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Cisneros R, Nair A, Kashyap R, Pineda-Solis K. Page phenomenon in a transplanted kidney: is it salvageable? BMJ Case Rep 2022; 15:e249625. [PMID: 36162963 PMCID: PMC9516073 DOI: 10.1136/bcr-2022-249625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A male in his late 70s with a history of an uncomplicated kidney transplantation 20 years prior was brought to the Emergency Department after experiencing blunt abdominal trauma following a motor vehicle collision. Imaging revealed a large perinephric haematoma, a retroperitoneal haematoma and multiple fractures. He was admitted to the intensive care unit where a renal haematoma was found to be expanding with ultrasonography (US) and developed renal dysfunction including anuria and hyperkalemia. His creatinine rose to twice his baseline and Doppler US showed elevated resistive indices, confirming extrinsic compression and causing a Page phenomenon. An open surgical exploration through the upper aspect of his Gibson incisional scar was performed followed by evacuation of the haematoma. An intraoperative US was done demonstrating good flow in the renal vessels. His postoperative course was uncomplicated and was discharged home with renal function back to baseline. On follow-up, he continued to have a good renal function.
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Affiliation(s)
- Rafael Cisneros
- School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Amit Nair
- Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Randeep Kashyap
- Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Karen Pineda-Solis
- Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
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2
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Lee TW, Bae W, Choi J, Bae E, Jang HN, Chang SH, Park DJ. Page kidney following spontaneous subcapsular hematoma immediately after kidney transplantation: a case report. BMC Nephrol 2022; 23:239. [PMID: 35799146 PMCID: PMC9260983 DOI: 10.1186/s12882-022-02855-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Page kidney (PK) is the occurrence of kidney hypoperfusion and ischemia due to pressure on the kidney by a subcapsular hematoma (SH), a mass, or fluid collection. SH after renal transplantation may result in kidney ischemia and graft loss. CASE PRESENTATION We present a rare case of early spontaneous SH in an allograft kidney that led to a decrease in renal function. A 56-year-old male patient underwent deceased donor kidney transplantation. After declamping, appropriate renal perfusion and immediate diuresis were observed, with no evidence of SH. However, his urinary output abruptly decreased 6 h postoperatively. Abdominal ultrasonography showed 28 mm deep SH on transplant and the resistive index (RI) increased to 0.98-1 and diastolic flow reversal was observed. Surgical interventions were performed 2 days after transplantation, following a further decrease in urinary output. Serum creatinine decreased to 2.2 mg/dL, urinary output increased to an average of 200 cc per hour and the RI value was decreased to 0.7 on POD 7. CONCLUSION In patients with abrupt decreased renal function after transplantation, SH should be suspected and the presence of PK should be determined using Doppler USG. In these cases, surgical intervention may avoid allograft dysfunction.
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Affiliation(s)
- Tae Won Lee
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Wooram Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jungyoon Choi
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Eunjin Bae
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea.,Department of Internal Medicine, Changwon Gyeongsang National University Hospital and Gyeongsang National University College of Medicine, 11 Samjungja-ro Sungsan-gu, Changwon, 51472, Republic of Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea
| | - Ha Nee Jang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Se-Ho Chang
- Department of Internal Medicine, Changwon Gyeongsang National University Hospital and Gyeongsang National University College of Medicine, 11 Samjungja-ro Sungsan-gu, Changwon, 51472, Republic of Korea.,Institute of Health Science, Gyeongsang National University, Jinju, South Korea.,Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Dong Jun Park
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea. .,Department of Internal Medicine, Changwon Gyeongsang National University Hospital and Gyeongsang National University College of Medicine, 11 Samjungja-ro Sungsan-gu, Changwon, 51472, Republic of Korea. .,Institute of Health Science, Gyeongsang National University, Jinju, South Korea.
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Endo N, Shimizu H, Tanaka T, Nakase Y, Kawazoe T, Watanabe T. Rapidly Progressive Kidney Failure Associated with Perirenal Capsular Lesion Due to IgG4-Related Disease. Intern Med 2021; 60:1893-1897. [PMID: 33456038 PMCID: PMC8263170 DOI: 10.2169/internalmedicine.6232-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 71-year-old Japanese man with progressive kidney failure was referred to our hospital. Laboratory tests showed elevated IgG4 levels. Contrast-enhanced computed tomography (CT) revealed soft tissue surrounding the left kidney and right atrophic kidney. A histopathological examination revealed inflammation and fibrosis with rich IgG4-positive cells in the thickened kidney capsule, but not in the kidney parenchyma. Poor enhancement in the left kidney on contrast-enhanced CT and wrinkling of glomerular capillaries in pathological tissues were also observed. These findings indicated IgG4-related perirenal lesions leading to low renal perfusion and kidney failure. The perirenal lesions and kidney failure were improved by corticosteroid therapy.
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Affiliation(s)
- Nobuhide Endo
- Department of Nephrology, Japanese Red Cross Nagoya Daiichi Hospital, Japan
| | - Hitomi Shimizu
- Department of Nephrology, Japanese Red Cross Nagoya Daiichi Hospital, Japan
| | - Tomoki Tanaka
- Department of Nephrology, Japanese Red Cross Nagoya Daiichi Hospital, Japan
| | - Yukiko Nakase
- Department of Nephrology, Japanese Red Cross Nagoya Daiichi Hospital, Japan
| | - Tomohiro Kawazoe
- Department of Nephrology, Japanese Red Cross Nagoya Daiichi Hospital, Japan
| | - Tomoharu Watanabe
- Department of Nephrology, Japanese Red Cross Nagoya Daiichi Hospital, Japan
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Efe O, McGrath MM, Hu FY, Ramanathan V, Cotton RT, Adler JT, Azzi J. Urinoma From Surgical Cyst Rupture and Page Kidney Phenomenon in a Kidney Transplant Recipient. Kidney Med 2021; 3:307-308. [PMID: 33851129 PMCID: PMC8039420 DOI: 10.1016/j.xkme.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Orhan Efe
- Division of Nephrology, Brigham and Women's Hospital, Boston, MA
| | | | - Frances Y Hu
- Division of Transplant Surgery, Brigham and Women's Hospital, Boston, MA
| | | | - Ronald T Cotton
- Division of Abdominal Transplantation, Baylor College of Medicine, Houston, TX
| | - Joel T Adler
- Division of Transplant Surgery, Brigham and Women's Hospital, Boston, MA
| | - Jamil Azzi
- Division of Nephrology, Brigham and Women's Hospital, Boston, MA
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Subcapsular Renal Hematoma in Simultaneous Pancreas Kidney Transplantation. Case Rep Transplant 2020; 2020:6152035. [PMID: 32455046 PMCID: PMC7238346 DOI: 10.1155/2020/6152035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/28/2020] [Indexed: 11/18/2022] Open
Abstract
Subcapsular renal hematoma (SRH) is a challenging condition, which may jeopardize kidney function or constitute a life-threatening event. This is particularly true in single-kidney patients, such as kidney-transplant recipients. SRH may exert an excessive pressure on the surrounding parenchyma, thus resulting in hypoperfusion and ischemia, with high risk of acute kidney failure and graft loss. Moreover, SRH may precede an overt renal rupture with subsequent hemorrhage and hemodynamic instability. The indication to an interventional management for this condition is still a matter of debate, with some authors advocating the high possibilities of spontaneous resolution and others advocating the high-risk of graft loss and even internal bleeding in case of overt renal rupture. Herein, we report the case of a 51-year-old simultaneous pancreas-kidney transplantation recipient who presented a SRH following a mild trauma. The therapeutic choices were carefully balanced on the specific case, and the conservative management proved successful.
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Garcher D, Ekwenna O, Ortiz J, Rees M, Selman S, Sindhwani P. Role of Synthetic Mesh Renorrhaphy and Neocapsule Reconstruction to Salvage Posttransplant Severely Damaged Renal Allografts. EXP CLIN TRANSPLANT 2020; 19:32-37. [PMID: 32133942 DOI: 10.6002/ect.2019.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES As the recipient pool continues to rise, it is vital to conserve donor organs whenever possible. Injured renal allografts continue to be discarded for a variety of reasons, and salvaging potentially useable grafts is of utmost importance. Little information is available on outcomes of salvaged allografts. Here, we present an easily replicable technique to salvage damaged renal allografts using polyglactin mesh. MATERIALS AND METHODS Polyglactin woven mesh was used to salvage 4 otherwise irreparably injured allografts. In the first case, unidentified extracorporeal shockwave lithotripsy-induced microfractures 2 months before procurement of a deceased-donor kidney led to significant capsular injury. In the second case, rapid recovery of a deceased-donor kidney limited evaluation, and severe capsular rupture was diagnosed after perfusion. In the third case, an anticoagulated pediatric recipient received a living related-donor kidney from his mother, and a biopsy-induced hematoma 2 months posttransplant led to severe capsular denudation. In the fourth case, a pumped kidney from a donor after cardiac death developed severe focal capsular denudation. In each case, a keyhole hilar-sparing incision was made in an industry-standard 12 × 12-inch polyglactin mesh sheet, which was then fitted and sutured in a vest-over-pants method to provide a scaffold for hemostasis and capsular healing. Topical hemostatic agents were added in the first and fourth cases. Patients were followed longitudinally. RESULTS All allografts were successfully salvaged using our technique, and none developed Page kidney, hydronephrosis, urinoma, or hemorrhage. At last follow-up, recipient 1 had kidney loss 7 years postrepair secondary to chronic allograft nephropathy, recipient 2 was lost to follow-up at 1 year with normal renal function, and recipients 3 and 4 had normal renal function at years 3 and 7 posttransplant. CONCLUSIONS This simple technique using readily available materials can salvage allografts that would have been potentially explanted or discarded.
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Affiliation(s)
- Damian Garcher
- From the Department of Urology, The University of Toledo, Toledo, Ohio, USA
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Acute Renal Failure in Kidney Transplantation Due to Subcapsular Hematoma After a Renal Allograft Biopsy: Report of Two Cases and Literature Review. Transplant Proc 2020; 52:530-533. [PMID: 32033833 DOI: 10.1016/j.transproceed.2019.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 09/03/2019] [Indexed: 11/23/2022]
Abstract
The compression of the renal parenchyma due to a subcapsular hematoma, also known as the "Page kidney," is a potentially serious but treatable complication of renal biopsy. Hypertension is very common and, in some cases, renal failure may be present. In kidney transplantation, it is a not well-described entity. Rapid intervention is essential to avoid irreversible damage of the graft and preserve its function. We report 2 cases of acute renal failure due to Page kidney in patients with renal transplant after a percutaneous biopsy with successful recovery after surgical treatment. In addition, we conducted a literature review in order to describe the clinical characteristics of this infrequent complication in patients with a history of renal transplant.
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Hori S, Tomizawa M, Maesaka F, Owari T, Morizawa Y, Nakai Y, Miyake M, Yoneda T, Tanaka N, Yoshida K, Fujimoto K. Unexpected presentation of allograft dysfunction triggered by page kidney phenomenon immediately after kidney transplantation: a case report. BMC Nephrol 2018. [PMID: 29534686 PMCID: PMC5851246 DOI: 10.1186/s12882-018-0860-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Page kidney phenomenon is caused by strong renal parenchymal compression and leads to renal hypoperfusion and microvascular ischemia, resulting in renal dysfunction and hypertension. Although the development of Page kidney phenomenon in allograft is rare, most of its cases are induced by allograft biopsy or trauma. We observed a case of Page kidney phenomenon that was induced by unusual causes immediately after kidney transplantation. Case presentation A 66-year-old man, whose wife donated a kidney, underwent ABO-compatible living kidney transplantation. The allograft had three renal arteries that were trimmed and formed into one piece on the back table, and subsequently, it was anastomosed to the internal iliac artery. Intraoperative Doppler ultrasonography (US) revealed adequate blood flow of each renal artery. Urine output was also observed as soon as allograft blood flow was reperfused. After the surgery, the urine output decreased, and serum creatinine level increased to 6.0 mg/dL. Doppler US did not show evidence of acute rejection, ureteral obstruction, or anastomotic stenosis of the renal arteries. On postoperative day 7, surgical exploration was performed and revealed that the blood flow of each renal artery was adequate but subcapsular hematoma was detected at the upper pole of the allograft. Capsulotomy and hematoma evacuation were performed. Subsequently, urine output increased and serum creatinine level decreased up to 1.7 mg/dL. Allograft sample was obtained 1 h after the transplantation from the lower pole of the allograft. Although the cause of subcapsular bleeding was unclear in this case, a small cyst of the allograft, which might have ruptured during donor nephrectomy, was located in the middle of the hematoma, and oozing around the cyst was observed. Conclusions Our case indicated that the small ruptured cyst of the allograft could be the cause of subcapsular hematoma and Page kidney phenomenon. Subcapsular hematoma caused by oozing over time could be difficult to diagnose using Doppler US, and thus, other imaging modalities, such as computed tomography, should be considered. Knowledge of the Page kidney phenomenon in the allograft can lead to early diagnosis and intervention, resulting in better outcomes for recipients with allograft dysfunction.
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Affiliation(s)
- Shunta Hori
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Mitsuru Tomizawa
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Fumisato Maesaka
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Takuya Owari
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yosuke Morizawa
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Tatsuo Yoneda
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Nobumichi Tanaka
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Katsunori Yoshida
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
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Sarno G, Ferrara A, Cerbone V, Russo E, Vicedomini D, De Rosa P. Prolonged Delayed Graft Function Due to an Extensive Renal Graft Subcapsular Hematoma: Is Conservative Management Justified? EXP CLIN TRANSPLANT 2017; 17:681-684. [PMID: 28952918 DOI: 10.6002/ect.2017.0156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 62-year-old male patient with diabetes underwent deceased-donor kidney transplant at our transplant unit. At reperfusion, a small and clinically not significant subcapsular hematoma was noted. The patient's postoperative course was characterized by delayed graft function since the beginning but was further complicated on postoperative day 6 by evidence (shown at daily Doppler ultrasonography) of a wide increase of the hematoma. The hematoma, which was just visible before, was now leading to graft compression because it covered up to two-thirds of the cortical surface. The patient showed no hemo-dynamic instability and showed no significant drop in hemoglobin values. Capsulotomy was not performed because it was deemed too risky. The patient was given strict follow-up with Doppler ultrasonography and high-resolution imaging techniques (magnetic resonance imaging and computed tomography scan). In the following days, spontaneous resolution of the hematoma and progressive improvement of Doppler findings were observed, which preceded full recovery of graft function. Conservative management, in hemodynamically stable patients, seems to be a valid approach of this condition. By avoiding surgery or other interventional procedures, a conservative approach allows reduced risk of further complications. Strict monitoring with Doppler ultrasonography is a valid tool for follow-up, along with high-resolution imaging techniques such as magnetic resonance imaging and computed tomography to confirm diagnosis.
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Affiliation(s)
- Gerardo Sarno
- From the General Surgery and Transplantation Unit of the "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, Salerno, Italy
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