A Case of Recurrent Episodes of Acute Renal Allograft Failure Caused by Renal Pedicle Tortion

Simultaneous Pancreas-Kidney Transplant Complicated by Kidney Allograft Torsion and Pseudoaneurysms of the Y-Allograft: A Case Report and Review of the Literature

Background. We report and review the literature of two rare complications of simultaneous pancreas-kidney transplantation (SPKT) occurring in one patient. Case Report. A 39-year-old man with dialysis-dependent kidney failure secondary to type 1 diabetes mellitus underwent successful SPKT in October 2018. Three months later, he presented with an acute kidney injury (AKI) and returned to dialysis. Kidney scintigraphy showed a central photopenic region, and angiograms showed absent flow in the kidney transplant artery without treatable thrombus and the incidental finding of two pseudoaneurysms of the pancreatic Y-graft. He remained dialysis-dependent for three weeks before spontaneous partial recovery of allograft function; repeat kidney scintigraphy showed significant improvement in perfusion. However, in April 2019 he was readmitted with a sudden deterioration in kidney allograft function again necessitating haemodialysis. Repeat imaging confirmed that the kidney allograft had shifted from the left iliac fossa to the midline. He underwent surgical exploration, during which torsion of the kidney allograft was confirmed and a nephropexy was performed. The kidney allograft was originally implanted in the left retroperitoneum via a midline transperitoneal approach, which likely predisposed it to torsion. The pseudoaneurysms of the pancreatic Y-graft were managed conservatively, and surveillance imaging demonstrated that they remained stable in size. The patient regained reasonable kidney allograft function (estimated glomerular filtration rate, eGFR, of 45 mL/min) and maintained normal pancreatic allograft function. Conclusion. Kidney allograft torsion should be considered post-SPKT in patients with AKI and absent arterial flow. Although most case reports describe surgical management of pseudoaneurysms post-SPKT, our case demonstrates successful conservative management.

Late renal allograft torsion in a pediatric transplant recipient

BACKGROUND

Kidney allograft torsion is a rare complication of kidney transplant that can lead to allograft loss from prolonged ischemia if not quickly corrected with detorsion and nephropexy. We report a case of late intraperitoneal renal allograft torsion in a pediatric transplant recipient.

CASE REPORT

The patient is a 7-year-old male with a history of end-stage renal disease secondary to renal dysplasia in the setting of bilateral high-grade vesicoureteral reflux. He underwent bilateral native nephrectomies for recurrent pyelonephritis and right ureteral kink with urinary tract obstruction. Torsion occurred 3 years after transplant in the setting of one day of emesis, loose stool, severe abdominal pain, and decreased urine output. Diagnosis of transplant torsion was suspected on non-contrast CT scan done after transplant Doppler ultrasound showed no flow to the allograft. The CT scan showed that the kidney had been medialized and renal hilum was flipped from the expected orientation. The patient required a transplant nephrectomy.

CONCLUSIONS

Renal transplant torsion is a rare event but should be suspected in any renal transplant recipient with acute onset of abdominal pain, acute kidney injury, and decreased urine output, regardless of length of time from transplantation. Patients suspected to have renal torsion should be evaluated emergently with a transplant ultrasound Doppler.

Partial Renal Transplant Torsion as a Cause of Abdominal Pain

Allograft torsion is a rare but potentially devastating outcome of renal transplantation. Patients typically present with an acute onset of abdominal pain, though symptoms are non-specific and can easily be missed in favor of more common diagnoses. Imaging, in particular ultrasound and computed tomography, can aid in the diagnosis of renal transplant torsion by demonstrating characteristic features, and once recognized immediate surgery is typically performed in an attempt to salvage the allograft. However, renal transplant torsion needs not be an acute event; patients can instead present with chronic, waxing, and waning symptoms if the allograft undergoes partial or intermittent torsion. The aforementioned characteristic imaging findings may not be present in this situation. It is essential to recognize partial, intermittent torsion as well, for which imaging can again play a role.

Symptomatic Nephroptosis of the Transplant: First Report of Diagnostic Workup and Successful Minimal-Invasive Treatment

The symptomatic nephroptosis of a kidney transplant is a rare and potentially fatal complication and requires fast diagnosis and treatment. In this report, we describe a case in which intermittent symptomatic hydronephrosis and an increase of the creatinine levels were the leading symptoms of nephroptosis. Moreover, we describe the diagnostic procedures and the successful minimal-invasive treatment. To our knowledge, this is the first report of a symptomatic transplant nephroptosis with consecutive intermittent hydronephrosis and without complications of perfusion solved with a minimal-invasive approach.

Recurrent Renal Allograft Torsion After Simultaneous Kidney and Pancreas Transplantation: Is it Still Possible to Salvage the Graft? A Case Report

BACKGROUND

Kidney allograft torsion (KAT) is defined as a rotation of the renal allograft around its vascular pedicle. It is a rare complication with high rate of graft loss. The nonspecific presentation and inability to provide a definitive diagnosis by imaging, mainly in cases of partial torsion, often delay the diagnosis and treatment. We report a case of recurrent complete torsion of the renal allograft after simultaneous kidney and pancreas transplantation, requiring 2 emergency exploratory laparotomies.

CASE REPORT

A 38-year-old woman with a history of intraperitoneal simultaneous kidney and pancreas transplantation underwent 2 separate emergency exploratory laparotomies secondary to complete renal allograft torsion, respectively, 7 and 11 months after the transplant. In both episodes, no adhesions were encountered. During the first operation, nephropexy was performed. During the second operation, an abdominal wall mesh was placed and fixed to the abdominal wall. Acute kidney injury related to KAT recovered in both occasions with a creatinine of 1.3 mg/dL at 4 months follow-up.

CONCLUSIONS

Renal torsion always should be suspected in intraperitoneally placed kidneys presenting with nonspecific symptoms, abdominal pain, oliguria, and worsening kidney function. Surgical exploration should be considered to salvage the renal graft. This case illustrates the reversibility of a severe injury related to this vascular complication with an adequate return to baseline kidney function even when diagnosis and surgical treatment of KAT might be delayed secondary to its misleading clinical presentation.

Laparoscopic Fixation for Torsion of Transplanted Kidney: A Case Report

BACKGROUND

Kidney graft torsion and subsequent acute kidney injury is a rare yet potentially devastating complication of intraperitoneal kidney transplant. We report a case of this elusive diagnosis and describe kidney salvage by using laparoscopic fixation.

CASE REPORT

A 49-year-old male patient presented with multiple episodes of anuric acute kidney injury 16 months after an uneventful combined orthotopic liver and kidney transplantation. After a thorough investigation, a diagnosis of kidney torsion was made, and the patient was urgently operated. Upon surgery, a complete torsion of a viable kidney was found. Laparoscopic fixation was achieved by using an absorbable mesh "pocket." The patient has experienced no similar episodes in the subsequent year.

CONCLUSIONS

Nephrologists and surgeons should be aware of this rare complication. Prompt diagnosis and operative repair are crucial to save the graft. Prophylactic nephropexy should be considered in all intraperitoneal transplantations.

Long-term Graft Survival After Kidney Allograft Torsion: Rapid Diagnosis and Surgical Management Key to Reversibility of Injury

INTRODUCTION

Kidney allograft torsion (KAT) is a rare complication of kidney transplantation (KT) that occurs when the transplanted kidney rotates around its vascular pedicle, which may result in a catastrophic compromise of the graft's blood supply, deterioration of kidney function, and eventually premature graft death.

CASE REPORT

We report the case of a patient who had an acute kidney injury (AKI) episode from KAT. Her diagnosis was ascertained expeditiously and she had prompt surgical management. Five years after the KAT event, her baseline creatinine (Cr) stabilized around 1.6 mg/dL and she has achieved >8-year graft survival.

DISCUSSION

This case illustrates the reversibility of injury that can occur after a KAT event with a commensurate return to baseline kidney function when KAT is promptly diagnosed and treated. A high index of suspicion of this uncommon but catastrophic complication of KT must be maintained to achieve desirable long-term outcomes. A diagnosis of KAT must be considered when routine etiologies of an acute deterioration of kidney allograft function have been excluded. Finally, prophylactic nephropexy must be strongly considered with intraperitoneal placement of a kidney allograft to avoid KAT.

Post-transplantation nephroptosis causing recurrent episodes of acute renal failure and hypertension secondary to intermittent vascular torsion of intraperitoneal renal allograft

Nephroptosis is a rare complication in renal transplantation, but one with significant associated risk. Due to non-specific clinical features, there may be a substantial delay in diagnosis and loss of the transplanted kidney due to renal pedicle thrombosis. We present a case of post-transplantation nephroptosis after simultaneous pancreas and kidney transplant, which resulted in accelerated hypertension and reversible acute kidney injury >1 year after transplantation. Prompt detection of this rare entity leading to expeditious surgical intervention is necessary to preserve viability of the renal allograft.

Graft Kidney Torsion After Simultaneous Kidney-Pancreas Transplant: Report of 2 Cases and Literature Review

Torsion of an allograft kidney is an extremely rare and potentially reversible complication. Imaging diagnosis plays a crucial role because of the absence of specific clinical features. We report 2 cases in which kidney torsion after simultaneous kidney-pancreas transplant was diagnosed by ferumoxytol-enhanced magnetic resonance imaging/angiography and present a review of the relevant literature. Radiologists and clinicians should be aware of this entity because graft salvage depends on rapid diagnosis and surgical detorsion.