Acute pain over the kidney graft and Duplex‐sonographic findings mimicking complete renal transplant vein thrombosis

Extract

(Section Editor: G. H. Neild)

A 33‐year‐old male ESRD patient received a cadaveric left kidney allograft in May 2001. The vascular anatomy of the kidney was normal but the renal vein was quite long. On the first postoperative day, Duplex‐ultrasound showed a well perfused graft, but the patient required further dialysis. On the fourth postoperative day the patient complained about tenderness and pain over the graft. Routine Duplex‐sonography showed again normal flow spectra (Figure 1). Three hours later the patient developed severe pain over the graft region. Immediately repeated B‐mode‐ultrasound and Doppler‐sonography could not detect bleeding, urinary leakage or other local changes but surprisingly the Doppler waveform showed oscillating flow resulting in a zero forward net flow (Figure 2).

Because of the typical Duplex‐sonographic criteria of outflow occlusion, a complete renal vein thrombosis was anticipated and the patient was transferred within the next hour to the operating room for venous thrombectomy without any other imaging. The intraoperative aspect seemed to confirm the diagnosis of renal vein occlusion: the capsula of the kidney was completely ruptured from a perirenal haematoma, the graft revealed an enormous size and a bluish colour. After mobilizing the kidney, kinking of the renal vein due to shrinking of the surrounding soft tissue and unfavourable tilting of the graft became apparent as the cause of renal vein obstruction. Fortunately venous thrombosis was not present. The fibrotic tissue surrounding the renal vein was removed and the kidney was placed in an oblique anatomical position to avoid compression of the vein.