Ultrasound-guided percutaneous renal biopsy-induced accessory renal artery bleeding in an amyloidosis patient

Pre-operative colour Doppler ultrasound for the prevention of bleeding complications after renal biopsy: A rare case of left renal lower pole vein

Albeit rare, renal vein abnormalities on autopsy and in cases of abdominal surgery complications have been reported and should be kept in mind when performing invasive procedures, such as renal biopsy. We detected a rare renal vein abnormality on colour Doppler ultrasound before renal biopsy, thereby, avoiding a haemorrhagic complication. A 10-year-old boy presented to our department for the first time because of incidental findings of haematuria and proteinuria. We suspected chronic glomerulonephritis and scheduled an ultrasound-guided percutaneous renal biopsy. A simple screening ultrasound at the initial visit revealed no renal or vascular abnormalities. The day before the renal biopsy, we confirmed the biopsy site by performing a colour Doppler ultrasound, which showed abnormal blood flow from the lower pole of the left kidney, which was the planned puncture site; therefore, we changed the biopsy site to the right and completed the examination. Subsequent computed tomography angiography depicted two renal veins; one was the usual left renal vein draining from the kidney hilum, and the second was an accessory vein draining from the inferior pole of the left kidney and entering the inferior vena cava through the dorsal side of the aorta. Although rare, abnormalities in the renal vessels on the inferior pole of the kidney, which is the usual site of renal biopsy, are essential to rule out preoperatively by colour Doppler ultrasound, because these can cause significant bleeding during renal biopsy if not recognized.

Retrospective Analysis of the Comparison Between Single Renal Artery Versus Multiple Renal Arteries in Living Donor Kidney Transplant: Does It Affect the Outcome?

OBJECTIVES

There is an increased risk of vascular complications in kidney transplant for allografts with multiple renal arteries versus a single renal artery. We compared the clinical outcomes of living donor kidney transplant recipients who received allografts with a single renal artery versus multiple renal arteries.

MATERIALS AND METHODS

This retrospective analysis included all living-related donor kidney transplants that were performed by a single skilled urologist. All donor nephrectomies were performed by open method. The left kidney was preferred over the right for donor nephrectomy, except in cases of vascular problems or other contraindications, for which the right kidney was preferred. In most of the cases, kidneys were placed in the right iliac fossa for transplant by an extraperitoneal approach.

RESULTS

Of 97 living donor kidney transplants, 82 had a single renal artery (group 1) and 15 had multiple renal arteries (group 2). Patients ranged in age from 18 to 76 years old. Recipient ages (33.00 vs 29.46 years) and baseline serum creatinine values (8.61 vs 8.82 mg/dL) were comparable in groups 1 and 2 (P > .05). However, mean operative time and total ischemia time were significantly higher in the multiple renal artery group (221 and 53.45 minutes, respectively) compared with the single renal artery group (202 and 77.6 minutes, respectively). Graft survival at 1 year was 95.12% in the single renal artery group and 93.33% in the multiple renal artery group. Patient survival at 1 year was 96.34% in the single renal artery group and 93.33% in the multiple renal artery group.

CONCLUSIONS

The safety of kidney transplants of allografts with multiple renal arteries is equal to the safety of transplants of allografts with a single renal artery in terms of vascular complications and acute tubular necrosis, as well as patient and graft survival.

Massive hemorrhage after percutaneous kidney biopsy caused by renal artery malformation: a case report and literature review

Background

Accessory renal artery (ARA) is the most common site for anatomical variation of renal supply artery. Rare studies reported interventional embolization for the management of massive hemorrhage caused by ARA injury after percutaneous kidney biopsy (PKB).

Case presentation

We describe a 35-year-old man who developed massive hemorrhage after PKB leading to shock. Digital subtraction angiography (DSA) showed hemorrhage in the ARA at the inferior pole of the right kidney and hemostasis was noticed after renal artery embolization.

Conclusions

We proposed that much attention should be paid to the presence of ARA before PKB. In addition, digital subtraction angiography combined with superselective embolization is the best choice for the treatment of renal artery injury.

The Anatomy of Renal Arteries in Adults

Detailed extraparenhymal renal hilar dissection was performed on 110 fixed cadaveric kidneys (60 from male cadavers and 50 from female cadavers). We analyzed the number of renal arteries, angles between renal arteries and abdominal aorta, length and diameter of the renal arteries. Multiple renal arteries were present in 20.9% of cases, with a slightly higher incidence on the right side (21.8%: 20.0%). The angle between the aorta and the RRA varied from 30° to 100° with a mean of 64.1°, while the angle between the abdominal aorta and the LRA was 40° to 115°, with a mean of 67.3°. The external caliber of the RRA at the point of origin from the abdominal aorta was 5 mm to 9.1 mm, with a mean of 6.8 mm. The same caliber of the LRA was 3.7 to 9.6 mm with a mean of 7.0 mm. The average length of the renal artery from the point of origin from the abdominal aorta to the branching point was 36.2 mm for the right renal artery and 30.7 mm for the left renal artery. The average length of the renal artery from the point of origin from the abdominal aorta to the renal hilum was 65.1 mm for the right one and 54.7 mm for the left one. Knowledge of the number of renal arteries, their mode of entry into the kidney, the angles they build with the abdominal aorta, their diameter and length has practical applications in interventional radiology and surgery of the kidney and its environment.

Morphological and clinical aspects of the occurrence of accessory (multiple) renal arteries

Renal vascularization variants vastly differ between individuals due to the very complex embryogenesis of the kidneys. Moreover, each variant may have implications for clinical and surgical interventions. The number of operating procedures continues to grow, and includes renal transplants, aneurysmorrhaphy and other vascular reconstructions. In any surgical technique, unawareness of the presence of multiple renal arteries may result in a fatal outcome, especially if laparoscopic methods are used. The aim of this review is to comprehensively identify the variation within multiple renal arteries and to highlight the connections between the presence of accessory renal arteries and the coexistence of other variants of vascularization. Another aim is to determine the potential clinical implications of the presence of accessory renal arteries. This study is of particular importance for surgeons, intervention radiologists, nephrologists and vascular surgeons.

Accessory (multiple) renal arteries - Differences in frequency according to population, visualizing techniques and stage of morphological development

The aim of this paper is to comprehensively analyze the literature focused on frequency of the presence of the accessory renal arteries in the human body. A systematic analysis of papers has been made. With regard to ethnicity, the incidence of accessory renal arteries fluctuates from 4% in a Malaysian population to 61.5% in a Brazilian population. The frequency is lowest in eastern and southern Asia (from 4% to 18.4%). In some, not ethnically homogenous populations, wide span of occurrence of accessory renal arteries is described (e.g. American - averaging from 18% to 28.8%). A higher frequency of accessory renal arteries was observed in fetuses compared to adults. Moreover, differences in the presence and number of accessory renal arteries reported in different papers are a consequence of type of visualizing technique used in research - especially when computed tomography and anatomical dissection were compared. The increasing number of surgical interventions, especially where laparoscopic methods are concerned, underlines the importance of such knowledge especially to surgeons, interventional radiologists, nephrologists, and vascular surgeons.

Primary systemic amyloidosis initially presenting with digestive symptoms: a case report and review of the literature

Primary systemic amyloidosis (PSA) is one of systemic amyloidosis, characterized by clonal plasma cell disorder. The disease is rare and with high fatality. Signs and symptoms of PSA are various and complex, which depend on the organs involved. Here we report a case in which the patient initially suffered from gastrointestinal symptoms. Gradually periorbital purpura, skin fragility, and subsequent petechiae, ecchymoses and sclerosis of the distal limbs, appeared. Biopsy of his palmar skin showed scleroderma-like changes. However, histopathology of the petechiae lesion on forehead with Crystal Violet Staining prompted deposition of amyloid; gastric mucosal biopsy with Congo Red staining was also positive, which made clear the diagnosis of PSA. Bone marrow biopsy and serum immunofixation electrophoresis (IFE) revealed plasmacytosis and M proteinemia. Other examinations were performed to assess the function of organs. PSA was challenging due to the initial atypical clinical presentation and absence of biopsy with special staining. The case demonstrates that PSA should be considered in patients with multisystemic symptoms and biopsy with Congo Red staining should be performed to exclusively diagnose amyloidosis.

Resolution of proteinuria after transarterial embolization of aberrant renal artery in a patient with focal segmental glomerulosclerosis

A 24-year-old man was admitted to our hospital for persistent proteinuria. He was born with a low birth weight but had grown up uneventful until the age of 20 when he was found to have proteinuria. Because his body mass index was 30.9 kg/m² at that time, he was diagnosed as obesity-related nephropathy. However, weight reduction and administration of ACE inhibitor were minimally effective for the amelioration of proteinuria. Ultrasound-guided percutaneous renal biopsy at the lower pole of right kidney was performed. As serious bleeding occurred from the right aberrant renal artery soon after biopsy, he was treated with transarterial embolization (TAE). The day after TAE, proteinuria completely disappeared. Renal biopsy showed benign nephrosclerosis with secondary focal segmental glomerulosclerosis (FSGS). Proteinuria could be induced by increased blood flow and pressure due to abnormal blood supply from aberrant renal artery. This is the first report of resolution of proteinuria after TAE of aberrant renal artery in a patient with FSGS.