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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 796-798
A page in transplantation

Department of Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

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Date of Web Publication9-Jul-2011

How to cite this article:
Okechukwu O, Reddy S, Guleria S. A page in transplantation. Saudi J Kidney Dis Transpl 2011;22:796-8

How to cite this URL:
Okechukwu O, Reddy S, Guleria S. A page in transplantation. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2021 Feb 26];22:796-8. Available from: https://www.sjkdt.org/text.asp?2011/22/4/796/82701
To the Editor,

The "Page Kidney" phenomenon, named after Irwin Page, [1] refers to any extra-renal process causing significant compression of the renal parenchyma, leading to hypo-perfusion and ischemia, with subsequent activation of the renin-angiotensin-aldosterone axis. [2] Any cause leading to compression of the kidney, such as peri-nephric or sub-capsular hematoma (and rarely cysts and tumors), may cause the Page Kidney. With solitary kidneys (such as renal transplant), renal insufficiency has also been reported. [1]

In Page's model, in 1939, cellophane wrapping of the kidney caused constrictive peri-nephritis, with resulting hypertension. [3],[4] Since then, there have been many reports describing various etiologies for the Page Kidney. In this report, we describe a case of Page Kidney in a renal allograft, which occurred following an antegrade pyelogram/stenting for a urine leakage at the uretero-vesical anastomosis. Early recognition of this phenomenon is vital because evacuation of the hematoma can save the allograft and lead to complete recovery of renal function. [5]

A 32-year-old man underwent an uncomplicated live-related kidney transplantation for end-stage renal disease secondary to chronic glomerulonephritis. The immediate post-operative course was smooth and routine Doppler ultrasound and Renal Dynamic Scintigraphy on the sixth post-operative day were normal. However, two days later, following removal of the Foley's catheter, the urine output dropped from 1,950 mL to 725 mL/24 hrs. Doppler ultrasonography revealed hydroureteronephrosis. Renal Dynamic Scintigraphy revealed a transplanted kidney in the right iliac fossa, with preserved function, non-obstructed clearance and evidence of urine leakage from the site of anastomosis. An antegrade pyelogram/stenting of the transplant ureter under ultrasound and fluoroscopic guidance using 4 Fr. Double J Stent was performed. A free flow of contrast across the stent was clearly demonstrated. Urine output immediately improved.

Forty-eight hours following the antegrade pylogram/stenting the patient developed a progressively increasing painful lump at the transplant site and subsequently became anuric. The serum creatinine, which was 2.0 mg/dL, rose to 4.8 mg/dL. An urgent ultrasound examination revealed a large sub-capsular hematoma compressing the pelvi-calyceal system [Figure 1]. A diagnosis of allograft compression from the sub-capsular hemotoma was made and the patient was taken for an emergency exploration and evacuation of the sub-capsular hematoma. Four hundred milliliters of clotted blood was evacuated. Output of urine recommenced immediately. The patient made an uneventful recovery, and was discharged on the eighth post-operative day, with a serum creatinine level of 1.4 mg/dL.
Figure 1: Ultrasound examination showing a large sub-capsular hematoma compressing the pelvi-calyceal system.

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In 1939, Irwin Page, [4] in an experimental study on the kidney of a dog, demonstrated the "Page Kidney" phenomenon. The first documented clinical case of the Page Kidney was reported in 1955 by Engel and Page [6] in a football player following blunt renal trauma. Most patients who present with this report a remote history of blunt abdominal flank trauma, [7] which is regarded as the most frequently associated etiological factor. [8]

Percutaneous renal biopsy, both in native and in allograft kidneys, has been well described as an etiologic factor in the literature. [9] Wanic Kossoska et al [10] reported three cases of the Page Kidney occurring in 800 consecutive native renal biopsies. As a complication of needle biopsy, perirenal hematoma is encountered more frequently than sub-capsular hematoma. [11]

Page Kidneys due to spontaneous bleeds and iatrogenic causes [9],[12] have been described as also secondary to spontaneous rupture of microaneurysms in patients with necrotizing arteritis. [13]

A small number of cases of Page Kidney in the setting of a renal allograft have also been reported. This entity has been called "pseudo rejection". [14] Nguyen et al [15] described a case arising immediately post-transplantation due to a large peri-renal hematoma. Yussim et al [16] reported the development of hypertension due to allograft compression by a lymphocele. In the classical Page Kidney phenomenon, hypertension is a hallmark presentation. Our patient's blood pressure rose only marginally to 150/100 mmHg, but returned to normal after the evacuation of the sub-capsular hematoma.

Early recognition of the Page Kidney and aggressive management are of paramount importance in transplant recipients, particularly in the setting of abnormal Doppler findings, to save the allograft. [5],[17]

   References Top

1.Patel TY, Goes N. Page kidney. Kidney Int 2007;72(12):1562.  Back to cited text no. 1
2.Chung J, Caumartin Y, Warren J, et al. Acute page kidney following renal allograft biopsy: a complication requiring early recognition and treatment. Am J Transplant 2008;8(6):1323-8.  Back to cited text no. 2
3.Moriarty KP, Lipkowitz GS, Germain MJ. Capsulectomy: a cure for the page kidney. J Pediatr Surg 1997;32(6):831-3.  Back to cited text no. 3
4.Page IH. The production of persistent arterial hypertension by cellophane perinephritis. JAMA 1939;113:2046-8.  Back to cited text no. 4
5.Gibney EM, Edelstein CL, Wiseman AC, et al. Page kidney causing reversible acute renal failure: an unusual complication of transplant biopsy. Transplantation 2005;80:285.  Back to cited text no. 5
6.Engel WJ, Page IH. Hypertension due to renal compressive resulting from subcapsular hematoma. J Urol 1955;73:735.  Back to cited text no. 6
7.Heffernan E, Zwirewich C, Harris A, et al Page kidney after renal allograft biopsy: sonographic findings. J Clin Ultrasound 2008;3:1-4.  Back to cited text no. 7
8.Castle EP, Herrell SD. Laparoscopic management of Page Kidney. J Urol 2002;168(2):673-4.  Back to cited text no. 8
9.McCune TR, Stone WJ, Breyer JA. Page kidney: case report and review of the literature. Am J Kidney Dis 1991;18:593.  Back to cited text no. 9
10.Wanic-Kossowska M, Kobelski M, Oko A, et al. Arterial hypertension due to perirenal and subcapsular hematoma induced by renal percutaneous biopsy. Int Urol Nephrol 2005;37:141.  Back to cited text no. 10
11.Machida J, Kitani K. Inadome A, et al. Sub-capsular hematoma and hypertension following percutaneous needle biopsy of a transplanted kidney. Int J Urol 1996;3:228.  Back to cited text no. 11
12.Hayder A, Bakri RS, Prime M, et al. Page kidney: a review of the literature. J Nephrol 2003;16:329-33.  Back to cited text no. 12
13.Pintar TJ, Zimmerman S. Hyperreninemic hypertension secondary to a subcapsular peri-nephric hematoma in a patient with poly-arteritis nodosa. Am J Kidney Dis 1998;32 (3):503-7.  Back to cited text no. 13
14.Crome WJ, Jordan MH, Leapman SB. Pseudo-rejection: the page kidney phenomenon in renal allografts. J Urol 1976;116:658.  Back to cited text no. 14
15.Nguyen BD, Nghiem DD, Adatepe MH. Page kidney phenomenon in allograft transplant. Clin Nucl Med 1994;19:361.  Back to cited text no. 15
16.Yussim A, Shmuely D, Levy J, et al. Page kidney phenomenon in kidney allograft following peritransplant lymphocele. Urology 1988;31:512.  Back to cited text no. 16
17.Dempsey J, Gavant ML, Cowles SJ, et al. Acute page kidney phenomenon: a cause of reversible renal allograft failure. South Med J 1993; 86:574.  Back to cited text no. 17

Correspondence Address:
Sandeep Guleria
Department of Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
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PMID: 21743233

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