Papillary Necrosis in a Kidney Transplant Following Profound Hypotension

Abstract

We describe a case of a young woman developing profound hypotension requiring inotropic support for 10 days following her second cadaveric renal transplant. Her central venous pressure was adequate, with no evidence of myocardial infarction, and an echocardiogram later showed normal left ventricular function. She had delayed graft function with gradual recovery of her renal functions. On day 45, she developed acute renal failure after removal of a ureteric stent. Ultrasound confirmed hydronephrosis, and a subsequent nephrostogram demonstrated filling defects, likely to be sloughed papillae, causing obstruction. She later had percutaneous removal of necrotic material from the ureter in order to establish free urinary flow with stability of her renal functions. The most likely explanation for papillary necrosis in our patient was profound hypotension postoperatively. We believe our patient's hypotension was secondary to dialysis‐associated cardiovascular autonomic dysfunction, with substantial improvement in blood pressure after a successful renal transplant.