Acute pain over the kidney graft and Duplex-sonographic findings mimicking complete renal transplant vein thrombosis

Abstract

Keywords: Duplex-sonography; renal transplant veinthrombosis; renal vein kinking; renal vein obstructionA 33-year-old male ESRD patient received a cadavericleft kidney allograft in May 2001. The vascular ana-tomy of the kidney was normal but the renal vein wasquite long. On the first postoperative day, Duplex-ultrasound showed a well perfused graft, but thepatient required further dialysis. On the fourth post-operative day the patient complained about tendernessand pain over the graft. Routine Duplex-sonographyshowed again normal flow spectra (Figure 1). Threehours later the patient developed severe pain over thegraft region. Immediately repeated B-mode-ultrasoundand Doppler-sonography could not detect bleeding,urinary leakage or other local changes but surpris-ingly the Doppler waveform showed oscillating flowresulting in a zero forward net flow (Figure 2).Because of the typical Duplex-sonographic criteriaof outflow occlusion, a complete renal vein thrombosiswas anticipated and the patient was transferred withinthe next hour to the operating room for venousthrombectomy without any other imaging. The intra-operative aspect seemed to confirm the diagnosis ofrenal vein occlusion: the capsula of the kidney wascompletely ruptured from a perirenal haematoma, thegraft revealed an enormous size and a bluish colour.After mobilizing the kidney, kinking of the renal veindue to shrinking of the surrounding soft tissue andunfavourable tilting of the graft became apparent asthe cause of renal vein obstruction. Fortunately venousthrombosis was not present. The fibrotic tissue sur-rounding the renal vein was removed and the kidneywas placed in an oblique anatomical position to avoidcompression of the vein.Postoperative Duplex-sonography revealed unre-stricted renal perfusion with normal arterial and venousspectra (Figure 3). Diuresis started 2 weeks later andno further haemodialysis was necessary. Serum creati-nine at dismission was 2.0 mg