Correspondence To Editor

CLINICS 2008;63(1):147-8
LETTER TO THE EDITOR
A WELL-DOCUMENTED CASE OF CHRONIC RENAL

FAILURE DUE TO MISPLACEMENT OF THE
TRANSPLANTED KIDNEY
Paulo Rodrigues a, Flavio Hering a, Antonio Gil b
INTRODUCTION
There may be many reasons for the malfunctioning of

transplanted organs. Percutaneous biopsy can easily be un-
dertaken to give greater specificity to possible immunologi-
cal causes of rejection.1,2
Acute venous or arterial thrombosis frequently leads to
graft loss after a short period of anuria which justifies a
diagnosis of vascular occlusion. This causes graft dysfunc-
tion or loss in 3.5% to 12.5% of cases. 3,4 Progressive
malperfusion with rising or stabilized serum creatinine at
higher levels demands aggressive imaging investigation to
exclude possible aneurismal formation, progressive steno-
sis, or vascular fistula. This paper reports a rare case of
kinking of the main artery due to organ rotation occurring
after a simultaneous pancreas-kidney transplant.
CASE REPORT Figure 1 - Magnetic resonance showing an upper pole lymphocele displacing
the renal graft.
A 52-year-old non-dialytic man with long-standing dia-

betes was submitted to simultaneous cadaveric pancreas-
kidney transplant through peritoneal access. The right kid-
ney and the pancreas from the same donor were sewn into
the left flank by venous and arterial termino-lateral anas-
tomosis in the iliac vessels. After an uneventful operation,
the serum creatinine level dropped from 4.5 mg/dl and sta-
bilized at 1.8 mg/dl on the seventh PO day in conjunction
with a mild hypertension. Magnetic resonance angiogra-
phy (MRA) showed a well perfused kidney (Figure 1). The
patient had a renal biopsy revealing acute tubular necrosis
(ATN). Cyclosporine, prednisone and mycophenolate
mofetil were maintained. On clinical follow-up, creatinine
level varied from 2.2 to 4.4 mg/dl and a new biopsy re-
vealed persistent ATN. The cyclosporine level was kept at
150-250mg/dl. After three months, new MRA imaging re-
vealed a well perfused, but dystopic kidney (Figure 2) dis-
a
Urology Department, Hospital Beneficncia Portuguesa - So Paulo/SP,
Brazil.
b
Urology Department, Hospital do Corao - So Paulo/SP, Brazil. Figure 2 - Magnetic resonance angiography showing the main renal artery
[email protected] of the graft twisted.
147
A well-documented case of chronic renal failure due to misplacement of the transplanted kidney CLINICS 2008;63(1):147-8
Rodrigues P et al.
placed by a 500 ml lymphocele in the upper pole. reported in the literature.7 The kidney becomes loose in the
On the 120th PO day, the patient was submitted to open peritoneal cavity and, as seen in our case, the intra-perito-
surgical exploration but the arterial de-torsion was quite dif- neal approach did not prevent lymphocele formation.
ficult due to an intense fibrotic reaction, resulting in kid- Although widely discussed, torsion or compression of the
ney retrieval after massive arterial lesion. pedicle and displacement of the graft have rarely been re-
ported in the literature8,9 due to inadequate methods of visu-
DISCUSSION alization or restricted usage of imaging tools because of their
invasiveness and lack of contrast. Arterial stenosis or kinking
Complications arising from kidney transplants may re- at the vascular anastomosis may occur in 3.5% to 12.5%3,4
sult from immunological, urological, or vascular causes.5 of grafts, but invasive investigation could not be justified un-
Leakage of urine through the incision and/or persistent anu- less hypertension or progressive graft loss supervenes.
ria are signs of early urological problems. These scenarios The advent of MRA has allowed for the study of the
are usually investigated by percutaneous biopsy and ultra- vascular pedicle with minimal clinical manipulation and
sound exploration, either of which may indicate problems no nephro-toxicity. Conventional arteriography, despite high
with causes ranging from immunological to surgical issues. resolution, is limited by its planar nature. MRA is a desir-
Asymptomatic lymphocele collections are a well-known able approach due to the possibility of image reconstruc-
complication related to rejection or to improper donor lym- tion into a 3D image.
phatic ligation during the harvesting dissection. In our case, there was evident torsion of the pedicle in
Lymphocele formation is a frequent event in kidney the post-operative period leading to stabilization of the de-
transplantation, occurring in 22% of cases, although it does creasing creatinine levels at an elevated level with fluctua-
not seem to be associated with the source of the kidney, tions thereafter. The torsion was evident in the open field,
but rather with rejections or ATN episodes.6 but the fibrosis impeded a simple manual de-torsion. Knotty
Most lymphocele formations are asymptomatic and do resection and re-anastomosis led to thrombosis and graft
not harm the graft, but large or irregularly positioned for- loss, revealing the difficulty in approaching the pedicle in
mations may hamper the functioning of the ureter or im- surgical revisions for vascular complications. As reported
pede vascular flow. by others, this results in a higher rate of transplant nephrec-
In our case, it is noteworthy that the decrease in the cre- tomies.3
atinine level ceased after the patient resumed walking, which It is impossible to determine the real cause of the de-
possibly contributed to kidney displacement and torsion. Since scribed displacement, but it may be related to the intra-peri-
fluid collection is more frequent in simultaneous pancreas-kid- toneal position of the kidney frequently used for simulta-
ney grafting, some authors advocate intra-peritoneal placement neous pancreas-kidney transplants. This approach, as well
of both organs in order to avoid retroperitoneal collections fre- as peritoneal fenestration, has been advised10 in order to
quently seen from minor pancreatic collections. minimize the formation of lymphoceles and to facilitate
The potential complication of renal pedicle torsion re- peritoneal absorption of intra-abdominal collections, but it
lated to this approach is a concern, though it has never been did not provide absolute prevention in our case.
REFERENCES
1. Doyle AJ, Gregory MC, Terreros DA: Percutaneous renal biopsy: 6. Hauli RB, Stoff JS, Lovewell T: Post-transplant lymphoceles: a critical
comparison of a 1.2 mm spring-driven system with a traditional 2 mm look into risk factors, pathophysiology and management. J Urol.
hard-driven system. Am J Kidney Dis. 1994;23:498-451. 1993;150, 22-26.
2. Burstein DM, Korbet SM, Schartz MM: The use of the automatic core 7. Knight RJ, Matsumoto C: Renal pedicle torsion as a cause of acute allograft
biopsy system in percutaneous renal biopsies: a comparative study. Am after kidney-pancreas transplantation. Abstract P1-09, Acta Chirurgica
J Kidney Dis. 1993;22:545-548. Astriaca, 8th Congress IPITA, Innsbruck. June 12-15, 2001, 33:174.
3. Roye SFS, van der Vliet JA, Hoitsma AJ, Reinaerts HHM, Buskens FGM: 8. Williams SG,McVicar JP,Low RK: Endopyelotomy of ureteropelvic
Early vascular complications of renal transplanation. Clin junction obstruction caused by torsion of a renal allograf. J Urol. 1999,
transplantation. 1993;7:496-500. 161:1560-1564.
4. Rijksen JFW, Koolen MI, Warassewski JE: Vascular complications in 400 9. Marvin RG, Halff GA, Elshihabi I: Renal allograft torsion associated
consecutive renal alotransplants. J Cardiovasc Surg. 1982;23:91-95. with Prune-Belly syndrome. Ped Nephrol. 1995;9:8-10.
5. Shoskes DA, Hanbury D, Cranston D, Morris PJ: Urological 10. Zaontz MR, Firlit CF: Pelvic lymphocele after pediatric renal
complications in 1000 consecutive renal transplant recipients. J Urol. transplanation: A successful technique for prevention. J Urol.
1995;153:18-21. 1988;139:557-560.
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CLINICS 2008;63(1):147-8

LETTER TO THE EDITOR

A WELL-DOCUMENTED CASE OF CHRONIC RENAL

Paulo Rodrigues a, Flavio Hering a, Antonio Gil b

There may be many reasons for the malfunctioning of

A 52-year-old non-dialytic man with long-standing dia-

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