PMC6260141_01
Representative allograft images of Doppler US and CT before surgical exploration.. Notes: Doppler US revealed a decrease in end-diastolic blood velocity (4.2 cm/s) and an elevated RI (0.85) (A). CT revealed a hematoma with air in the urinary tract of the allograft (B): coronal image, (C): sagittal image, red arrow: hematoma with air.. Abbreviations: CT, computed tomography; RI, resistive index; US, ultrasonography; PS, peak systolic; ED, end-diastolic; MD, mean diastolic; TAMAX, time averaged maximum; PI, pulsatility index; RI, resistance index; AT, acceleration time.
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US on POD 2 showed a decrease in the diastolic flow and an elevated RI without obvious evidence of TRVT (Figure 1A); thus, rejection was considered, and steroid pulse therapy was initiated. Despite this therapy, allograft function did not improve, hydronephrosis worsened, and urine output decreased. Unenhanced computed tomography (CT) on POD 4 revealed a hematoma with air in the urinary tract of the allograft (Figure 1B and C), and serum creatinine levels increased to 7.0 mg/dL.
Representative allograft image and schematic for surgical exploration.. Notes: Representative image of the allograft during surgical exploration. Arterial anastomotic stenosis was not observed. The proximal renal vein was branched into two, and one branch was compressed by the surrounding tissues, including the allograft, renal artery, and abdominal wall, resulting in TRVT. In addition, the upper urinary tract of the allograft was occupied by a hematoma with clots and air (A), red arrow: renal artery, blue arrow: renal vein, green arrow: allograft, and yellow arrow: ureter. A schematic of the intraoperative allograft is shown. The trunk of the renal vein had no evidence of thrombosis, and a thrombectomy was performed. In addition, a hematoma with a clot of the upper urinary tract was evacuated (B). Doppler US showed improved end-diastolic blood velocity (11.7 cm/s) and RI (0.56) (C).. Abbreviations: RI, resistive index; TRVT, transplant renal vein thrombosis; US, ultrasonography; PS, peak systolic; ED, end-diastolic; MD, mean diastolic; TAMAX, time averaged maximum; PI, pulsatility index; RI, resistance index; AT, acceleration time.
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TRVT was detected. Therefore, subsequent surgical thrombectomy was performed, and Doppler US revealed improved diastolic flow and RI (Figure 2A-C).
Representative allograft images of CT after surgical exploration.. Notes: CT revealed a loss of the hematoma with air in the upper urinary tract of the allograft. (A): coronal image, (B): sagittal image, red arrow: allograft.. Abbreviation: CT, computed tomography.
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Postoperative CT also showed that hydronephrosis and the urinary tract hematoma were no longer present (Figure 3A and B).
Clinical course of serum creatinine levels and urine output and the immunosuppression regimen.. Notes: On POD 4, the serum creatinine level was 7.0 mg/dL, and urine output decreased; thus, surgical exploration was performed. After evacuation of the transplant renal vein thrombosis and hematoma of the upper urinary tract of the allograft, serum creatinine levels decreased to 1.8 mg/dL, and urine output increased. The immunosuppression regimen was as follows: tacrolimus, MMF, PSL, and BXM. At discharge, the doses of each immunosuppressive agent were as follows: 10 mg/day tacrolimus, 1,000 mg/day MMF, and 5 mg/day PSL.. Abbreviations: BXM, basiliximab; MMF, mycophenolate mofetil; POD, postoperative day; PSL, prednisone; Tac, tacrolimus.
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After surgical thrombectomy, urine output increased, and serum creatinine levels decreased to 1.8 mg/dL (Figure 4).