Perirenal Collection Research Articles

Surgical modifications to the conventional kidney transplant technique: the Miami Transplant Institute approach in a retrospective cohort study.

At our center, surgical modifications to the conventional kidney transplant technique were developed with two goals in mind: to minimize the risk of developing post-transplant urologic/vascular/other surgical complications, and to simultaneously eliminate the need for initial ureteral stent placement and surgical drainage. Here, the authors describe these modifications along with (what we believe are) their advantages over the conventional technique: creating an abdominal flap for easier abdominal closure (reflecting the parietal peritoneum from the abdominal wall), mobilizing the bladder before transplant (creating more space for bladder dissection, allowing it to move upward during abdominal wall closure), minimizing the dissection of iliac vessels to only anterior lymphatic tissue (attempting to minimize the incidence of fluid collections), using plastic arterial vascular bulldog clamps (causing less trauma to the iliac artery), performing vascular anastomosis of the renal artery first (making it easier for the surgeon to perform the anastomoses), creating longer ureteral spatulation, and inclusion of bladder mucosa along with some detrusor muscle layer in performing the ureteral anastomosis (attempting to minimize the incidence of urologic complications). Of note, no initial ureteral stent placement or surgical drainage was used. The authors report our experience during the first 12 months post-transplant of a single transplant surgeon who used each of these modifications among 707 consecutive recipients of kidney-alone transplants at our center since 2014. During the first 12 months post-transplant, 2.3% (16/707) of patients developed a urologic complication; only 1.0% (7/707) required surgical repair of their original ureteroneocystostomy. Additionally, 2.7% (19/707) developed a vascular complication; 8.8% (62/707) developed some other type of surgical complication (wound complication, lymphocele development, or development of a peri-renal hematoma or peri-renal collection). These overall results were advantageous when compared with other studies. The authors believe that this modified kidney transplant technique clearly helped in reducing post-transplant risks of developing urologic/vascular/other surgical complications. Importantly, these results were achieved without initial ureteral stent placement or surgical drainage.

Pancreatic pseudocyst mimicking a left kidney abscess: a case report

BackgroundPancreatic pseudocyst are fluid filled sacs that develop as a result of dissection of pancreatic enzyme tissue. While most commonly found near the pancreas, they can also rarely occur in other areas such as the perirenal region.Case presentationThis study reports a new case of an infected perirenal pancreatic pseudocyst mimicking a left kidney abscess in a 46-year-old North African patient with history of recurrent acute pancreatitis, who presented with left lumbar region pain and fever. Computed tomography revealed a left perirenal collection that turned out to be an infected pancreatic pseudocyst, The diagnostic was first suspected based on the medical history of the patient and confirmed by biochemical examination detecting a high level of pancreatic enzymes in the computed tomography-guided percutaneous drainage fluid. The patient evolved well after early resuscitation, rapid and effective antibiotic therapy, and computed tomography-guided percutaneous drainage of renal collection.ConclusionPancreatic pseudocyst is an uncommon disorder, which may present at a complicated stage and that must be considered in patients with a history of pancreatitis.

PD45-10 A MULTICENTER PROPENSITY SCORE MATCHED PAIR STUDY IN 313 PATIENTS COMPARING PERCUTANEOUS NEPHROLITHOTOMY VERSUS RETROGRADE INTRA RENAL SURGERY FOR MANAGEMENT OF UROLITHIASIS IN CALYCEAL DIVERTICULUM

PD45-10 A MULTICENTER PROPENSITY SCORE MATCHED PAIR STUDY IN 313 PATIENTS COMPARING PERCUTANEOUS NEPHROLITHOTOMY VERSUS RETROGRADE INTRA RENAL SURGERY FOR MANAGEMENT OF UROLITHIASIS IN CALYCEAL DIVERTICULUM

Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children.

in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years. retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children. only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series. the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.

PARTIAL NEPHRECTOMY IN RENAL TRAUMA WITH GRADE IV INJURY: DESCRIPTION OF A CASE AND REVIEW OF THE LITERATURE.

Renal trauma is present in 5% of polytrauma cases, which is more frequent in young males. The management of severe renal trauma is a diagnostic and therapeutic challenge that requires the participation of multidisciplinary Urology and Radiology teams. We present the case of a 19-year-old male, with polytrauma secondary to an electric skateboard accident at a speed of 30 km/hour, with direct trauma against a bollard in the right lumbar region. In the chest-abdominal-pelvic CT, right renal lacerations are identied, the largest in the upper pole, without signs of vascular avulsion or active bleeding and retroperitoneal collection suggestive of perirenal hematoma with high-attenuation content surrounding it, compatible with urinary extravasation. Given the hemodynamic stability of the patient and the fact that there was signicant urine extravasation, a double J catheter was inserted. The CT performed at 48 hours shows hypoperfusion of the upper pole and peripheral vascular injury, compatible with several pseudoaneurysms, the largest of which was approximately 14 mm, and small peripheral anomalous vessels with arteriovenous stulas. Given the radiological ndings, selective catheterization of arteriovenous stula afferents and embolization of pseudoaneurysms with microcoils and with cyanoacrylate-lipiodol were performed. Due to the absence of vascularization of the upper renal pole and the persistence of the perirenal collection of blood and urine, it was decided to perform an open lumbar heminephrectomy of the upper pole of the right kidney. The evolution of the patient was satisfactory without hemodynamic or infection problems. One month after surgery, the double J catheter was removed. Six months after the heminephrectomy, the patient is asymptomatic with the disappearance of the perirenal collection and good morphology of the lower right hemi-kidney. Preservation of nephrons after major renal trauma in young patients is a therapeutic approach to be taken into account, despite the technical difculties that may exist.

Emphysematous pyelonephritis: Nephrectomy is still standard of treatment? 15 years ‘experience

Emphysematous pyelonephritis (EPN) is a severe form of urinary tract infection with a high mortality unless treated rapidly and effectively. Our objective is to review our experience over 15 years (from 2005 to 2020) on conservative treatment according to clinical, bacteriological, radiological, therapeutic and evolutionary aspects of EPN. We analyzed the medical record of patients treated for EPN at the Urology service of Mohammed the VIth University Hospital of Marrakesh. There were 18 patients with an average age of 54 years. They were all diabetics. Lithiasis obstruction of the upper excretory tract was found in 15 patients (83%). The germs involved were Gram-negative bacilli, especially E. coli (61% in our series) followed by Staphylococci (22.2%), Klepsiella (11.1%), and proteus mirabilis in 5.5% of cases. Resuscitation measures, including antibiotic and insulin therapy, were introduced as a matter of urgency for patients if needed. In 77.8% of cases, treatment was conservative: 11 patients (61.1%) underwent endoscopic drainage with a JJ stents and 3 patients (16.6%) underwent open drainage of peri-renal collections with a nephrostomy tube placement). Only 4 patients (22.2%) patients underwent nephrectomy. No deaths were observed during the course.

Perirenal Extravasation After Retrograde Intrarenal Surgery for Renal Stones: A Prospective Study.

BackgroundThe incidence and consequences of the perirenal extravasation of the irrigation fluid during retrograde intrarenal surgery (RIRS) are not fully elucidated. The objective of this study was to assess the incidence, risk factors, and complications of perirenal extravasation of irrigation fluid during RIRS.MethodsThis prospective observational study was conducted in the Department of Urology, Bir Hospital, Kathmandu, Nepal, from January 2020 to March 2021. Patients undergoing RIRS for renal stones less than 2 cm in diameter were included in the study. Irrigation during the procedure was performed using isotonic normal saline under gravity at 50 cm from the symphysis pubis of patients with intermittent manual compression if required. Lithotripsy was performed with 120-Watt Ho:YAG laser using 200-micron laser fiber. Retrograde pyelogram was performed after the completion of lithotripsy to document the presence or absence of extravasation on fluoroscopic images. A double-J stent was placed at the end in all patients. Patients were observed for systemic inflammatory response syndrome (SIRS) features. Postoperative abdominal ultrasonography was performed on the first postoperative day to assess the perirenal collection together with complete blood count. The visual analogue scale (VAS) was used to assess pain in postoperative period. The preoperative patient’s and stone characteristics, hydronephrosis, intraoperative characteristics, and postoperative findings were analyzed.ResultsA total of 71 patients who underwent RIRS during the study period were analyzed. The mean (SD) stone size was 13.19 (3.12) mm. Intraoperative perirenal extravasation of contrast was noted in eight (11.26%) patients; however, no patient had ipsilateral perirenal collection on ultrasonography obtained on the first postoperative day. No significant differences were observed among patients with or without perirenal extravasation in terms of mean stone size, laser settings, operative duration, and lasing duration. Use of ureteral access sheath (UAS) was associated with lower incidence of extravasation; however, it was not significant. SIRS was documented in eight patients overall, with none of the patients with extravasation having features of SIRS. Patients with extravasation experienced more postoperative flank pain (p<0.05).ConclusionPerirenal extravasation was common during RIRS and was associated with higher postoperative pain scores. Stone size, use of UAS, laser settings, operative duration, and lasing duration were not associated with an increased risk of extravasation. Extravasation was not associated with increased postoperative complications.

Renal Lymphangiectasia as an Unusual Cause of Perirenal Collections: A Case Report and Literature Review

Renal lymphangiectasia (RLM) is a rare condition characterized by dilatation of perirenal, parapelvic or intrarenal lymphatics. We report an unusual case of bilateral RLM in a 20-year-old Malay male who presented with 1 month duration of bilateral flank pain. Bedside ultrasound showed bilateral perinephric collections, which were further confirmed on computer tomography intravenous pyelogram (CT IVP). Other causes of perinephric collections were ruled out based on laboratory and radiological findings, and he was managed conservatively as for RLM with surveillance ultrasound kidneys at 3 to 6 monthly intervals.

Urinothorax, another complication of bladder tumor: case report

BackgroundRupture of the fornix is a rare and serious urological complication of obstructive pathologies. The main cause is ureteral stone, but rarely a bladder tumor. Described complications of fornix rupture are superinfection, perirenal abscesses and even sepsis, but not urinothorax.Case presentationPatient of 56 years old, active and chronic smoker, was hospitalized for anemia and obstructive renal failure on a non-documented bladder tumor; clinically, he was presented with hematuria and an intense right loin pain associated with homolateral basithoracic pain and dyspnea. The CT scan without injection showed a right perirenal collection with bilateral renal dilatation on endo-vesical tumor and a right pleural effusion of less abundance. The ratio of pleural fluid creatinine to blood creatinine was greater than 1, confirming urinothorax. As an emergency, a percutaneous nephrostomy was performed. After clinical stabilization, the patient underwent a trans-urethral resection of the bladder and derivation by a double j stent. The ultimate evolution was favorable.ConclusionsBeyond the metabolic complications secondary to obstructions, mechanical complications, which can also be fatal, must be included.

Urinoma following blunt renal trauma in a patient with anomalous solitary kidney: A case report.

Introduction and importanceBlunt traumatic injury to the genitourinary system is uncommon. Urinoma formation may occur in patients with blunt trauma after high grade renal injuries. In such cases, the presence of solitary kidney must be ruled out as it may affect treatment decisions.Case presentationA 21 years old male presented to our facility with complaints of abdominal pain and frank hematuria following physical assault. Physical examination revealed tenderness at the right flank. Laboratory evaluation showed a decreased hemoglobin level and urinalysis showed proteinuria and marked hematuria. Imaging findings were consistent with AAST Grade IV right renal injury affecting the renal pelvis with urinoma formation and congenital megacalyces. Incidental finding of unilateral renal agenesis on the left side was also noted. Our patient underwent Ureteroscopy with double-J stenting. Subsequent ultrasonography after the procedure showed resolution of the perirenal collection.DiscussionThe presence of solitary kidney must be ruled out in cases of high grade renal trauma as operative procedures may lead to catastrophic consequences in such cases. Urinoma formation after renal trauma may occur if the renal pelvis is injured and should be managed preferably by urinary diversion in the form of ureteral stenting over other operative procedures, especially in patients with anomalous solitary kidney.ConclusionPresence of bilateral kidneys should be confirmed before subjecting patients with high grade renal injury to operative procedures. Early ureteric stenting appears to be an effective method of urinary diversion for management of symptomatic urinomas in patients with anomalous solitary kidney.

POS-756 DELAYED GRAFT FUNCTION POST RENAL TRANSPLANTATION: URINE COLLECTION CAN BE THE CULPRIT!

Renal transplantation is the optimal treatment for patients with renal failure. Delayed graft function (DGF) due to surgical complications used to be a major worry, however, improvement in techniques minimised this risk to less than 5%. Nevertheless, 2.5-30% of recipients can experience a perirenal collection mainly as a urinary leak or lymphocele, causing DGF. Imaging, alongside with fluid analysis, can lead to early diagnosis, treatment and graft survival. Case presentation: A 28-year-old recipient noted to have high drain volumes in day 2 and 3 post live related renal transplantation. Fluid was immensely high in creatinine with five times higher K level compared to plasma. Graft function plateaued. Patient was euvolemic and stable otherwise. Imaging revealed severe hydronephrosis with extraperitoneal leak. Haematoma, seroma, abscess and lymphocele excluded and CT urography demonstrated urine extravasation (picture 1). Outcome: A small urine leak can be successfully managed conservatively in approximately 60% of patients, with maximal release of tension and urine diversion, to allow healing of the leaking. In the index case, high volume urine extravasation will need surgical intervention and restoration of the ureteric continuity (table 2). Urinary leak presents the most common urological complication in early post transplantation period and can result in DGF due to mechanical issues, hypovolemia and sepsis. Biochemical analysis of fluid and comparison to serum is essential to differentiate from lymphocele, hematoma or abscess. Imaging is a key point to confirm, diagnose collection and determine severity and location. Organ harvesting should be meticulous to avoid damaging ureter and vessels. Implantation should be tension free. DJ stenting has been promising in reducing incidence of urine leak, therefore, it should be routinely used and removed 6 weeks postoperatively.

A Case of Persistent Retroperitoneal Abscess with Large Right Perinephric Collection

Introduction: Retroperitoneal abscess is a rare condition which is difficult to diagnose and treat because of its insidious onset and nonspecific clinical manifestations. Case Report: 55 years old male, underlying DM, Hypertension, Gouty arthritis. Referred to us for right Hypochondriac pain with persistent fever for past 2 days duration. Abdominal examination showed soft, tender over right side of abdomen, localized guarding. An abdominal CT scan showed right pyonephrosis complicated by a large right perirenal collection.Right Nephrostomy was performed. 1 week later, patient had fever and persistent right sided abdominal pain with increasing septic parameters. CT abdomen performed and showed Right pyonephrosis complicated by a large right perinephric abscess extending into the pelvic and inguinal region. Right Perinephric drainage performed. Patient developed worsening sepsis, repeated CT abdomen revealed residual multiloculated right perinephric collection. Open retroperitoneal drainage was performed, noted retroperitoneal abscsess, caccon right kidney and peritoneal, slough ,unhealthy tissue and necrotic debris over right psoas muscles.1 week after surgery, patient still not improving, repeated CT Abdomen showed features of D2 ischemia with focal retroperitoneal perforation causing large and recurrent right perinephric inflammation with increasing intraabdominal free fluid and enlarging right perinephric collection. Laparotomy done shiwed 1L clear ascites intraperitoneally, no pus collection seen. Cocoon inflammatory mass involving hepatic flexure and duodenum to the retroperitoneum, hepatic flexure appeared normal with no intraluminal mass.Right retroperitoneal exploration done, noted adhesion between hepatic flexure to Gerota's fascia, pus ~30ml at upper part of Gerota's fascia. Repeated CT abdomen showed slightly larger right paracolic gutter collection with similar right perinephric collection. Discussion: Retroperitoneal abscess is very rare. Retroperitoneal abscess may result from a variety of causes, such as pyelonephritis, pancreatitis, retroperitoneal appendicitis, diverticulitis, peptic ulcer disease, perforated cancer, infammatory bowel disease, spinal infection, trauma, and post instrumentation. For our patient ,the exact aetiology of retroperitoneal collection and peri renal collection are still unknown.

1970 Spontaneous Page Kidney as a Cause of Gastric Variceal Bleed

INTRODUCTION: Gastric variceal bleeding occurs in 15–50% of patients with non-cirrhotic portal venous thrombosis but can also occur in cases of splenic vein thrombosis (SVT) due to the formation of isolated gastric varices (IGV). We present the first reported case of a page kidney causing splenic vein compression, thrombosis, and subsequent gastric variceal bleeding. CASE DESCRIPTION/METHODS: A 31-year-old stuntman presented with epigastric pain and worsening exertional dyspnea over 3 weeks. History was notable for melena and anemia with no reported ulcers on endoscopy. On admission, he had hemoglobin of 4.1 g/dl with severe iron deficiency and elevated reticulocyte count. There was no serologic evidence of hepatic or renal disease. A computed tomography (CT scan) of the abdomen revealed a large left-sided perirenal collection consistent with page kidney, splenomegaly and decreased caliber of the mid and distal splenic vein suggestive of nonocclusive SVT. His liver was normal. Initial endoscopy revealed an IGV type 1 and mild portal hypertensive gastropathy (Figure 1). CT angiography did not reveal a splenorenal shunt to pursue a balloon retrograde transvenous obliteration (BRTO). While admitted, he developed hematemesis and worsening anemia. Ultimately, underwent IR splenic vein stenting with a bare-metal stent and subsequent decompression of the gastric varices with brisk flow of the portal vasculature (Figure 2). DISCUSSION: Gastric varices are classified primarily by location with most involving the gastroesophageal junction due to portal hypertension. The incidence of bleeding is highest in IGV, typically associated with SVT. Common etiologies of SVT include pancreatitis, malignancy or trauma. Our case described an extrinsic splenic vein compression and subsequent thrombosis due to a sub-capsular renal hematoma possibly of unclear etiology. Treatment for GV often depends on local expertise, but commonly consists of cyanoacrylate injection, banding (especially in type 1 gastro-esophageal varices), transjugular intrahepatic portosystemic shunt (TIPS) placement, BRTO, and even splenectomy. More recently, in cases of IGV due to isolated SVT, splenic vein stenting has been increasingly utilized. In our case, TIPS would not address the pre-hepatic portal hypertension and cyanoacrylate was not available. Splenic vein stenting was thus chosen to decompress the IGV with excellent response seen on subsequent follow-up (Figure 1).

A Decade of Live Related Donor Kidney Transplant: Experience in a Tertiary Care Hospital of Bangladesh

Background: Kidney transplantation is the preferred treatment for end stage kidney disease (ESKD). Live related donor kidney transplant was started in BIRDEM General Hospital, Bangladesh, on 6th November 2004. The aim of this study was to share our last 10 years’ experience of live related donor kidney transplant.Methods: A questionnaire was formed and data were collected from the hospital records. We retrospectively evaluated patients’ clinical and laboratory findings.Results: A total of 111 live related donor kidney transplants were performed from 2004 to 2014. Male:female was 2.3:1. The mean age of the recipients was 37.45 ± 10.58 years. The causes of ESKD were chronic glomerulonephritis (CGN) (52, 46.9%), diabetes mellitus (DM) (31, 27.9%), hypertension (26, 23.4%), chronic pyelonephritis (1, 0.9%) and obstructive nephropathy (1, 0.9%). Pre-emptive transplantation was done in 4 (3.6%) patients. Patients on continuous ambulatory peritoneal dialysis and haemodialysis were 2 (1.8%) and 105 (94.6%) respectively. Most of the donors were siblings (55.9%). Majority (64.9%) had an uncomplicated recovery. The commonest complication during post-transplant hospital stay was infection (27.0%), mostly urinary tract infection (21.6%). Surgical failure was experienced in 1 (0.9%) and acute rejection was noted in 2 (1.8%) patients. Other complications were renal vein thrombosis (1, 0.9%), haemolytic uremic syndrome (1, 0.9%), acute tubular necrosis (1, 0.9%), peri-renal collection (1, 0.9%), pericardial effusion (1, 0.9%) and clot retention in urinary bladder (2, 1.8%). Mean post-transplant hospital stay was 12.39 ± 4.27 days. Mean duration from surgery to normalization of serum creatinine was 5.75 ± 4.15 days. During discharge, 71.2% patients had normal renal function (RF) with mean serum creatinine 1.03 ± 0.15 mg/dl and 26.1% patients had gradually improving RF with mean serum creatinine 2.01 ± 1.04 mg/dl. As induction, 61 (55%) patients received basiliximab and as maintenance therapy all patients received oral prednisolone, calcinurine inhibitor and mycophenolate. In the first year of transplant, 49.5% patients suffered from infections, of which urinary tract infection was the commonest (55.9%). Incidence of chronic allograft nephropathy in CGN, DM and hypertension patients were 25%, 19.4% and 23.1% respectively. Graft survival at 1 year, 3 years and 5 years was 94.06%, 85.88% and 77.27% respectively. Patient survival at 1 year, 3 years and 5 years was 98.1%, 88.24% and 84.09% respectively.Conclusions: Our results are comparable or in some aspects, even better in comparison to other centers of both developing and developed world. In a center of a developing country with limited facility and resource, these achievements are encouraging.Birdem Med J 2018; 8(3): 198-202

Hématome spontané du rein

We here report the case of a 54-year old patient with a history of appendectomy performed 6 years before and suffering from left lower back pain evolving for 3 months aggravated 3 days before admission to the Emergency Department. Moreover, there was no sign of hematuria or stones emission nor of lumbar or abdominal trauma. On admission physical examination showed fairly good general condition, slight discoloration of the conjunctivas, hemodynamic stability. Laboratory tests showed hemoglobin at 7.7g/dl, the remainder of the laboratory tests was normal. Uroscan revealed a predominantly posterior heterogeneous,voluminous left peri-renal collection with spontaneous hyperdense areas (A). The patient underwent two packed red blood cell transfusion. Simple monitoring associated with analgesic and antibiotic treatment to avoid superinfection of the hematoma was performed based on hemodynamic stability. Control uroscan was performed one month later showing marked regression of the hematoma (B).

Renal lymphangiectasia presenting with hypertension and polycythemia

We report a very rare case of renal lymphangiectasia, an accumulation of lymph in the renal lymphatic system secondary to obstruction. Our patient presented to his family doctor for an annual check-up which resulted with high blood pressure and polycythemia. An ultrasound was performed and revealed a large right perirenal collection. A year later, a controlled abdominal computed tomography scan showed a progression and compression of perirenal collection on the right kidney, as well as apparition of a left perirenal collection. Percutaneous drainage of both collections was unsuccessful. Laparoscopy-guided marsupialisation was performed and successful. Blood pressure lowered to normal range without medication. The patient's hemoglobin level decreased within normal range after 3 additional phlebotomies postoperatively.

Complications associated with renal graft biopsy in transplant patients

Percutaneous biopsy of renal grafts is a diagnostic method for the assessment, management and clinical monitoring of renal transplant, so it is necessary to know its complications. There are few data in the literature regarding complications from biopsies in renal grafts. To evaluate the rate of complications in renal graft biopsies performed at our centre. We performed a retrospective observational study, including data from patients who underwent renal graft biopsies from January 2000 to September 2012. Major complications were defined as: anemia requiring blood transfusion, intraparenchymal arteriovenous fistula or arterial bleeding requiring embolisation, nephrectomy, other surgery and exitus. And as minor complications: anemia without blood transfusion, intraparenchymal arteriovenous fistula without embolisation, haematomas or perirenal collections, hematuria and fever. Kidney biopsies were performed with ultrasound guidance and automatic devices. We performed 390 kidney graft biopsies. 49 complications occurred. 22 were major: 12 per anemia that required blood transfusion, 6 requiring embolisation (5 arteriovenous fistulae and 1 arterial bleeding), 2 exitus, 1 trasplantectomy and 1 surgery (haematoma). 27 were minor: 12 perirenal collections, 9 arteriovenous fistulae without embolisation, 3 hematuria, 2 anemisation without blood transfusion and 1 fever. The rate of complications related to renal graft biopsy observed in our centre is similar to those described for native kidneys, therefore we believe it remains a safe and effective technique, and an important diagnostic tool.

Kidney transplantation in children weighing less than 15 kg: Extraperitoneal surgical access–experience with 62 cases

Small children are a challenging group in whom to perform KT. This retrospective study analyzed the results of 62 KTs in children weighing <15kg, performed between 1998 and 2010, using extraperitoneal access and anastomosis of the renal vessels of donors to the aorta and IVC or iliac vessels of the recipients. Thirty-two (51.6%) grafts were LRDTs and 30 (48.4%) were DDRTs-28 of them pediatric. The mean age at KT was 3.7±2.2yr (1-12), and the mean weight was 12.3±2.1kg (5.6-14.9). Ten children weighed <10kg, and five (8.1%) children presented previous thrombosis of the venous system. At one and fiveyr, patient survival was 93.2% and 84.2%, and graft survival was 85.2% and 72.7%. There were no differences between the rates for LRDT and DDRT. There were six vascular complications (four vascular thromboses, one laceration, and one renal artery stenosis) and two perirenal collections. Extraperitoneal access is a valid KT technique in children weighing <15kg.

Pyogenic renal abscess masquerading as malignancy

Dear Editor, Renal abscess may arise from both an initial urinary tract infection and hematogenous spreading of bacteria from a primary focus of infection outside the kidney.[1] We present a case of pyogenic renal abscess which presented to us masquerading as renal malignancy. A 64-year old male farmer presented in the emergency unit of Medical College, Kolkata with history of painless hematuria for 1 month and severe loss of weight and appetite for 2 months. There was a history of single episode of fever for 1 day without chills and rigors, about 1 month ago. There was no history of tuberculosis. On examination the patient had severe pallor, tachycardia but no fever and no obvious swelling palpable per abdomen. The renal angle was nontender. His hemoglobin on admission was 5.7 g% and the total count of white blood cells was 4500. His erythrocyte sedimentation rate was 15 mm/h and C-reactive protein was 3.4 mg/l (normal < 10 mg/l). Ultrasonography showed a hypoechoic lesion 3.1 × 2.5 cm at the lower pole of the right kidney. The patient was nondiabetic and did not have any features suggestive of vescico-ureteral reflex, nephrolithiasis or urinary tract obstruction. The patient received 6 units packed cell transfusion and was put on intravenous ciprofloxacin 500 mg IV twice daily which the patient received for 5 days. Contrast-enhanced CT scan showed right kidney having irregular low-density lesion with perirenal fluid collection. Left kidney, ureters, urinary bladder, and prostate were normal [Figure 1]. Urine for culture sensitivity showed growth of Escherichia coli with colony count of 100,000/ml sensitive to norfloxacin. The patient was then put on oral norfloxacin 400 mg twice daily for 14 days. Figure 1 Contrast-enhanced CT of the patient showing the right kidney having irregular low density lesion with perirenal collection. Left kidney appears normal History and presentation were suggestive of renal malignancy, but CECT showed a low-density lesion and urine had no malignant cell. Pyogenic abscess was a possibility but the patient had no burning sensation of urine, single episode of fever without chills and rigor or back pain and total count of white blood cells was also normal. Tubercular abscess was another possibility as the patient presented with pallor and weight loss but his chest X-ray was normal, sputum and urine for acid fast bacilli was negative, and a Montaux test was also negative. Repeat hemoglobin was after 2 weeks of presentation was 9.8 g% and the total count of white blood cells was 4000. A CT-guided fine-needle aspiration biopsy was planned for the patient for a definite diagnosis, but a repeat ultasonography before the procedure showed both kidneys to be normal. A thin rim of perirenal collection was seen around the right kidney with minimal collection noted in hepatorenal pouch of Morrison. The lesion had vanished! The patient had been on oral norfloxacin for about 2 weeks. The patient was then asked to continue the antibiotic for 2 more weeks. On follow-up, after 6 months of discharge the patient was asymptomatic with normal kidneys on ultrasonography. Image-guided renal biopsy is safe, reliable, and accurate. It changes clinical management in many cases avoiding nephrectomy or other surgical options. It should be promoted as a potentially useful option for managing suspicious or indeterminate renal masses.[2,3] This case did not require image-guided biopsy but one should not hesitate in cases of suspicious renal lesions. Various conditions seem to predispose to renal abscesses urinary tract infection, urinary calculi, and diabetes mellitus being a common cause.[4,5] Treatment of renal abscess requires at least 4 weeks of antibiotic therapy according to etiological agent.[6] Larger abscess may require parenteral antibiotic or surgical intervention if fever or symptoms do not settle down.

Primary renal lymphoma: an uncommon diagnosis for acute kidney failure.

A 70-year-old male, previously well, had developed confusion. On investigation, he was found to have acute kidney injury (AKI) with a creatinine of 565 µmol/l, and a palpable irregular mass in the right flank. Abdominal ultrasound showed large voluminous kidneys with thickened parenchyma and probable peri-renal collection on the right side. Abdominal computerized tomography scan showed expansive right sided, peri-renal solid lesion. A renal biopsy was performed. Using light microscopy, an infiltration of neoplastic cells in the capsule and parenchyma, with destruction of the kidney architecture was detected (Figure 1A). Atypical and pleomorphic neoplastic cells were observed, with little cytoplasm and large vesicular nuclei and evident nucleoli. Immunohistochemistry showed: CD20 (Figure 1B), CD79a, Ki-67 and LCA (CD45RB) to be highly positive. The findings were consistent with a lymphoblastic lymphoma of B cells with high proliferation index. No primary focus could be found and it was assumed to be a primary renal lymphoma (PRL). Fig. 1. Photomicrographs of renal biopsy: (A) Infiltration of atypical neoplastic and pleomorphic cells, with little cytoplasm and large nucleus, vesiculous and with nucleoli evident in the kidney parenchyma, and destruction of its architecture (Hematoxylin and ... PRL represents 0.1% of all lymphomas and up to 0.7% of extranodal lymphomas [1–3]. To be considered primary renal, the lymphoma must be located only in the kidney without extrarenal involvement [1, 4]. Less than 100 cases of PRL have been described in the literature [2], and the initial presentation as AKI is extremely rare [4]. The diagnosis of PRL may be suggested by radiological imaging; however, the definitive diagnosis is obtained from histo-pathological examination with the exclusion of other extrarenal sites of lymphoma [4]. Despite being a rare etiology, it is important to remember that PRL must be considered as a differential diagnosis in patients with unexplained AKI, when renal imaging shows enlarged kidneys.