominis infection in renal transplantation, Nephrol Dial Transplant 2002;17: 495-6.  Back to cited text no. 2    
3.Figueroa TE, Frentz GD. "Anuria secondary to percutaneous needle biopsy of a transplant kidney: a case report. J Urol 1988;140(2):355-6.  Back to cited text no. 3    
4.Lee S, Park SK, Jin Gy, et al, Spontaneous renal subcapsular haematoma and acute renal failure complicated by severe pre-eclampsia. Nephrol Dial Transplant 2003;18: 625-6.  Back to cited text no. 4    
5.Rea R, Anderson K, Milchell D, Harper S, Williams T. Subcapsular haematoma: a cause of post biopsy oliguria in renal allografts. Nephrol Dial Transplant 2000;15: 1104-5.  Back to cited text no. 5    
6.Murty MSN et al, Should we be doing renal graft biopsy without ultrasound guidance?, Indian J Nephrol 2002;12: 25-26.  Back to cited text no. 6    

Top
Correspondence Address:
Nasrulla Abutaleb
King Fahad Specialist Hospital, P.O. Box 15215, Dammam-31444
Saudi Arabia
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PMID: 17496403

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    Figures

  [Figure - 1], [Figure - 2]

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    Abstract
    Introduction
    Case Report 1
    Case Report 2
    Case Report 3
    Discussion
    References
    Article Figures
 

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