Page Kidney Causing Reversible Acute Renal Failure: An Unusual Complication of Transplant Biopsy

Abstract

Despite its importance, kidney allograft biopsy carries the limitations of potential morbidity. Among the most unusual complications is the occurrence of Page Kidney. Page Kidney generally refers to the development of renin-dependent hypertension due to the effects of external compression of the kidney by either acute or chronic hematoma. This phenomenon was initially demonstrated in dogs by Page in 1939 after wrapping one or both kidneys in cellophane. Currently, Page Kidney is most often seen following renal trauma (1–3). In this report, we describe a dramatic form of Page Kidney following allograft biopsy. A 32-year-old male with type 1 diabetes mellitus presented with nausea, vomiting, allograft pain, and decreased urine output. One year prior to admission, the patient had received a living unrelated kidney transplant. His posttransplant course was unremarkable. Three weeks prior to admission, the patient underwent a kidney allograft biopsy at another center due to an increase in serum creatinine to 1.8 mg/dL from a baseline of 1.3 mg/dL. The biopsy disclosed mild cyclosporine toxicity; the patient was discharged with a serum creatinine of 1.4 mg/dL. Two weeks postbiopsy, the patient noticed a dull pain over the transplanted kidney and found the kidney to be enlarged and firm. One day prior to admission, nausea and vomiting ensued. On presentation, the patient was acutely ill with persistent retching and blood pressure of 190/89 mmHg. The transplant allograft in the left lower quadrant was firm, enlarged, and minimally tender, with an audible bruit. Anuria developed, and the serum creatinine was 6.7 mg/dL. After emergent hemodialysis, an ultrasound demonstrated a circumferential fluid collection of the allograft. The presence of circumferential fluid collection, recent biopsy, and anuric renal failure led us to consider the diagnosis of Page Kidney. Figure 1 is an arteriogram of the allograft. At the lower pole is a moderate-sized pseudoaneurysm which was treated with embolization. Also seen is the attenuation of the demarcation at the cortex with a blush-like appearance, a visual effect of external compression.FIGURE 1.: Angiography of the transplanted kidney, demonstrating a moderate size pseudoaneurysm (dark arrow) and blushing of the cortical demarcation (whitearrows).The patient then underwent open surgery for evacuation of the peritransplant hematoma. Anuria had been present at this time for nearly 24 hr. Evacuation of the hematoma was followed by the immediate formation of urine. Postoperatively, the blood pressure fell to 150/85 mmHg and urine output increased to 3 L/day by the second postoperative day. By the fourth postoperative day, the serum creatinine had returned to 1.4 mg/dL and the patient was discharged. This case report represents a serious complication of kidney biopsy, an acutely developing Page Kidney that resulted in severe hypertension and acute renal failure. It also documents for the first time a multidisciplinary approach to Page Kidney from nephrologists, radiologists, and transplant surgeons. In the transplant population, external compression of a solitary kidney causes acute renal failure, which may have devastating and permanent consequences (4, 5). In the present report, early recognition of Page Kidney and immediate radiologic and surgical intervention were paramount in saving the transplanted kidney. Eric M. Gibney Charles L. Edelstein Alexander C. Wiseman Division of Renal Diseases and Hypertension University of Colorado Health Sciences Center Denver, Colorado Thomas Bak Division of Transplant Surgery University of Colorado Health Sciences Center Denver, Colorado