Perirenal Fluid Collection Research Articles

Perirenal Fluid in Renal Parenchymal Medical Disease (‘Floating Kidney’): Clinical Significance and Sonographic Grading

AIM: To study the clinical significance and radiologic features of perirenal fluid in patients with renal parenchymal disease. MATERIALS AND METHODS: During the previous 5 years, nine patients were found to have perirenal fluid on sonography associated with renal parenchymal medical disease. The clinical, radiological, histopathological and laboratory data were analysed. RESULTS: The perirenal fluid is a spontaneous subcapsular transudate in patients suffering from a nephropathy with a sodium retention state, with or without renal failure. Three sonographic patterns of perirenal fluid were observed: grade 1 is a thin layer of perirenal fluid; grade 2 is a moderate amount of perirenal fluid collection with indentations of the renal parenchyma and strands in the fluid, grade 3 is a large fluid collection surrounding the kidney. CONCLUSION: The perirenal fluid represents a sign of sodium retention state and oedema in patients with intrinsic renal parenchymal medical disease which may be caused by several nephropathies. Haddad, M. C.et al. (2001). Clinical Radiology56, 979–983.

Is common femoral artery flow affected by the ipsilateral transplanted kidney?

RENAL transplantation is the preferred treatment for the majority of patients with end-stage renal disease. Many potential complications of renal transplantation are well-documented in the literature. A transplanted kidney placed in the iliac fossa is presumed to decrease blood flow to the lower extremity on the same side by the “steal phenomenon” and/or by compression of the iliac arteries due to the mass effect. To our knowledge, there are no reports in the literature concerning posttransplantation flow changes in the femoral arteries in the absence of atherosclerotic disease or perirenal fluid collection. We used Doppler ultrasound imaging to assess blood flow velocity and volume in the common femoral artery ipsilateral to the graft, and compared these findings to those on the contralateral side.

Spontaneous resolution of an in utero perirenal urinoma associated with posterior urethral valves

Ultrasound imaging of a 26-week-gestation fetus demonstrated a large, nonemptying bladder. At 27 weeks, a distended, thick-walled bladder, left hydronephrosis, and a perirenal urinoma were present, without ascites. Observation was undertaken, as the amniotic fluid volume was normal. At 29 weeks, the left perirenal fluid collection persisted but, at 30 weeks, was absent. After delivery at 36 weeks, no ultrasound evidence for perirenal urinoma or ascites was present. Isotope renal scan showed preserved renal function bilaterally. This case illustrates that in utero urinomas associated with posterior urethral valves can resolve spontaneously, with preservation of renal function.

Radiodiagnosis following kidney transplantation

Diagnostic imaging after renal transplantation is of high importance in the differential diagnosis of peri- and postoperative complications. Sonography with color duplex imaging is the method of choice in the diagnosis of acute transplant rejection. MRI is an additional method in the diagnosis of transplant dysfunction especially in diagnosis of perirenal fluid collections. MR angiography and MR urography are noninvasive diagnostic modalities with the potential to replace angiography and pyelography. Angiography, complemented by carbon dioxide angiography, still is the gold standard in the diagnosis of transplant artery stenosis.

OGILVIE'S SYNDROME POST RENAL TRANSPLANT AND ITS ASSOCIATION WITH DELAYED GRAFT FUNCTION OR PRIMARY NON-FUNCTIONING GRAFT

316 Ogilvie's syndrome (acute colonic pseudo-obstruction), a known complication of retroperitoneal surgery, is a potentially serious condition that may lead to severe life threatening complications (e.g. colonic perforation or necrosis) if unrecognized. Here we report the first retrospective study showing an association between delayed graft function (DGF) or primary graft non-function (PGNF) post renal transplant and Ogilvie's syndrome (OS). Methods: All renal transplant patients with intra-abdominal complications were reviewed. Cases of acute colonic pseudo-obstruction were identified. Presence or absence of immediate renal function, cause of renal dysfunction, age, amount of narcotic analgesics and presence of retroperitoneal collections were noted. DGF was defined as lack of >15% spontaneous drop in serum creatinine by day 3 ± need for dialysis in the first week post transplant. PGNF was due to hyperacute rejection or vascular complications. Results: Between July 1993- December 1998, 511(350 cadaveric, 161 live donor) renal transplants were performed in adult patients at our institution. 15 patients had OS diagnosed by clinical picture+abdominal series±colonoscopy±contrast colon studies. Only 2 patients with OS had peri-renal fluid collection. Sixty-nine patients had DGF (67 cadaveric, 2 live donor transplant) and 11 patients had PGNF. Of 80 patients with DGF or PGNF, 11 developed OS (13.7%), compared to 4 patients with OS and immediate graft function (4/432, 0.9%) (p=0.0000, χ2 test, odds ratio=17). There was no statistically significant difference in age between patients with or without OS (mean±SD 43±14 vs 41±13 year). Patients with and without OS received equivalent narcotic analgesic in first week post transplant (424±141 mg meperidine HCl and 348±128 mg codeine phosphate vs 484±110 mg meperidine HCl and 467±122 mg codeine phosphate, respectively; differences were not statistically significant). OS was treated conservatively ± rectal tube decompression in 10 cases. Four patients had one or more colonoscopic decompression. Two patients with OS developed colonic perforation and subsequently underwent open surgery; one of them developed septic shock post-operatively and died despite aggressive treatment. Conclusion: OS is associated with DGF and PGNF post-renal transplant. To our knowledge this is the first retrospective study showing this association. Knowledge of this association can lead to early recognition of this potentially serious condition, which in turn might prevent occurrence of further complications.

Anatomical communications of the perirenal space.

There are controversies over the anatomical communications between the perirenal space and the adjacent extraperitoneal spaces. Clinical studies, mainly based on CT, show fluid collections extending into the adjacent space; into the bare area of the liver on the right, into the superior extraperitoneal space on the left, towards the midline from each perirenal space, and into the lower retroperitoneal space of the abdomen and pelvis. There are certain constant anatomical barriers limiting free extension of fluid or pathology. The pattern of fluid collection in the perirenal space and extension into the adjacent extraperitoneal space is relatively consistent although it varies with the amount and nature of the pathological fluid collection. This pictorial review illustrates anatomical barriers and CT findings of perirenal fluid collections and their extension into adjacent extraperitoneal spaces.

Dengue haemorrhagic fever: ultrasound as an aid to predict the severity of the disease.

In a prospective study, the relationship between the clinical severity of dengue haemorrhagic fever (DHF) and the sonographic findings was examined. The study comprised 73 cases classified as mild (grades I-II) and 75 as severe (grades III-IV). Ultrasonography in the mild group revealed pleural effusions in 30%, ascites in 34%, gallbladder wall thickening in 32%, hepatomegaly in 49%, splenomegaly in 16%, and pancreatic enlargement in 14%. In the severe group, pleural effusions, ascites and gallbladder wall thickening were found in 95%, pararenal and perirenal fluid collections in 77%, hepatic and splenic subcapsular fluid collections in 9%, pericardial effusion in 8%, hepatomegaly in 56%, splenomegaly in 16%, and pancreatic gland enlargement in 44%. Ultrasound may be useful for early prediction of the severity of DHF in children.

Occurrence of lymphoceles after allogeneic kidney transplantation and their therapy

We conducted a prospective evaluation of 301 consecutive renal transplants to define the prevalence and therapy of lymphoceles following renal transplantation. Using a management scheme, we identified in 52 patients (17.3%) perirenal fluid collections. Using this management scheme, we treated 47/52 patients conservatively. Only 5 (1.7%) patients required internal marsupialization. We conclude that groin lympho cysts after renal transplantation can be successfully treated with conservative methods.

Percutaneous Drainage in the Treatment of Emphysematous Pyelonephritis: 10-Year Experience

Purpose We investigated the effect of percutaneous drainage for the treatment of emphysematous pyelonephritis. Materials and Methods A retrospective analysis was done of 25 patients with emphysematous pyelonephritis who were treated initially with computerized tomography (CT) guided percutaneous drainage during a 10-year period. The patients were concomitantly treated with antibiotics, fluids, and correcting blood glucose and/or ureteral obstruction. We also compared our results of percutaneous drainage to CT findings. Results CT identified 12 patients with emphysematous pyelonephritis who had gas with little fluid and 13 who had gas with renal or perirenal fluid collections. In 20 of 25 patients (80%) antibiotic therapy combined with percutaneous drainage constituted the only treatment required. Three patients (12%) whose clinical status improved after percutaneous drainage subsequently underwent elective nephrectomy without further complications. Two patients (8%) died of multiple organ failure. There was no correlation between the gas patterns of emphysematous pyelonephritis and initial success with the antibiotics and percutaneous drainage. There were no recurrences and no complications during a followup of 1 to 10 years (mean 5). Mean duration of treatment was 5.54 weeks (range 1 to 12.6). Conclusions CT is an efficient imaging method for diagnosis, guiding the drainage procedures and monitoring response to percutaneous drainage of emphysematous pyelonephritis. Antibiotic therapy combined with CT guided percutaneous drainage of emphysematous pyelonephritis is an acceptable alternative to antibiotic therapy with surgical intervention.

The Clinical Introduction of a Third Generation Lithotriptor: Modulith SL 20

The Modulith SL 20* was designed as a third generation lithotriptor with outstanding disintegrative efficacy in vitro, and equipped with a combined flouroscopic and ultrasound localization system integrated in a multifunctional table. Its introduction to clinical extracorporeal shock wave lithotripsy took place in 3 phases. In phase 1 (49 patients) only in line ultrasound localization was possible. The many caliceal stones were adequately disintegrated with restricted generator voltage. In phase 2 (81 patients) flouroscopic localization with the virtual focus of an adapted x-ray C-arm unit enabled in situ lithotripsy of ureteral stones in 33 percent of all patients. Phase 3 (549 patients) was characterized by additionally increasing the generator voltage to 20 energy resulted in the possibility for successful disintegration of stones in the entire upper urinary tract (including the complete ureter), decreased treatment time (52 to 39 minutes) and an improved efficiency quotient (0.45 to 0.67). During phase 3 auxiliary measures were performed before lithotripsy in 24 percent of the cases. After 1.8 percent of the treatments minor or moderate perirenal fluid collection or bleeding was detected by routine followup sonography. A 91 percent stone-free rate was achieved with only 9.3 percent curative auxiliary measures after extracorporeal shock wave lithotripsy, including a 23 percent retreatment rate. Thus, the Modulith device had a high efficacy quotient compared with other lithotriptors. *Storz Medical, Kreuzlingen, Germany.

Laparoscopic ultrasound-guided drainage of lymphoceles following renal transplantation.

The development of a lymphocele is an uncommon but well-documented complication of renal transplantation. In most patients, lymphoceles remain asymptomatic, and no intervention is required. In some cases, however, lymphoceles become symptomatic and cause systemic and local manifestations. Ultrasonic scanning can easily diagnose and locate the size and position of perirenal fluid collections. Many of these patients can be managed conservatively by aspiration and drainage of the lymphocele under radiologic guidance. However, if the lymphocele remains symptomatic or reaccumulates after aspiration and drainage, surgical intervention may be required. We describe two different ultrasound-guided laparoscopic techniques for drainage of a perirenal lymphocele into the peritoneal cavity. Successful drainage was accomplished in 5 patients, with 1 patient suffering an injury to the ureter of the transplant kidney. Recommendations regarding patient selection and operative technique are presented.

Post-Transplant Lymphoceles: A Critical Look into the Risk Factors, Pathophysiology and Management

To define better the prevalence and pathophysiology of lymphoceles following renal transplantation, we prospectively evaluated 118 consecutive renal transplants performed in 115 patients (96 cadaveric, 22 living-related, 7 secondary and 111 primary). Ultrasonography was performed postoperatively and during rehospitalizations or whenever complications occurred. Perirenal fluid collections were identified in 43 patients (36%). Lymphoceles with a diameter of 5cm. or greater were identified in 26 of 118 cases (22%). Eight patients (6.8%) had symptomatic lymphoceles requiring therapy. The interval for development of symptomatic lymphoceles was 1 week to 3.7 years (median 10 months). Risk factors for the development of lymphoceles were examined by univariate and multivariate analysis, and included patient age, sex, source of transplants (cadaver versus living-related donor), retransplantation, tissue match (HLA-B/DR), type of preservation, arterial anastomosis, occurrence of acute tubular necrosis-delayed graft function, occurrence of rejection, and use of high dose corticosteroids. Univariate analysis showed a significant risk for the development of lymphoceles in transplants with acute tubular necrosis-delayed graft function (odds ratio 4.5, p = 0.004), rejection (odds ratio 25.1, p <0.001) and high dose steroids (odds ratio 16.4, p <0.001). When applying multivariate analyses using stepwise logistic regression, only rejection was associated with a significant risk for lymphoceles (symptomatic lymphoceles—odds ratio 25.08, p = 0.0003, all lymphoceles—odds ratio 75.24, p <0.0001). When adjusting for rejection, no other risk factor came close to being significant (least p = 0.4). Therapy included laparoscopic peritoneal marsupialization and drainage in 1 patient, incisional peritoneal drainage in 4 and percutaneous external drainage in 3 (infected). All symptomatic lymphoceles were successfully treated without sequelae to grafts or patients. We conclude that allograft rejection is the most significant factor contributing to the development of lymphoceles. Therapy of symptomatic lymphoceles should be individualized according to the presence or absence of infection.

An unusual case of renal involvement in non-Hodgkin lymphoma

Ultrasonography of a patient with non-Hodgkin lymphoma revealed a thick subcapsular layer of lymphomatous tissue surrounding the kidney, quite separate from retroperitoneal nodes, that simulated a perirenal fluid collection or hematoma; the solid appearance on computed tomography scans and fine needle biopsy led to the diagnosis.

Renal damages after extracorporeal shock wave lithotripsy evaluated by Gd-DTPA-enhanced dynamic magnetic resonance imaging.

Renal damages after extracorporeal shock wave lithotripsy (ESWL) were evaluated by magnetic resonance imaging (MRI) including Gd-DTPA-enhanced dynamic MRI in 37 patients with renal stone by spin echo methods (T1 and T2-weighted scan) and small tip angle gradient echo method (T2-weighted scan). Sixty-eight percent of the patients had changes in the MRI findings after ESWL. The frequently observed findings were perirenal fluid collection (38%), loss of corticomedullary junction (35%), and increased signal intensity of muscle and other adjacent tissue (34%). Preoperative Gd-DTPA-enhanced dynamic MRI showed low intensity band which suggests Gd-DTPA secretion from the glomerulus into the renal tubulus. In all cases the low intensity band became unclear after ESWL because of renal contusion due to ESWL. MRI, including Gd-DTPA-enhanced dynamic MRI, is considered to be a good procedure for evaluation of renal damages due to ESWL.

Role of Magnetic Resonance Imaging in Blunt Renal Parenchymal Trauma

The accuracy of magnetic resonance imaging (MRI) in the evaluation of blunt renal parenchymal trauma was compared with that of contrast-enhanced computed tomography (CT) and ultrasonography (US) in a prospective study of 12 patients. CT was superior to other methods in identifying and characterising the renal parenchymal lesion, and both CT and US exceeded low field MRI in recognising a perirenal fluid collection. The role of high field MRI in the evaluation of blunt renal trauma requires further study.

Right perirenal space computed tomography evidence of communication between the bare area of the liver

Computed tomography (CT) images from one cadaver and 11 patients with perirenal fluid collection were reviewed to study whether the right perirenal space communicates with the bare area of the liver. CT of a cadaver obtained after meticulous right perirenal injection of contrast media showed that contrast media extended superiorly into the bare area of the liver. CT of 11 patients with right perirenal hemorrhage or infection showed that fluid collection within the right perirenal space continued upward, crossing the coronary ligament, extending into the bare area of the liver. The inferior vena cava were completely or partially surrounded by fluid. CT of two patients with bleeding hepatocellular carcinoma showed that blood in the bare area continued extending downward into the perirenal space. We conclude that the right perirenal space is open toward the bare area of the liver and fluid collection within one space may communicate with the other space across the coronary ligament.

Abdominal Radiograph and Renal Ultrasound Versus Excretory Urography in the Evaluation of Asymptomatic Patients after Extracorporeal Shock Wave Lithotripsy

A prospective study was done to compare the relative efficacy of an abdominal radiograph and renal ultrasound to excretory urography for the evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy.We evaluated 101 renal units in 84 asymptomatic patients who had undergone extracorporeal shock wave lithotripsy 1 month previously with abdominal radiography, excretory urography and ultrasonography to evaluate the presence of retained stone fragments, dilatation of the collecting system and intrarenal or perirenal fluid collections or masses. The combination of abdominal radiography and ultrasonography identified retained fragments in 62 renal units, while excretory urography identified them in 54. Ultrasonography was less specific in identifying dilatation of part or all of the collecting system; proving falsely positive in 7 renal units and falsely negative in 14 compared to excretory urography. However, the case of obstruction was diagnosed correctly by both modalities. Finally, ultrasound appeared to be more specific and more sensitive in the evaluation of the presence of intrarenal or perirenal abnormalities.We conclude that a combination of abdominal radiography and ultrasonography is as good or better than excretory urography in identifying residual stone fragments and intrarenal or perirenal abnormalities. However, the finding of dilatation of all or part of the collecting system by ultrasonography is nonspecific and probably is better evaluated by excretory urography. We suggest that the routine radiological evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy could be limited routinely to abdominal radiography and ultrasonography. However, when abnormalities of the collecting system are visualized on these studies excretory urography should be performed.

Blunt renal and ureteral trauma in childhood: CT patterns of fluid collections.

The CT scans of 25 children with blunt renal and ureteral trauma were analyzed to determine the severity of injury, the appearance of retroperitoneal fluid collections, and whether the extent of these collections correlated with the severity of injury. CT showed renal parenchymal injuries in 23 patients and ureteral injuries in two patients. Retroperitoneal fluid was detected in 19 (76%) of 25 patients. Perirenal fluid collections were present in all 19, periureteral fluid in 12, interfascial fluid in eight, anterior pararenal fluid in four, and psoas hemorrhage in three. The presence of perirenal and periureteral fluid was not a good predictor of the extent of renal injury. Fluid collections in the interfascial or anterior pararenal spaces and psoas muscle appeared to correlate with the severity of injury. Patients with these fluid patterns usually had renal fractures, arterial injuries, or ureteral disruptions. The presence of perirenal and periureteral fluid did not correlate with the extent of renal injury, while the presence of interfascial, anterior pararenal, and psoas muscle fluid correlated somewhat with renal fractures and renal pedicle disruption.

The Natural History of and Therapy for Perirenal Fluid Collections Following Renal Transplantation

Fluid collections following renal transplantation are not rare and may be associated with serious complications. We studied the incidence, clinical features, pathology and treatment outcome of perirenal fluid collections after kidney transplantation. Between January 1977 and June 1985, 386 consecutive renal transplants were performed at our university. All allografts were studied with B- mode ultrasonography together with a renal scan in the immediate post-transplant period, at 6- month intervals or when clinically indicated. Symptomatic fluid collections, those associated with rejection episodes and those containing more than 50 to 100 ml. fluid were aspirated under sonographic control via aseptic techniques. There were 190 fluid collections (49 per cent) observed during followup (2 to 11 years). Of these collections 98 (51 per cent) were estimated to be less than 50 ml. in volume, were clinically insignificant and resulted in no morbidity. A total of 92 collections was aspirated with 1 aspiration being diagnostic and therapeutic in 57 instances (serous or serosanguinous fluid). The 35 collections remaining were revealed to be lymphoceles on biochemical grounds. Of 13 lymphoceles associated with rejection episodes 8 resolved on initial aspiration. Of the recurrent lymph collections 27 were treated with repeated aspiration, tetracycline sclerotherapy or an operation (10 were treated with marsupialization into the peritoneal cavity). No large collections of urine or blood were detected and 1 infected lymphocele required external drainage. No renal allograft was lost as a result of a fluid collection and over-all graft survival was not affected by the development of perirenal fluid collections.We conclude that perirenal fluid collections are detected commonly in the post-transplant period using B-mode ultrasonography. The majority of these collections are small and will require careful observation only or they will resolve with a single aspiration. Aggressive diagnostic and therapeutic measures are used only for those collections that are symptomatic or result in allograft dysfunction. A rational approach to the diagnosis and treatment of peritransplant fluid collections is described in the form of an algorithm. (J Urol, 140: 716-720, 1988)

Computed Tomography after Percutaneous Renal Stone Extraction

Eighty patients were examined with computed tomography (CT) of the kidney and the retroperitoneal space after percutaneous stone extraction. Most examinations were done within a week after the operation. The morphologic changes were usually small or none. In 7 patients minor renal or perirenal fluid collections were found. Their operations had been complicated by bleeding or leakage. In 66 patients CT was compared with conventional radiographs. Residual stones were more often detected by CT. They were usually small. Percutaneous renal stone extraction is considered a safe and efficient method.