Spontaneous renal allograft rupture complicated by urinary leakage: case report and review of the literature

A thirty-nine-year-old woman with end stage renal disease secondary to eclampsia was admitted to our institution for her primary deceased donor kidney transplantation on January 2006. Pre-transplant comorbidities included hypertension, dyslipidemia and secondary hyperparathyroism. The donor was a twenty-six-year-old male who died from acute obstruction of the foramina of Monroe. Cold ischemia time was ten hours. The kidney was medium-sized, had one artery, one vein and one ureter. The donor and the recipient were blood group compatible and six HLA antigens mismatched. The highest recipient Panel Reactivity Antibody was 15 % and the direct microcytotoxicity crossmatch was negative. Macroscopically, the kidney looked normal. It was extraperitoneally transplanted in the left iliac fossa, as standard procedure. After declamping, the organ reperfused immediately. The graft ureter was anastomosed to the bladder according to the single stitch technique. The patient was enrolled in a phase III randomized, multicenter, clinical trial and received basiliximab (Simulect®, Novartis Pharmaceuticals Corporation), cyclosporine (Sandimmune Neoral®, Novartis Pharmaceuticals Corporation), everolimus (Certican®, Novartis Pharmaceuticals Corporation) and steroids.

The early post-operative course was complicated by delayed graft function requiring haemodialysis. According to the protocol, her baseline immunosuppression was not changed. Daily ultrasound evaluation showed a well-sized graft with no fluid collections, no hydronephrosis, and good intra-parenchymal flow. Haematologic and coagulation profiles were normal.

On post-operative day four, the recipient suddenly complained of abdominal pain and the urinary output dropped. Blood pressure, pulse rate and haemoglobin concentration remained stable. Four hours later, the abdominal pain increased and the area over the graft became distended and tender. Hypotension rapidly developed, the pulse rate increased and the patient became anuric. Aggressive resuscitation was promptly initiated. An urgent Doppler ultrasound scan was performed. It showed a large hypoechoic collection surrounding the graft with good flow in the renal artery and a patent renal vein. Subsequent contrast-enhanced CT scan revealed a ruptured graft and a massive retroperitoneal haematoma with active bleeding from the transplanted kidney (Fig.  1). The patient was immediately brought to theatre and explored. A large peri-graft haematoma was evacuated. The kidney was swollen but pink and the arterial pulse was good. A 5 cm long and 1.5 cm deep laceration was found along the middle portion of the convex border of graft, actively bleeding. After en block clamping of the renal vessels, the transplant was fully inspected. Haemostasis was achieved using a haemostatic matrix (Floseal® Hemostatic Matrix, Baxter International Inc.) and by apposition of several mattress polyglactin 910 (Vicryl™, Ethicon Inc.) sutures tied over flaps of absorbable hemostats (Surgicel® Original Absorbable Hemostat, Ethicon Inc.). To prevent extension of the rupture, a polyglactin 910 mesh (Vicryl™ Woven Mesh, Ethicon Inc.) was wrapped around the graft. The procedure took 140 min and renal clamping was 45 min. The total intra-operative blood loss (including the haematoma) was 500 mL and two units of packed red blood cells were transfused. Considering the severity of the bleeding, the complex repair, and the risk of further damage to the kidney, a graft biopsy was not taken at the time of the operation. However, the clinical picture was highly suggestive of acute rejection and we therefore decided to administer a course of rabbit anti-thymocyte globulins (Thymoglobulin®, Genzyme Inc.). Cyclosporine and everolimus were also switched to tacrolimus (Prograf®, Astellas Pharma Inc.) and mycophenolate mofetil (CellCept®, Genentech USA Inc.). After the operation, the patient remained anuric requiring haemodialysis for twenty-one days. Renal function improved and serum creatinine concentration fell to 2 mg/dL.

On post-operative day fifty-two, clear fluid started to seep from the wound. Urgent CT scan showed a large (5 × 2.3 cm) fluid collection in continuity with the area of the previous rupture (Fig.  2). Urinary leakage was confirmed by chemical analysis of the fluid. A nephrostomy tube and a trans-abdominal drain were inserted to control the leak and evacuate the collection. Two days later, the patient became febrile and the urinary output dropped. A nephrostogram was performed. It demonstrated another urinary leak at the site of the ureteral anastomosis (Fig.  3). Following an unsuccessful simultaneous cystoscopy and fluoroscopy guided ureteral stent placement, a surgical exploration was planned. The abdomen was entered through a midline incision and the graft was inspected. The distal part of the transplanted ureter, partially necrotized, was resected and the proximal stump was anastomosed to the bladder according to the Lich-Gregoire technique. A double-J pyeloureteral stent was placed to protect the anastomosis. The procedure took 143 min. The post-operative course was uneventful. Renal function gradually recovered, serum creatinine fell to 1.7 mg/dL and the patient was eventually discharged.

Eight years after transplantation, the patient is doing well and her serum creatinine is 1 mg/dL.

Written informed consent for publication of this Case report and any accompanying images has been obtained from the patient. A copy of the written consent is available for review by the Editor of this journal.