Letter to the Editor
Anuria after renal graft biopsy: Multidisciplinary intervention
Anuria tras biopsia del injerto renal: intervención multidisciplinar
María José Torres Sáncheza,
, Pilar Galindo Sacristána, Almudena Pérez Marfila, Javier de Teresa Alguacila, Francisco Javier Barroso Martína, José Manuel Osorio Moratallaa, Pedro Pablo Alcázar Romerob, Antonio Martínez Morcilloc, Javier Vicente Pradosc, José Antonio Aparicio Gómeza, Antonio Osuna Ortegaa
Corresponding author
a Unidad de Gestión Clínica de Nefrología, Complejo Hospitalario Universitario de Granada, Hospitales San Cecilio y Virgen de las Nieves, Granada, Spain
b Servicio de Angiorradiología, Complejo Hospitalario Universitario de Granada, Hospitales San Cecilio y Virgen de las Nieves, Granada, Spain
c Servicio de Urología, Complejo Hospitalario Universitario de Granada, Hospitales San Cecilio y Virgen de las Nieves, Granada, Spain
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Antonio" "apellidos" => "Aparicio Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 10 => array:3 [ "nombre" => "Antonio" "apellidos" => "Osuna Ortega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Nefrología, Complejo Hospitalario Universitario de Granada, Hospitales San Cecilio y Virgen de las Nieves, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Angiorradiología, Complejo Hospitalario Universitario de Granada, Hospitales San Cecilio y Virgen de las Nieves, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Urología, Complejo Hospitalario Universitario de Granada, Hospitales San Cecilio y Virgen de las Nieves, Granada, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anuria tras biopsia del injerto renal: intervención multidisciplinar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figs. 1 and 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1500 "Ancho" => 925 "Tamanyo" => 219500 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Arteriogram of the renal graft with contrast extravasation in a distal branch. Selective embolisation of a distal branch of the artery of the graft with resolution of the extravasation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Biopsy of both native and transplanted kidneys is an essential procedure for diagnosis in a considerable proportion of kidney diseases,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> although the benefit is more limited if performed in advanced stages of the disease. However, it is not a harmless procedure, and there may present uncommon complications such as haematuria or the need for a nephrectomy/transplantectomy due to organ damage.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 61-year-old male with CKD of unknown aetiology who, after 9 months in haemodialysis, received a transplant from a cadaver donor without complications. Seven years later he underwent a graft biopsy because the patient had chronic graft dysfunction and non-nephrotic proteinuria. The biopsy was performed under ultrasound monitoring, with no immediate complications. On the third day, he complained of lumbar pain radiating to the right lower limb, suggestive of lumbar sciatica. On the fourth day, he experienced the onset of oligoanuria and was diagnosed of a perirenal haematoma by ultrasound. He was haemodynamically stable and had pain on palpation of the graft. In a situation of anuria, a limited urine sample was analysed, with low sodium, 47<span class="elsevierStyleHsp" style=""></span>mEq/l and fractional excretion of sodium (FENa)<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1%. In the first few hours presented anaemia (Hb of 13<span class="elsevierStyleHsp" style=""></span>g/dl dropped to 10.5–9.6<span class="elsevierStyleHsp" style=""></span>g/dl) and an increase in creatinine (7.41<span class="elsevierStyleHsp" style=""></span>mg/dl) were confirmed. A basic coagulation study was normal. Doppler ultrasound showed a graft of 14<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>cm, with an avascular area in the upper pole, dependent on a cortical area of 10<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm, suggestive of a renal haematoma, contained by the renal capsule and without dilatation of the urinary tract; vessels were permeable with normal resistive indices.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A urologist was consulted owing to suspected active bleeding. The urologist believed that the patient was at high risk of a transplantectomy if surgery was performed, and so it was decided to perform a diagnostic arteriogram with the possibility of embolisation of the bleeding point. Selective renal artery catheterisation was performed through the femoral approach, up to the area of contrast extravasation, with an image suggestive of an AVF, and embolisation of 2 distal branches was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1 and 2</a>). Afterwards, a urologist drained the parenchymal haematoma of the upper pole and placed haemostatic material. After clinical stabilisation, he required haemodialysis and multiple blood transfusions, and started effective diuresis with improvement in his glomerular filtration rate. A year later, the patient remains stable and has preserved his renal function.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Follow-up of a patient who has received a transplant is essential to prevent, diagnose and treat the complications that may occur during his or her clinical course. Standard biopsy or biopsy indicated in several situations such as suspected acute rejection, chronic dysfunction and proteinuria is a cost-effective procedure.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> However, it is not free of risks, especially in patients with platelet aggregation disorders, on anticoagulants or of advanced age.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Signs and symptoms of compartment syndrome, or “Page kidney”, have been reported after graft biopsy, which have required surgical decompression and in some cases have led to graft loss. Even after implantation, this clinical picture has also been reported in relation to surgical trauma (renal allograft compartment syndrome, or RACS).<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4–8</span></a> Renal dysfunction is caused by various mechanisms, including compression of the parenchyma due to a subcapsular or intrarenal haematoma and/or with involvement of the hilum, vessels or urinary tract, with the kidney behaving as though renal ischaemia or a urinary obstruction were caused. In any case, it occurs with oligoanuria and its resolution requires release of the compromised organ, in some cases after spontaneous reabsorption of the haematoma<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> and in other cases with a surgical procedure,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> provided that there is resolution of the bleeding point.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case, the size of the haematoma, the late symptoms (third day) and the drop in haemoglobin, although the patient's haemodynamics were not affected and were perhaps sustained through hyperreninaemia, suggested the possibility of persistent bleeding. As a result, prior action by an angioradiologist, before the surgical procedure, was proposed. After the active bleeding point was identified and embolised, the patient underwent urological surgery in which the haematoma was drained and diuresis and renal function were recovered.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The risk of transplantectomy in a late surgical procedure<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> (7th year post-transplant) is high owing to fibrosis and the difficulty of identifying structures and the location of the bleeding point. Prior haemostasis by the endovascular route allowed this risk to be reduced and the haematoma to be drained, with no risk of rebleeding.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Some complications of kidney transplant require an assessment and multidisciplinary action for their resolution, owing to their diagnostic and therapeutic complexity.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Torres Sánchez MJ, Galindo Sacristán P, Pérez Marfil A, de Teresa Alguacil J, Barroso Martín FJ, Osorio Moratalla JM. Anuria tras biopsia del injerto renal: intervención multidisciplinar. Nefrologia. 2016;36:456–457.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figs. 1 and 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1500 "Ancho" => 925 "Tamanyo" => 219500 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Arteriogram of the renal graft with contrast extravasation in a distal branch. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 5 | 9 |
| 2024 October | 40 | 36 | 76 |
| 2024 September | 42 | 22 | 64 |
| 2024 August | 64 | 68 | 132 |
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| 2024 May | 59 | 42 | 101 |
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| 2024 January | 49 | 27 | 76 |
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| 2023 November | 39 | 23 | 62 |
| 2023 October | 48 | 32 | 80 |
| 2023 September | 83 | 26 | 109 |
| 2023 August | 54 | 27 | 81 |
| 2023 July | 42 | 25 | 67 |
| 2023 June | 59 | 17 | 76 |
| 2023 May | 56 | 32 | 88 |
| 2023 April | 30 | 11 | 41 |
| 2023 March | 52 | 21 | 73 |
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| 2022 December | 53 | 30 | 83 |
| 2022 November | 68 | 24 | 92 |
| 2022 October | 73 | 38 | 111 |
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| 2021 March | 74 | 34 | 108 |
| 2021 February | 57 | 37 | 94 |
| 2021 January | 42 | 20 | 62 |
| 2020 December | 33 | 16 | 49 |
| 2020 November | 29 | 18 | 47 |
| 2020 October | 37 | 20 | 57 |
| 2020 September | 33 | 16 | 49 |
| 2020 August | 46 | 17 | 63 |
| 2020 July | 25 | 15 | 40 |
| 2020 June | 38 | 14 | 52 |
| 2020 May | 54 | 20 | 74 |
| 2020 April | 53 | 17 | 70 |
| 2020 March | 46 | 11 | 57 |
| 2020 February | 51 | 16 | 67 |
| 2020 January | 42 | 27 | 69 |
| 2019 December | 60 | 26 | 86 |
| 2019 November | 38 | 22 | 60 |
| 2019 October | 41 | 12 | 53 |
| 2019 September | 68 | 13 | 81 |
| 2019 August | 49 | 19 | 68 |
| 2019 July | 54 | 28 | 82 |
| 2019 June | 44 | 21 | 65 |
| 2019 May | 40 | 10 | 50 |
| 2019 April | 55 | 24 | 79 |
| 2019 March | 41 | 18 | 59 |
| 2019 February | 27 | 19 | 46 |
| 2019 January | 51 | 20 | 71 |
| 2018 December | 122 | 49 | 171 |
| 2018 November | 240 | 19 | 259 |
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| 2018 September | 118 | 13 | 131 |
| 2018 August | 54 | 21 | 75 |
| 2018 July | 57 | 16 | 73 |
| 2018 June | 62 | 14 | 76 |
| 2018 May | 90 | 14 | 104 |
| 2018 April | 87 | 6 | 93 |
| 2018 March | 104 | 12 | 116 |
| 2018 February | 76 | 2 | 78 |
| 2018 January | 56 | 5 | 61 |
| 2017 December | 91 | 11 | 102 |
| 2017 November | 47 | 9 | 56 |
| 2017 October | 32 | 9 | 41 |
| 2017 September | 41 | 42 | 83 |
| 2017 August | 25 | 7 | 32 |
| 2017 July | 42 | 12 | 54 |
| 2017 June | 34 | 28 | 62 |
| 2017 May | 41 | 10 | 51 |
| 2017 April | 38 | 9 | 47 |
| 2017 March | 26 | 16 | 42 |
| 2017 February | 27 | 8 | 35 |
| 2017 January | 25 | 6 | 31 |
| 2016 December | 39 | 11 | 50 |
| 2016 November | 35 | 7 | 42 |
| 2016 October | 51 | 7 | 58 |
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