A 54 year old male with past history of allogeneic stem cell
transplant for acute lymphocytic leukemia. He developed ESRD post stem cell
transplant from thrombotic microangiopathy (TMA). He was on tacrolimus and steroid at the time of renal failure. The exact etiology of TMA was
not clear. Native urine output is about a liter/day. He underwent living
unrelated renal transplant with simulect induction and FK, MMF and steroid
maintenance. The donor was a 63 year old gentleman with hypertension
(controlled on one medication). The recipient’s pre transplant BP is 90/50 mmHg. Peri-transplant,
recipient’s systolic BP dropped frequently to 80’s in spite of multiple boluses
of IV fluids. Post op day 1, the patient made 30cc/hour of blood stained urine.
Creatinine remained unchanged at 6.4 mg/dL. What is the differential diagnosis
and next steps?
(case provided by Anand Vadivel, MD and Sayeed Malek, MD, Brigham
and Women’s Hospital, Boston, MA)
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Answer to the Transplant Quiz 10/13/11 is A, Renal ultrasound.
A 51-year old male underwent living related renal transplant for ESRD secondary to IgA nephropathy. His serum creatinine stabilized at 1.8 mg/dL at discharge. On follow-up visit (day 10 post op), he felt well. He had a urine output of approximately 2 liters of urine/day. He was tolerating his medications well. However, he continued to have about 700cc of Jackson Pratt (JP) drain output per day. On post op day 14, he developed pain (scale 3-4/10) at the transplant site. His JP drain output was 90cc two days ago and 0 over the past 24 hours. His serum creatinine was 2.3 mg/dL (the serum creatinine was 1.8 mg/dL, four days previously). What do you do next?
A.) Renal ultrasound
B.) MRI with gadolinium
C.) Allograft biopsy
D.) An angiogram using low osmolality contrast agent
E.) Continue to observe closely and ask him to return for follow-up in 3 days
(Case and Discussion from Dr. Anand Vadivel, Renal Division, and Dr. Sayeed Malek, Renal Transplant Surgery, Brigham and Women's Hospital)
Explanation / Additional Slides
The differential diagnosis is: 1.) lymphocele, 2.) Urinary leak (urinoma), 3.) Urinary obstruction, and 4). Acute rejection. Therefore, a renal US is the best non-invasive test. MRI with gadolinium (the gadolinium would be contraindicated here with a serum creatinine of 2.3 mg/dL) and the CT (IV contrast should be avoided if possible) should not be done. The renal allograft US revealed a 11.8 cm transplant kidney, new minimal hydronephrosis, and normal resistive indices (RI 0.6 – 0.7). However, there were two collections noted in the medial aspect of the kidney. Deep collection measured 10 X 6 X 12 cm (360 mls). A percutaneous drain was placed - the diagnosis: urinoma. The serum creatinine improved to 1.7 mg/dL and the drain was removed after 1 week.
