Retroperitoneal Compartment Syndrome in Renal Transplantation: How to Salvage the Graft?

Delayed-Onset Renal Allograft Compartment Syndrome in a Pediatric Kidney Transplant Recipient: The Role of Surgical Re-Evaluation

BACKGROUND

Renal allograft compartment syndrome (RACS) represents a rare and potentially underdiagnosed cause of allograft dysfunction, typically occurring in the immediate post-transplant period. However, delayed-onset RACS remains underrecognized.

METHODS

We present a case of a 14.5-year-old girl with nephronophthisis, who received a kidney transplant from her father and who was diagnosed with late-onset renal allograft compartment syndrome on post-transplant day 20.

RESULTS

In the post-transplant follow-up of this patient, the serum creatinine level increased from the 2nd day. On day 5, surgical re-evaluation was performed as she did not respond to acute rejection therapy with prednisolone, anti-human T-lymphocyte immunoglobulin, and plasmapheresis. Although macroscopic examination of the allograft did not reveal any abnormalities, serum creatinine levels rapidly returned to normal after surgery. However, on the 20th day, serum creatinine started to rise again. Calcineurin toxicity and infectious causes have been ruled out. She received treatment with immunoadsorption and intravenous immunoglobulin as the second biopsy showed glomerulitis and tubulitis. Despite these treatments, the serum creatinine level increased to 6 mg/dL, and she was reassessed surgically. Although the allograft appeared normal, there was edema in the surrounding tissue. Serum creatinine levels returned to normal (0.9 mg/dL) spontaneously after surgery. So, she was diagnosed with late-onset renal allograft compartment syndrome due to the edema surrounding the allograft and improvement observed in serum creatinine levels after fascia opening.

CONCLUSIONS

RACS should be considered beyond the immediate post-transplant period, particularly when standard interventions fail to improve graft function. Surgical exploration remains a critical diagnostic and therapeutic tool in such cases.

Systematic review of intra-operative duplex scanning during renal transplantation

INTRODUCTION

A systematic review of the value of intra-operative duplex scanning during renal transplantation was undertaken.

METHODS

Studies assessing intra-operative renal cortical flow in the arcuate vessels with outcomes of ultrasound directed interventions during the initial procedure, delayed graft function, post-operative resistive indices, graft losses and early returns to theatre for graft hypoperfusion were reviewed. PROSPERO registration: (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203873).

RESULTS

Literature searching identified 2069 articles for screening, with 131 reviewed and 12 selected for analysis comprising 5 individual case reports, one case series of 11 patients and 6 non-randomised controlled trials. Studies with similar methodologies were pooled because of the low number of studies and outcomes. Outcomes of interest were not reported for all patients. Intra-operative interventions comprising graft repositioning in 18 (16%) and vascular revision in 2 (2%) were performed in 115 patients undergoing intra-operative scans. There were no graft losses or returns to theatre for graft hypoperfusion (0 of 108 cases) compared to 7 of 71 (10%) without intraoperative scanning (P = 0.003). Three of 8 (38%) patients with high intra-operative resistive indices (RIs) were returned to theatre for hypoperfusion compared to 1 of 110 (1%) patients with normal resistive indices (P = <0.001). Ten of 13 (77%) patients with high RIs had delayed graft function compared to 10 of 40 (25%) with normal RIs (P = 0.001).

CONCLUSION

Despite the absence of randomised controlled trials, and heterogeneous small studies, adverse outcomes were reduced with intra-operative scanning. High intraoperative RIs were predictive of both delayed graft function and return to theatre for hypoperfusion.

Renal allograft compartment syndrome: a review

Renal allograft compartment syndrome (RACS) is the result of extrinsic compression resulting in graft dysfunction and loss due to ischaemia. A literature review was performed by computerized searches from the following data sources Medline, EMBASE, PubMed and Cochrane Library databases. Risk factors include size mismatch between graft and recipient. Intraoperative suspicion should be exercised if there is poor tissue turgor, cyanosis and loss of urine output upon fascial closure. Doppler ultrasound is the modality of choice amongst the literature to aid in diagnosis of RACS. From our study, the accepted form of treatment is early detection and appropriate surgical intervention. Nevertheless, it is clear from the paucity of literature that further investigation into this area of transplantation is necessary.

Complications during multiorgan retrieval and pancreas preservation

In pancreas transplantation, complications can arise at each step of the process, from the initial selection of donors and recipients through the surgical technique itself and the post-operative period, when lifelong immunosuppression is required. In the early steps, careful retrieval and preservation of the pancreas are crucial for the viability of the organ and ultimate success of the transplant. The pancreas is a low-flow gland, making it highly sensitive to transplantation conditions and presenting risk of pancreatitis due to periods of ischemia. The two groups of donors - after brain death (DBD) or after cardiac arrest (DCD) - require different strategies of retrieval and preservation to avoid or reduce the risk of complications developing during and after the transplantation. For DBD donor transplantation, multiorgan retrieval and cold preservation is the conventional technique. Asystole donor (DCD) transplantation, in contrast, can benefit from the newest technologies, such as hypothermic and especially normothermic preservation machines (referred to as NECMO), to optimize organ preservation. The latter has led to an increase in the pool of donors by facilitating recuperation of organs for transplantation that would have been discarded otherwise.