Postrenal Transplant Allograft “Page Kidney” Identified and Salvaged using ^99mTc-diethylenetriaminepentaacetic acid Renogram and Single-photon Emission-computed Tomography

A 48-year-old female with chronic hypertension, diabetic nephropathy, and chronic kidney disease Stage V underwent a complicated live related donor renal transplant. Despite an uneventful surgery, the patient developed decreased graft function 4 h poststabilization with progressive oliguria and a serum creatinine level of 3.4 mg/dl requiring dialysis. Emergency Doppler images [Figure 1] demonstrated a high-resistance flow pattern (resistance index ≥1) in transplanted renal artery showing decreased flow and intrarenal arteries showing diastolic reversal of flow with normal venous flow.

Close

Figure 1 Emergency renal Doppler images demonstrating a high-resistance flow pattern (resistance index ≥ 1) in transplanted renal artery (a, with reduced diastolic flow [arrow]) and intrarenal arteries (b, with diastolic reversal [arrowhead]) with normal venous flow

Export to PPT

A ^99mTc-diethylenetriaminepentaacetic acid (DTPA) diuretic-renogram (F-15 protocol) study [Figure 2] was performed on postsurgery day 2 to rule out possibility of suspected early acute tubular necrosis (ATN). It demonstrated markedly reduced perfusion to the transplant kidney in the right iliac fossa with insignificant cortical tracer uptake in dynamic and prevoid images, respectively, and high background activity suggestive of possible hyperacute/acute rejection.

Close

Figure 2 A ^99mTc-diethylenetriaminepentaacetic acid diuretic renogram (F-15 protocol) study was performed on day 2 to rule out suspected early acute tubular necrosis which demonstrated markedly reduced perfusion to the transplant kidney in the right iliac fossa (a, arrow) with insignificant cortical tracer uptake (b, arrowhead) in dynamic and prevoid images, respectively, and high background activity suggestive of possible hyperacute/acute rejection

Export to PPT

An immediate single-photon emission- computed tomography (SPECT-CT) [Figure 3] performed postcompletion of dynamic scanning revealed a large hypodense perigraft collection suggesting a subcapsular hematoma (yellow-arrow), raising the possibility of secondary hypoperfusion. Revisiting surgical notes revealed the use of robotic arm for harvesting donor kidney, suggesting a possible cause for hematoma development.

Close

Figure 3 An immediate single-photon emission-computed tomography performed postcompletion of dynamic scanning revealed a large hypodense perigraft collection suggesting a subcapsular hematoma (yellow arrow) raising the possibility of secondary hypoperfusion. Revisiting surgical notes revealed the use of robotic arm for harvesting donor kidney, suggesting a possible cause for hematoma development

Export to PPT

On open reexploration, SPECT-CT findings were confirmed revealing a large subcapsular hematoma which was deroofed. This resulted in subsequent improved graft function, decline in serum creatinine levels (2.4 mg/dl on day 4 and 1.2 mg/dl on day 5), and good urine output. Poststabilization, follow-up ^99mTc DTPA [Figure 4] was performed on day 5, revealing prompt perfusion to graft in the right iliac fossa with good cortical tracer uptake and drainage and significantly reduced background tracer activity compared to day 2 study.

Close

Figure 4 On open reexploration, single-photon emission-computed tomography findings were confirmed, and a large subcapsular hematoma was deroofed and hemostasis achieved resulting in improved graft function, creatinine levels (2.4 mg/dl on day 4 and 1.2 mg/dl on day 5), and good urine output. Poststabilization, ^99mTc diethylenetriaminepentaacetic acid was reperformed on day 5, revealing prompt perfusion to graft in the right iliac fossa (Fig 4a-arrows) with good cortical tracer uptake and drainage (Fig. 4b, arrowhead) and significantly reduced background tracer activity compared to day 2 study

Export to PPT

Follow-up renal Doppler [Figure 5] performed 45 days later revealed the normalization of flow pattern in transplanted renal artery and the intrarenal arteries.

Close

Figure 5 Follow-up renal Doppler performed 45 days later revealed the normalization of flow pattern in transplanted renal artery (a, at site of anastomosis [arrow]) and intrarenal arteries (b, arrow head)

Export to PPT

Posttransplant anuria is commonly associated with ATN and is rarely due to a subcapsular hematoma causing external compression of the allograft parenchyma and pelvicalyceal system. When associated with hypertension and renal failure, this is commonly referred to as “Page kidney phenomenon” after its first description by Irvine Page in 1939[1] for cellophane-associated perinephritis and later extended to other perinephric etiologies including hematoma.

Subcapsular hematoma forms a major contributor to complications associated with postrenal allograft biopsy [2] and may occur due to trauma associated with robotic harvesting of donor kidney as was observed in our case. Timely recognition is warranted as immediate surgical decompression can salvage allograft as illustrated.[3]

Among several modalities available, ultrasound guided carries advantage of being available and inexpensive but lacks specificity due to operator dependency. Although CT abdomen is considered the preferred modality for its ability to detect even small hematomas,[4] the use of fusion imaging modalities such as ^99mTc-DTPA SPECT-CT may serve as a single tool allowing baseline allograft function quantification, differential diagnosis, and following up for the success of reexploratory surgery apart from hematoma detection prompting an immediate action as was demonstrated in this case..