321 Rare Case Presentation of Renal Transplant Torsion: When Imaging Is Nondiagnostic

Abstract

RARE CASE PRESENTATION OF RENAL TRANSPLANT TORSION: WHEN IMAGING IS NONDIAGNOSTIC Kim Tran, Samir Nangia, University of California, San Diego, California, USA Renal transplant torsion is a rare complication of intraperitoneal renal transplantation and has been reported to occur as long as 10 years post transplant. Previous case reports suggest that CT scan is more sensitive than ultrasound in detecting renal transplant torsion by showing changes in orientation, swelling, hydronephrosis, or abnormal enhancement. We report a unique case presentation of renal torsion where imaging becomes non-diagnostic and the delay in diagnosis leads to graft loss. A 36 year old Hispanic female with history of ESRD secondary to type 1 diabetes with failed deceased donor kidney transplant in 1997 and simultaneous kidney-pancreas transplant (SKPT) in 2005, presents with 3 days of nausea, vomiting, fevers, and abdominal pain. She had decreased urine output over the previous 24 hours along with tenderness over the graft site on exam. She was on myfortic, cyclosporine, and prednisone for immunosuppression with a baseline serum Cr of 1.05 mg/dL noted on labs 2 weeks prior. On admit, she was noted to have serum Cr of 4.35 mg/dL and a trough cyclosporine of 241 mg/dL. Renal ultrasound showed no doppler flow in the renal artery and vein suggesting thrombosis. Abdominal CT showed inflammation and perinephric stranding of the intraperitoneal renal transplant, but otherwise no changes in orientation or hydronephrosis. Given that imaging was non-diagnostic, the patient was taken by radiology for stenting and/or angioplasty of a possible thrombosis. After unsuccessful attempts, she was the taken for an exploratory laporatomy where the intraperitoneal kidney transplant was found to have a dusky appearance with clockwise torsion. Despite surgical correction of the torsion, post operatively renal function did not improve. Biopsy showed necrosis of the kidney, and the patient was reinitiated on chronic hemodialysis. To our knowledge, this is the second documented case of renal torsion in SKPT occurring more than 5 years post transplant. We have also demonstrated a rare case of renal torsion where imaging becomes non-diagnostic and delay in diagnosis leads to graft loss.