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Post re-anastomosis demonstration of regain in function in non-visualized upper half of kidney in a dual arterial allogenic renal graft on renal scintigraphy
Address for correspondence: Dr. Sunita Tarsarya Sonavane, Department of Nuclear Medicine and PET, Bombay Hospital and Medical Research Centre, 12, Marine Lines, Mumbai - 400 020, India. E-mail: drsunitatarsarya@yahoo.co.in
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Abstract
A young male patient with end stage renal disease underwent renal allograft having dual arterial supply. Immediate post-operative urine output dropped, an urgent Technetium-99m-mercaptoacetyltriglycine (99mTc-MAG3) renogram revealed non-visualized upper-half and the preserved perfusion and parenchymal function of the small transplant kidney. Patient was re-explored and re-anastomosis was performed. A renogram at 24h post re-anastomosis revealed increase in the size of renal allograft, with preserved perfusion to the upper-half of transplant. Transplant kidney biopsy of the Upper-half showed acute tubular necrosis. 99mTc-MAG3renogram at 10 days post re-vascularization remains unchanged with persistent improvement at 2 months follow-up. We conclude that early recognition of renal functional loss allows early management and the high probability of salvaging the renal function.
Keywords
Dual artery
dynamic renogram
perfusion
renal transplant
technetium-99m-mercaptoacetyltriglycine
INTRODUCTION
Renal scintigraphy has provided a clinically important functional evaluation of renal transplants since the beginning of the transplantation era.[1] Nuclear medicine scanning and flow studies remain the primary means for evaluating vascular supply to the transplant after surgery.[2] Although the sensitivity of renal scintigraphy for functional abnormality is rather high, the specificity reports have been variable.[3] Since three decades, non-invasive radionuclide procedures for the evaluation of renal disease, provide a valuable data on perfusion and function of individual kidneys and has become an invaluable asset to clinicians in the evaluation of renal parenchyma and urologic abnormalities.[4]
CASE REPORT
A young male with end stage renal disease on maintenance hemodialysis since 6 months was subjected to renal transplant. Pre-transplant human leucocyte antigen (HLA) cross match with donor mother was 5% i.e., negative donor(Mother) Computed tomography (CT) renal angiography revealed dual arterial supply in both kidneys and accessory artery supplying the upper poles. Donor glomerulation filtration rate (GFR) by 99mTc Diethyene tetraamine pentaacetic acid (DTPA) was 94.8 ml/min. Patient underwent allograft renal transplant with dual arterial supply in right iliac fossa by end to side anastomosis. Post-operative urine output dropped significantly within 8h. Patient was urgently evaluated with 99mTc-mercaptoacetyltriglycine (99mTcMAG3) renogram, which revealed small transplant kidney in the right iliac fossa, the upper-half of kidney was not visualized and only inferior half of the transplant was visualized with preserved perfusion, preserved parenchymal function and non-obstructed drainage pattern. 99mTcMAG3 clearance was 26.7ml/min [Figure 1]. Subsequent Doppler of transplant kidney revealed absent perfusion in upper-half of the transplant corroborating with the renogram finding. Patient was re-explored, there was discolouration of upper-half of the transplant kidney with no pulsation in the artery supplying superior pole, re-anastomosis was performed. At 24 h post re-anastomosis, patient was re-referred for renogram which revealed increase in the size of renal allograft compared to the previous scan. Upper-half of the transplant was visualized and revealed preserved perfusion, mild to moderately impaired parenchymal function and progressive tracer concentration with no definite drainage. The lower-half of the transplant remained similar. 99mTcMAG3 clearance was 49.2ml/min [Figures 2 and 2a and 2b]. Upper-half of the transplant kidney on biopsy revealed acute tubular necrosis. 99mTcMAG3 renogram findings 10 days post re-anastomosis remained unchanged [Figures 3 and 3a and 3b]. Two months post re-anastomosis a 99mTcMAG3 follow-up renogram revealed further improvement in drainage pattern of upper-half. 99mTcMAG3 clearance improved to 88.4ml/min [Figures 4 and 4a and 4b]. We conclude that early recognition of renal functional loss allows early management and high probability of salvaging the renal function.
DISCUSSION
Mark Tulchinsky assessed 99mTcMAG3 for determination of renal transplant prognosis for recovery in patients with early post-operative dysfunction.[5] The postulate tested was that good tracer extraction may imply high likelihood of recovery, while poor extraction may confer a poor prognosis.[6] One of the most critical clinical questions in patients with dysfunctioning renal transplant during the early post-operative period is a likelihood of functional recovery. This is important because a patient who has no hope of transplant recovery could potentially benefit from early termination of immunosuppression and transplant removal.[3] Several reports have suggested that the absence of perfusion or tracer uptake on renal scintigraphy correlates with conditions that confer a grave prognosis for survival of the renal transplant,[4] uptake of OIH is proportional to the renal viability and is well-correlated to the kidney's ability to regain normal function after ischemic damage, as demonstrated in an animal model.[7] Importantly, it takes only a few minutes after initiation of renal scintigraphy to obtain this critical information, allowing a prompt decision regarding further patient management.[8] Recent evidence indicates that transplant function in those patients can be saved by prompt restoration of blood flow.[9] In today's era, where there is scarcity of donor organs, early recognition of deterioration of renal perfusion/function, allows early management of complication, thereby aid in prompt measures for salvaging the renal graft function.
Source of Support: Nil
Conflict of Interest: None declared
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