A Case of Recurrent Episodes of Acute Renal Allograft Failure Caused by Renal Pedicle Tortion

Abstract

Background: Acute allograft failure which occur intermittently after renal transplantation caused by graft tortion is a very rare entity. We here report highly unusual case of recurrent episodes of acute allograft dysfunction two years after kidney transplantation secondary to ischemic tubular necrosis caused by tortion of renal pedicle due to rotation of the allograft with body movements. Case Presentation: A 55 year-old male patient with living unrelated kidney transplantation for chronic renal failure caused by autosomal dominant polycystic kidney disease had presented recurrent acute deteriorations in renal functions. All laboratory values were within normal limits except elevated serum creatinine levels, acute tubular necrosis in graft biopsy, and detection of pelvic dilatation in renal ultrasonography from time to time. Changes in axis of graft in nuclear medicine scans taken at different times during the same study made us bring to mind the diagnosis of renal pedicle tortion. Renal blood flow measurements with Doppler ultrasonography in different body positions helped to reach the final diagnosis of mobile kidney right on time. The patient is now well after prompt surgical treatment with nephropexy. Discussion: Unfortunately, tortion of allograft once occurred is associated with very high rate of graft loss due to arterial compromise and infarction and it is very difficult to diagnose without high level of suspicion. We discuss the causes of renal allograft tortion and the measures to prevent its occurrence and the methods to diagnose.

Post-transplantation nephroptosis causing recurrent episodes of acute renal failure and hypertension secondary to intermittent vascular torsion of intraperitoneal renal allograft

“…Post-transplant nephroptosis is a rare but potentially severe complication of intraperitoneal kidney transplant that can be successfully managed with appropriate surgical intervention [5]. It should be suspected in all patients with acute vascular compromise or recurrent episodes of renal failure without discernable cause.…”

Partial Renal Transplant Torsion as a Cause of Abdominal Pain

“…[ 2 ] Placement of the transplanted kidney in an intraperitoneal position, rather than the standard extraperitoneal position, can enhance mobility of the allograft, further contributing to its potential to torse. [ 3 ] Another predisposing risk factor is immunosuppressive use after transplant, which can prevent the formation of adhesions and enable intra-abdominal movement of the grafted kidney. [ 4 ] Intraperitoneal transplantation of a renal allograft is often done when simultaneous kidney-pancreas transplantation is performed.…”

“…[ 1 ] Imaging at times can fail to make the diagnosis of torsion, and some cases are diagnosed during laparotomy for presumed renal infarction. [ 3 ]…”

“…[ 1 ] Prophylactic nephropexy may be recommended only for transplanted kidneys that have a relatively high probability of torsion, such as those with a pedicle longer than 5 cm or those with a >2 cm difference between the length of the renal artery and vein. [ 2 , 3 ]…”

“…[5] ere is currently debate as to which imaging modality best visualizes renal allograft torsion. e most suggestive finding is a change in axis of the allograft seen on CT or magnetic resonance imaging (MRI) [5] and less commonly on nuclear imaging; [3] previous imaging studies for comparison are useful. Contrast-enhanced imaging can demonstrate characteristic "kinking" of the renal artery.…”